A stroke occurs when your brain experiences either loss or reduced supply of blood, starving brain tissue of oxygen and food. Because of such a compromised flow of blood, brain cells begin to die resulting in a stroke, which is a medical emergency requiring prompt treatment. Early action can minimize brain damage and potential complications. The good news is that strokes can be treated and prevented. Better control of major stroke risk factors — high blood pressure, smoking and high cholesterol — may be responsible for the decline. A stroke may be caused by a blocked artery (ischemic stroke) or a leaking or burst blood vessel (hemorrhagic stroke). Some people may experience a temporary disruption of blood flow through their brain (transient ischemic attack). About 85 percent of strokes are ischemic, which are triggered ischemia—medical word for severely reduced blood flow caused generally by narrowed or blocked arteries. The most common ischemic strokes include: Thrombotic stroke, which occurs when a blood clot (thrombus) forms in one of the arteries that supply blood to your brain. A clot often may be caused by fatty deposits (plaque) that build up in arteries and cause reduced blood flow (atherosclerosis) or other artery conditions. An embolic stroke occurs when a blood clot or other debris forms away from your brain — commonly in your heart — and is swept through your bloodstream to lodge in narrower brain arteries. This type of blood clot is called an embolus. A hemorrhagic stroke occurs when a blood vessel in your brain leaks or ruptures.
To determine the most appropriate treatment for your stroke, your emergency will try and identify the type of stroke you’re having and the areas of the brain affected by it. They will also rule out other possible causes for the symptoms. Starting with a physical examination your doctor may use several tests to determine your risk of stroke, including blood tests and scans. (see Tech & Procedures)
The treatment options depend on the type of brain attack. If a brain blood vessel is blocked by a clot, dissolving the clot by giving clot-dissolving drugs intravenously and/or removing the clot directly using special devices in a cath lab can be attempted. The latter is proved to be more effective for large artery blocks. If stroke is due to rupture of blood vessel in the brain, the cause of rupture needs to be evaluated. If the cause is found to be due to loc balloning of blood vessel (Aneurysm) it may be managed by coiling( key hole surgery) or sometimes it may require open surgery and clipping.
Emergency treatment for stroke depends on whether you’re having an ischemic stroke blocking an artery — the most common kind — or a hemorrhagic stroke involving bleeding into the brain.
Ischemic stroke: To treat this, doctors must quickly restore blood flow to your brain and may therefore resort to any of the following approaches:
Medication: Therapy with clot-busting drugs (thrombolytics) must start within 4.5 hours if they are given into the vein — and the sooner, the better. Quick treatment not only improves chances of survival but also may reduce the complications from stroke. You may be given:
Aspirin: An anti-thrombotic drug, it is an immediate treatment after an ischemic stroke to reduce the likelihood of another stroke. Aspirin prevents blood clots from forming. The dose may vary, but if you already take a daily aspirin for its blood-thinning effect, you may want to make a note of that on an emergency medical card.
Intravenous injection of tissue plasminogen activator (TPA): Some people who are having an ischemic stroke can benefit from an injection of a recombinant tissue plasminogen activator (TPA), also called alteplase, usually given through a vein in the arm. This potent clot-busting drug needs to be given within 4.5 hours after stroke symptoms begin if it’s given into the vein. This drug restores blood flow by dissolving the blood clot causing your stroke.
Emergency procedures: Doctors sometimes treat ischemic strokes with procedures that must be performed as soon as possible. Medications delivered directly to the brain. Doctors may insert a long, thin tube (catheter) through an artery in your groin and thread it to your brain, and then release TPA directly into the area where the stroke is occurring. The time window for this treatment is somewhat longer than for intravenous TPA but still limited.
Mechanical clot removal: Doctors may use a catheter to maneuver a tiny device into your brain to physically grab and remove the clot. Other invasive procedures: To decrease your risk of having another stroke or TIA, your doctor may recommend a procedure to open up an artery that’s moderately to severely narrowed by plaque.
Doctors sometimes recommend these procedures to prevent a stroke. Options may include:
Carotid endarterectomy: A surgeon removes fatty deposits (plaques) from your carotid arteries that run along each side of your neck to your brain by making an incision along the front of your neck, opening your carotid artery, and removing the plaques. However, a carotid endarterectomy also involves risks, especially for people with heart disease or other medical conditions.
Angioplasty and stents: In an angioplasty, a surgeon inserts a catheter with a mesh tube (stent) and balloon on the tip into an artery in your groin and guides it to the blocked carotid artery in your neck. Your surgeon inflates the balloon in the narrowed artery and inserts a mesh tube (stent) into the opening to keep your artery from becoming narrowed after the procedure.
Emergency treatment of hemorrhagic stroke focuses on controlling your bleeding and reducing pressure in your brain. Surgery also may be used to help reduce future risk.If you take warfarin (Coumadin) or anti-platelet drugs such as clopidogrel (Plavix) to prevent blood clots, you may be given drugs or transfusions of blood products to counteract their effects. You may also be given drugs to lower pressure in your brain (intracranial pressure), lower your blood pressure or prevent seizures.
Once the bleeding in your brain stops, treatment usually involves bed rest and supportive medical care while your body absorbs the blood. Healing is similar to what happens while a bad bruise goes away. If the area of bleeding is large, surgery may be used in certain cases to remove the blood and relieve pressure on the brain.
Surgical blood vessel repair: Surgery may be used to repair certain blood vessel abnormalities associated with hemorrhagic strokes. Your doctor may recommend one of these procedures after a stroke or if you’re at high risk of a spontaneous aneurysm or arteriovenous malformation (AVM) rupture.
Surgical clipping: A surgeon places a tiny clamp at the base of the aneurysm, to stop blood flow to it. This can keep the aneurysm from bursting, or it can prevent re-bleeding of an aneurysm that has recently hemorrhaged.
Coiling (endovascular embolization): In this procedure, a surgeon inserts a catheter into an artery in your groin and guides it to your brain using X-ray imaging. Your surgeon then guides tiny detachable coils into the aneurysm (aneurysm coiling). The coils fill the aneurysm, which blocks blood flow into the aneurysm and causes the blood to clot.
Surgical AVM removal: Surgeons may remove a smaller AVM if it’s located in an accessible area of your brain, to eliminate the risk of rupture and lower the risk of hemorrhagic stroke. However, it’s not always possible to remove an AVM if it’s too large or if it’s located deep within your brain.
Stroke recovery and rehabilitation
Following emergency treatment, stroke care focuses on helping you regain your strength, recover as much function as possible and return to independent living. The impact of your stroke depends on the area of the brain involved and the amount of tissue damaged. If your stroke has affected the right side of your brain, your movement and sensation on the left side of your body may be affected. If your stroke has damaged the brain tissue on the left side of your brain, your movement and sensation on the right side of your body may be affected. Brain damage to the left side of your brain may cause speech and language disorders. In addition, if you’ve had a stroke, you may have problems with breathing, swallowing, balancing and vision.
Most stroke survivors receive treatment in a rehabilitation program. Your doctor will recommend the most rigorous therapy program you can handle based on your age, overall health and your degree of disability from your stroke. Your doctor will take into consideration your lifestyle, interests and priorities, and availability of family members or other caregivers.
Your rehabilitation program may begin before you leave the hospital. It may continue in a rehabilitation unit of the same hospital, another rehabilitation unit or skilled nursing facility, an outpatient unit or your home.
Blood tests: Your doctor may run several blood tests to gain important information such as how fast your blood clots, whether your blood sugar is abnormally high or low, whether critical blood chemicals are out of balance, or whether you may have an infection. Brain imaging plays a key role in determining if you’re having a stroke and what type of stroke you may be experiencing. A CT scan uses a series of X-rays to create a detailed image of your brain. A CT scan can show a brain hemorrhage, tumors, strokes and other conditions. Doctors may inject a dye into your blood vessels to view your blood vessels in your neck and brain in greater detail.
Magnetic resonance imaging (MRI): An MRI uses powerful radio waves and magnets to create a detailed view of your brain. An MRI can detect brain tissue damaged by an ischemic stroke and brain hemorrhages. Sometimes your doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow (magnetic resonance angiography, or magnetic resonance venography).
Carotid ultrasound: In this test, sound waves create detailed images of the inside of the carotid arteries in your neck. This test shows buildup of fatty deposits (plaques) and blood flow in your carotid arteries.
Cerebral angiogram: In this test, your doctor inserts a thin, flexible tube (catheter) through a small incision, usually in your groin, and guides it through your major arteries and into your carotid or vertebral artery. Then your doctor injects a dye into your blood vessels to make them visible under X-ray imaging. This procedure gives a detailed view of arteries in your brain and neck.
Echocardiogram: An echocardiogram uses sound waves to create detailed images of your heart. An echocardiogram can find a source of clots in your heart that may have traveled from your heart to your brain and caused your stroke. You sometimes may have a transesophageal echocardiogram. In this test, your doctor inserts a flexible tube with a small device (transducer) attached in your throat and down into your esophagus — the tube that connects the back of your mouth to your stomach. Because your esophagus is directly behind your heart, a transesophageal echocardiogram can create clear, detailed ultrasound images of your heart and any blood clots.