Stroke/Transient Ischemic Attacks Treatment

  • Treatment

    Call 911 or go to the nearest emergency room if you or someone close to you shows signs of TIA or stroke Table 03. There is no way to tell whether your symptoms are the result of a TIA and will go away shortly, or whether you are experiencing an acute stroke that could lead to disability or death. Therefore, you should treat any symptom of stroke as an emergency. Brain damage starts within minutes of a stroke, and may be irreversible in as little as an hour. Treatment for stroke is mosteffective if started a few hours after symptoms appear. Your chances of recovery depend on a quick response to the first signs of stroke.

    Table 3.  Signs and Symptoms of Stroke

    If you have sudden onset of any of the following symptoms, call 911 for emergency medical care immediately:
    Confusion or trouble understanding or speaking
    Numbness or weakness of you face, arm, or leg, especially on just one side of your body
    Difficulty seeing in one or both eyes
    Trouble walking, or loss of balance or coordination
    Severe headache or dizziness with no known cause
    Signs and symptoms of adverse drug reactions

    If you have had an ischemic stroke caused by blood clots, you will be given medication to dissolve the clots. If your symptoms began less than three hours earlier, the drug may be a relatively new, genetically engineered compound called rt–PA (recombinant tissue plasminogen activator). Detailed medical guidelines have been prepared to help physicians determine when this drug should be administered, as it is not appropriate for every patient. If you experienced a hemorrhagic stroke, the immediate goal is to prevent further bleeding. You may be given drugs to lower your blood pressure; surgery may also be necessary in some cases.

    When your condition is stable, you will be transferred to the intensive care unit or specialized stroke unit where you can be closely monitored for 24 to 48 hours. A neurologist, neurosurgeon, or stroke specialist may assume responsibility for your care, or your primary care physician may take the lead role. You may receive medication or undergo surgery. Rehabilitation, such as physical therapy, speech therapy, and occupational therapy, will begin as soon as possible, often within several days of hospital admission. The duration of your time in intensive care or a general hospital unit depends on various factors, including the extent of damage caused by the stroke and the speed of your recovery.

    As the focus of therapy shifts from managing a crisis situation to rehabilitation, you may be transferred to a rehabilitation unit or subacute care unit within the hospital, to a rehabilitation hospital, or to a long–term care facility where you can receive skilled nursing care and various forms of therapy. You may also be allowed to return home, where you will receive therapy from home health providers. Regardless of the setting where you receive care following stroke, the healthcare team will work to prevent complications such as pneumonia and bedsores.

    Much of the treatment for stroke involves prevention, either of an initial stroke or a recurrence. The approach should be based on your individual risk factors, such as high blood pressure or diabetes Table 04. Depending on your profile, you may need to take medication to lower your blood pressure or prevent blood clots and make lifestyle changes such as giving up smoking, eating a healthier diet, and exercising regularly.

    Table 4.  Risk Reduction Recommendations for Patients Who Have Had a Stroke

    Risk factor Recommendations
    Hypertension Modify your lifestyle and take antihypertensive medications
    Smoking Stop smoking
    Diabetes mellitus Make sure to follow your treatment plan for diabetes
    Lipids Adopt a low?fat, low?cholesterol diet, and exercise. If needed, you can take lipid?lowering medications
    Alcohol Stop excessive drinking, or join an alcohol cessation program.
    Physical activity Get moderate exercise daily (e.g., brisk walking, jogging, cycling, or another aerobic activity).
    If you are medically at risk (e.g., you have cardiac disease), you may want to adapt your exercise program under your doctor's supervision.
    Weight Exercise daily, and modify your diet.

    Your doctor is the best source of information on the drug treatment choices available to you.

    Physical, occupational, and speech therapy are important parts of rehabilitation for stroke patients. Psychological or psychiatric therapy may also be needed. You may need physical therapy to help you relearn functions such as walking, sitting, lying down, and switching from one type of movement to another. Occupational therapy can help you to relearn the basic tasks of daily living, such as eating, drinking, swallowing, dressing, bathing, toileting, cooking, reading, and writing. You also may need driver's training before you can safely get behind the wheel again. If the stroke affected your language and communications skills, you will require speech therapy. Some stroke patients experience a condition called aphasia, in which they can think clearly but are unable to express themselves clearly or fully comprehend what is said to them. Speech therapy is vital in overcoming this common problem.

    Rehabilitative services are offered in many settings, such as acute care and rehabilitation hospitals, long–term care facilities, outpatient facilities, and in your home. During the course of your recovery from stroke, you may receive therapy at more than one of these locations. The goal of rehabilitation is to help you relearn functions and become as independent as possible. How long this will take and how much independence you will regain is a very individual matter. Only about one–third of stroke patients recover with few or no lasting symptoms.

    Psychological problems are common following a stroke. You may experience depression, anxiety, or frustration and anger at your limited abilities. These emotional problems could hinder your recovery or, in extreme cases, lead to suicide. If you are having emotional problems following a stroke, consult your neurologist, primary care physician, a psychologist, psychiatrist, or other mental health professional. Talk therapy, medication, or a combination of the two approaches should alleviate your problems. It may also be beneficial for your family members or other caregivers to seek help in coping with the emotional and physical burdens of caring for someone who has experienced a serious illness such as stroke.

    Surgical procedures that may be performed following an ischemic stroke include a carotid endarterectomy and angioplasty. Both are intended to reduce the risk of recurrence. Carotid endarterectomy is performed to remove plaque from the carotid arteries. During this procedure, an incision is made in the side of the neck, and the main artery is clamped on both sides of the area where the blood vessel has narrowed because of plaque build–up. The plaque is removed, the blood vessel is sewn back together, and the clamps are removed. The procedure usually takes several hours, and can be performed with either local or general anesthesia. It is usually recommended for symptomatic patients with arterial blockage of 50% or more (50%–99%).

    Angioplasty is performed to remove plaque that is clogging your blood vessels. In this procedure, a long, thin, narrow tube called a catheter is inserted into an artery in your arm, leg, or groin. The surgeon guides the catheter to your carotid arteries with the help of x–ray images. Then, a second catheter tipped with a deflated balloon is inserted into the first. When it reaches the blocked area, the balloon is inflated. This action compresses the fat that is blocking the artery, allowing the blood to flow more freely. Fine metallic mesh tubes called stents are then implanted in the artery to help keep plaque from rebuilding. The procedure is usually performed under local anesthesia and typically lasts 30 minutes to two hours.

    Several types of surgical procedures may be performed for patients who have experienced hemorrhagic stroke. During a hemorrhage, blood collects in the brain, where it can dangerously increase pressure. Surgery is sometimes performed to remove blood clots within the damaged area. If an abnormal increase in the diameter of a blood vessel (aneurysm) is found on a diagnostic imaging scan, a surgeon may perform a procedure called clipping. A clip or clamp is placed across the neck or base of the aneurysm to reduce the chance that the aneurysm will burst and bleed.

    Endovascular therapy is a new, less–invasive technique for treating aneurysms in patients who have experienced hemorrhagic stroke. In this procedure, a catheter is guided to the site of the aneurysm where a small platinum coil is released. The coil triggers an immune response from the body, which then forms a blood clot inside the aneurysm that strengthens the artery walls and reduces the chance that it will rupture.

    Some patients use acupuncture as a supplement to standard therapy in stroke rehabilitation. It is unclear precisely how acupuncture could help stroke patients recover. One theory is that the needles placed in specific locations in the body stimulate undamaged brain cells to compensate for or take over the function of the cells that were destroyed during the stroke. However, further studies are needed before definitive recommendations can be made.

    The hormonal changes that take place during pregnancy, childbirth, and menopause pose stroke risks for women. Pregnancy can increase a woman's risk of stroke. However, women in their childbearing years are usually at a relatively low risk for stroke, so the increased risk from pregnancy does not put them in a high–risk category. About 25% of the strokes that occur during pregnancy end in death, and hemorrhagic stroke is the leading cause of maternal death in the US. The postpartum period is the time of highest risk. The reason for this increased risk is unknown.

    Menopause is another time of increased stroke risk. Studies are underway to see if hormone replacement therapy can lower this risk. Although findings are not yet certain, estrogen therapy may be able to lower stroke risk by affecting a woman's cholesterol level.

    Using birth control pills has also been associated with higher stroke risk. This risk was more of a problem in the past, when high–dose oral contraceptives were prescribed. Pills used today are safer because they have a lower dose of estrogen. There still may be a slightly increased risk of stroke, however; particularly if you smoke, have high blood pressure, diabetes, or migraine.

    Children and young adults may develop stroke as a result of a medical condition such as an intracranial infection, brain injury, vascular malformation, or a genetic disorder such as sickle cell anemia. Since stroke is usually considered to be a disease of the elderly, it may seem surprising to learn that children are at risk for stroke. Stroke symptoms in children commonly include seizures, sudden loss of speech or speech impairment, weakness or paralysis on one side of the body, convulsions, headache, or fever.

    Treatment will depend upon the underlying condition. Young adults (15 to 44) may experience a stroke as a result of some of the same risk factors found in older adults: heart disease, head and neck injuries, alcohol abuse, and drug use. Women in this age group face increased stroke risk during pregnancy and childbearing.

    Children tend to recover more fully from strokes than adults after treatment and rehabilitation. The success of childrens' recovery from stroke is due to the ability of their developing brains to adapt to the cell damage of a stroke.

    About one–third of patients who have had a stroke die within a year of the attack, one–third have permanent disabilities, and one–third recover with few or no lasting symptoms. Much has yet to be learned about the brain and how it is affected by stroke. Some of the brain cells may be only temporarily damaged rather than destroyed, and they may resume functioning. Your brain also may be able to compensate for damage in one area by shifting responsibility for certain functions to nondamaged areas. It is difficult to predict how completely any individual will recover. However, seeking medical treatment at the first sign of stroke increases your chances of survival and recovery.

    About one–fourth of individuals who recover from a stroke have another within five years. The risk of recurrence is highest immediately after a stroke, and decreases with time. The risk of disability or death increases with each stroke recurrence.

    If your symptoms persist for more than six months, they are likely to be permanent. Some patients with permanent disabilities will require care in a nursing home or other long–term care facility. Others will be able to live at home, but will require special care from home health services. Rehabilitation therapy is instrumental to recovering as much independence as possible. You should also follow your doctor's advice on reducing your risk factors to prevent a recurrence.

    Many products and devices are available to help stroke survivors perform the tasks of daily living, such as dressing, cooking, and bathing. Your therapy team can help you locate these items and provide suggestions on ways to modify your house. You may also want to become involved in a support group where you can exchange ideas with other stroke survivors and benefit from the companionship of others who are facing similar problems.

    Regular follow-up appointments are important for managing stroke. Your doctor will evaluate your blood pressure and cholesterol levels with the goal of preventing a recurrent stroke. The doctor will also assess how well you are doing in your rehabilitative therapy. Since recovery from stroke is often stressful for patients and their families, you and your doctor should discuss your mental well–being and your family's adaptation to your illness. The schedule for follow–up visits varies from patient to patient, since the effects of stroke and the need for additional care are also extremely variable.

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