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What to Expect After a Major Stroke: Examination & Therapy

By Dr. Harvey Gilbert, MD
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As of 2006, only two hundred hospitals in the U.S. had been certified as primary stroke centers to administer whatever therapy is deemed necessary immediately, although that number has been increasing rapidly. Direct routing of stroke patients to a primary stroke center within three hours of stroke onset is also rapidly progressing. Florida, New Jersey, Maryland, Massachusetts, New Mexico, New York and Texas mandate that stroke patients be routed to primary stroke centers where they can receive the proper care.

Primary stroke centers perform multiple testing and therapy rapidly and concurrently. This is just as important to do following a stroke as it is after a heart attack. The onset of the stroke counts from the time of the patient's previously "normal" state, whether the stroke is the first or a repeat episode. If the patient became unconscious, the onset should be measured from the time of losing consciousness.

Examination Following a Stroke

In addition to a thorough physical, the neurological exam is critical. The NIH Stroke scale evaluates the patient's level of consciousness, orientation, responses, gaze, visual fields, facial movement, motor function or arm and leg balance, language, speech and attention. Other tests involving heart, blood sugar, brain, lung and spinal fluid may be required. Bleeding tests may also be indicated. Selected patients need screening for toxicology, alcohol, pregnancy, and should be tested for liver, chest and oxygen function.

Imaging Tests

Imaging tests can help determine the part(s) of the brain affected by the stroke. A CT scan usually comes first, and an MRI may provide additional information. If treatment is properly administered in a timely manner, the X-ray findings may not be predictive of outcome. Treatment should not be delayed if an X-ray slows down the process.

General Supportive Care

Oxygen levels are important following a stroke. Managing an elevated body temperature is also important. Artificially lowering body temperature has not proven to be an effective measure. Heart monitoring is important, but medicines should only be used if problems are identified. Patients with elevated blood pressure may require lowering of the pressure if is it is too high prior to using tPA treatment. Low blood sugar should be treated, and physical rehabilitation is critical after a stroke.

Thrombolytic Therapy

Recombinant Tissue Plasminogen Activator (tPA) is the key treatment for stroke patients and should be administered rapidly. A clot-buster drug, tPA can cause bleeding and affect the airway. The outcome of this is related mainly to the severity of the deficits found and the patient's age. Patients should be treated with tPA within three hours of the onset of the ischemic stroke, if: the stroke is not clearing on its own; very high blood pressure can be controlled; the signs of stroke are not minor; there is no hemorrhage, no history of recent acute head trauma, no recent heart attack and no recent major surgery; if other hemorrhage precautions are taken; there is control of blood thinners; and pre- and post- seizure precautions are taken if there is major brain loss. If tPA is not an option and the patient is within six hours of stroke onset, intra-arterial rtPA may be another treatment option.

Other Post-Stroke Acute Therapy

Urgent anticoagulation is not indicated other than the tPA regimen. Aspirin can help prevent new strokes and is recommended to stroke patients after therapy, but is not thought to be helpful for treatment of the acute stroke itself. Surgery is not indicated. Angioplasty, stenting and clot removal may be helpful. Most patients should be admitted and observed in a hospital setting. There are no proven brain protection treatments in the post-stroke period. Patients with major deficits from a stroke should be monitored for brain swelling, which may require surgery.

Source: Harold P Adams, Jr. MD FAHA et al. Guidelines for the Early Management of Adults with Ischemic Stroke. Accessed on stroke.ahajournals.org. Published in Stroke, May 2007, pp. 1655–1693.