How Stroke Is Treated

Stroke treatment is about halting the potential problems that a stroke can cause before the damage is done. Depending on the type of stroke, a blood thinner such as tissue plasminogen activator (TPA) may be given to improve blood flow to the brain.

Doctors will also use medication and fluids, as appropriate, to manage blood pressure, electrolytes, and other factors that, if not maintained, can worsen your prognosis. In some cases, surgery may be needed to improve the potential of recovery.

The key lies in identifying and treating a stroke as early as possible—ideally, right after symptoms begin. Only highly trained emergency medical teams can administer stroke treatment due to the subtle signs and variations of stroke.

Whether you're near-certain a stroke has occurred or simply suspect that could be the case, seek treatment immediately.

Prescriptions

Blood thinners are given when a stroke is still in progress. When it is clear that a blood vessel is partially or completely obstructed, these drugs can help prevent a stroke from progressing by allowing some blood to flow, which is crucial to preventing or minimizing brain injury.

One of the principal challenges of acute stroke is rapidly determining whether a stroke is a hemorrhagic stroke or an ischemic stroke. Because a blood thinner should never be used for the former, your stroke care team works quickly to identify any bleeding in the brain before deciding whether you are a candidate for any of the following blood thinners.

Tissue Plasminogen Activator (TPA)

Tissue plasminogen activator (TPA) is a potent blood thinner that is administered intravenously for select cases of acute progressive stroke. The medication goes by the name Activase (alteplase).

TPA has been shown to partially or completely prevent permanent stroke damage in select situations by permitting blood to flow through the obstructed artery and, thus, preventing ischemia.

TPA can only be given by a well-trained medical team within the first few hours of stroke onset. Specifically, intravenous TPA administration has shown the most benefit when administered within the first three hours of the initial stroke symptoms. However, some research suggests TPA can be of help when used up to four and a half hours after symptoms start.

Because TPA must be administered almost immediately after arrival to an emergency department, there is no time to mull over the decision. Emergency TPA treatment decisions are made according to well-established protocols for maximal safety and effectiveness.

If it is unclear when your stroke symptoms began, then intravenous TPA is not used. In addition, because of the exclusions regarding the use of TPA, you cannot request TPA for a stroke for yourself or for a family member if the stringent guidelines are not met.

If you have a stroke, you do have the right to refuse treatment with TPA. But, it is important to remember that stroke teams do not administer this potent medication without good reason.

Intra-Arterial Thrombolysis

TPA can also be injected directly into the artery where a stroke-causing blood clot is located. This is done through the placement of a catheter directly into the cerebral blood vessel, a procedure called a cerebral angiogram. The use of intra-arterial TPA is an interventional procedure that is not as widely available as intravenous TPA, since it requires physicians with expertise in performing this type of treatment.

A large research study dubbed the MR CLEAN trial evaluated the safety and effectiveness of intra-arterial thrombolysis for stroke using a specific device called a stent retriever with good results. A stent retriever is a stent that is placed within the clot and helps remove it and re-establish the blood flow to the brain.

Intra-arterial thrombolysis is a procedure for which, like intravenous TPA, there are stringent criteria in place for the purpose of patient safety.

Heparin

Heparin is a medication that you can receive intravenously. Heparin can be used if you have an acute stroke if certain conditions are met:

• A blood clot is believed to be newly formed
• Stroke symptoms are present (new onset)
• A brain hemorrhage has been ruled out

If you have had significant ischemic changes on a brain imaging test, then heparin is often not recommended because it can cause recently damaged brain tissue to bleed.

Heparin is occasionally used to treat an acute stroke, but it is more often used in the setting of a TIA, particularly if a blood clot or a narrow artery is identified in your heart or carotid artery.

Aspirin

Aspirin is primarily used for stroke prevention because it is not considered powerful enough to dissolve a blood clot or prevent a growing blood clot from getting larger. However, aspirin is very commonly prescribed within the first 24 to 48 hours of an ischemic stroke's start to prevent further events.

Systemic Treatments

One of the most important aspects of stroke treatment is focused on maintaining the best physical situation in the hours and days after a stroke to give the brain the best chances of recovery. Certain parameters have been established regarding blood pressure, blood glucose, and some other measures to maintain the best physiological setting possible.

Blood Pressure

Blood pressure management is surprisingly one of the most important, complex, and controversial physical measures after a stroke. Doctors will pay close attention to blood pressure, using medications to maintain it at levels that are neither too high nor too low; both of these conditions are dangerous.

However, as blood pressure naturally fluctuates in the week after a stroke, your medical team will also meticulously watch the correlation between your neurological condition and your blood pressure as a means to determine and manage your best blood pressure in the days ahead.

Blood Glucose

Blood sugar levels can become erratic as a response to an acute stroke. Adding to this problem, you will likely not have your normal appetite in the days after a major stroke.

Elevated or low blood sugar levels can interfere with healing. That is why your stroke care team will devote consistent attention to stabilizing your blood sugar levels during this time.

Fluid Management

Swelling may occur in the brain after a stroke. This type of swelling, called edema, interferes with healing and may even cause further brain damage due to compression of vital regions of the brain.

If you or a loved one has had a recent stroke, intravenous fluid will likely be needed. IV fluid after a stroke is typically given at a slower rate and lower volume than usual IV hydration in the hospital setting, specifically for the purpose of avoiding edema.

If edema progresses rapidly, treatment with medication may be used to relieve the swelling. In cases of severe and dangerous edema, a surgical procedure might be necessary to release pressure.

Electrolyte Management

IV hydration in the setting of an issue such as a stroke consists of water enriched with important electrolytes, such as sodium, potassium, and calcium. The concentration of these electrolytes must be carefully managed to maintain the proper concentration of water and electrolytes in the brain in order to prevent edema.

Nerves require the right amount of electrolytes to control the brain’s functions. So, after a stroke, the concentration and quantity of electrolytes is even more important than usual, as brain function and healing are in a delicate state of balance.

Surgical Procedures

While it is not the most common treatment approach for a stroke, if you have had a large cortical stroke with substantial edema, you might need surgery to maximize recovery after a stroke.

Hematoma Evacuation

Some strokes are hemorrhagic strokes, meaning that there is bleeding in the brain. Most bleeding from these strokes is not easily removed. However, surgery may be the best option when a significant amount of blood is concentrated in a certain location.

If you need brain surgery after a stroke, you or your loved ones will be given time to carefully consider this option. You should be fully informed of the risks and benefits of the procedure.

Craniectomy

Sometimes, when edema from a stroke becomes severe and cannot be controlled by clinical measures, temporary removal of a portion of the skull bone prevents compression of vital regions of the brain so that the edema does not cause permanent damage.

The procedures, called craniectomy or hemicraniectomy, involve temporary removal of a portion of the skull until the edema subsides. The piece is preserved and then repositioned within a short period of time to protect the skull for the long term.

Rehabilitation

In the aftermath of a stroke, most patients undergo physical, occupational, and other therapies to help restore function and teach adaptive strategies to perform activities of daily living.

Stroke rehabilitation is based on a number of approaches, including physical and cognitive techniques designed to stimulate recovery after a stroke.

Rehab typically starts in the hospital once the condition has stabilized. Depending on the severity of the stroke, patients can be discharged from the hospital to a subacute care facility, an inpatient rehab center, in-home therapy, or outpatient therapy.

Physical Therapy

Muscle weakness and difficulty with walking and other movements can be common after a stroke. Physical therapy addresses problems with moving and balance, and includes specific exercises to strengthen muscles for walking, standing, and other activities.

Occupational Therapy

A stroke can impact your ability to care for yourself and handle activities of daily living, such as dressing, hygiene, writing, and doing housework. Occupational therapy helps with strategies to manage these tasks.

Speech Therapy

Some people have difficulty with language or swallowing following a stroke, and seeing a speech-language pathologist can help. This type of therapy works to improve communication, including talking, reading, and writing after a stroke, and also addresses swallowing and feeding problems.