Stroke

  • Medical Author:
    Benjamin Wedro, MD, FACEP, FAAEM

    Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.

  • Medical Editor: Charles Patrick Davis, MD, PhD
    Charles Patrick Davis, MD, PhD

    Charles Patrick Davis, MD, PhD

    Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

View Understanding Stroke Slideshow Pictures

Quick GuideStroke Pictures Slideshow: A Visual Guide to Understanding Stroke

Stroke Pictures Slideshow: A Visual Guide to Understanding Stroke

What is the treatment for stroke?

A stroke is a medical emergency and there is now ability to intervene and restore blood supply to the brain of some stroke patients if they present for medical care early enough.

As in many emergencies, the first consideration is the ABCs (Airway, Breathing, and Circulation) to make certain that the patient can breathe and has adequate blood pressure control. In severe strokes, especially those that involve the brainstem, the brains ability to control breathing, blood pressure, and heart rate may be lost.

Patients will have intravenous lines established, oxygen administered, and appropriate blood tests and CT scans performed at the same time that the health care professional is performing an assessment to make the clinical diagnosis of stroke and deciding whether thrombolytic therapy (tPA, a clot busting medication) is an option to treat the stroke.

If the diagnosis of ischemic stroke has been made, there is a window of time when thrombolytic therapy using tPA (tissue plasminogen activator) may be an option. tPA dissolves the clot that is blocking an artery in the brain and restore blood supply. For many patients, that time window is 3 hours after the onset of symptoms. In a select group of patients, that time frame may be extended to 4.5 hours. In that time, the patient or family needs to recognize the stroke symptoms, get the patient to a hospital (call 9-1-1), have the patient assessed by the health care professional, get blood test results, perform a CT scan to look for other causes of stroke (including hemorrhage or tumor), consult with a neurologist, and administer the tPA or call an interventional radiologist or neurosurgeon.

Hemorrhagic strokes are difficult to treat and a specialist (neurosurgeon) should be consulted immediately to help determine if any treatment options are available to the patient (possibly aneurysm clipping, hematoma evacuation, or other techniques). Treatment for hemorrhagic strokes, in contrast to ischemic strokes, does not use tPA or other thrombolytic agents as these would potentially make the symptoms of hemorrhagic stroke worse or cause death. Consequently, it is important to distinguish between a hemorrhagic stroke and an ischemic stroke before treatment begins.

Hospital emergency department doctors and nurses are trained to act quickly in caring for stroke patients. The most common delay that prevents tPA from being administered is due to patient delay in seeking medical attention. A CT of the head is done emergently to help distinguish an ischemic from a hemorrhagic stroke. This may also cause a delay in a few instances.

Some smaller hospitals may have the ability to virtually consult neurology specialists who can help make the diagnosis of stroke, review the CT scan, and help decide whether tPA is a reasonable option. The thrombolytic drug may be given and the patient is then transferred to a more well equipped hospital for further care.

The decision to administer tPA in the appropriate patient (there are many reasons that the drug is not indicated even if the patient arrives in time) is one that is discussed with the patient and family, since there is risk of bleeding in the brain with the use of tPA. While there is potential great benefit, because the blood vessels are fragile, there is a 6% risk that an ischemic stroke can turn into a hemorrhagic stroke with bleeding into the brain. This risk is minimized the earlier the drug is given and if the appropriate patient is selected.

In certain types of strokes involving the vertebrobasilar system and posterior circulation, the time frame may be extended beyond 4.5 hours.

If tPA is given, the patient will need to be admitted to an intensive care bed for monitoring. As well, depending upon circumstances, the patient may be transferred to a stroke center.

In some patients, instead of intravenous tPA, an option may exist to perform an angiogram where dye is injected into the arteries of the brain, identify the area of blockage, and inject tPA directly into the clot. It is also possible to suck the clot out of the artery. These procedures require the skill of a specially trained interventional neuroradiologist or neurosurgeon.

In those patients where tPA and other interventions are not possible or are not indicated, the patient is usually admitted to the hospital for observation, supportive care, and referral for rehabilitation.

Medically Reviewed by a Doctor on 2/18/2016
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