How are strokes treated?

A Stroke can be Ischemic or Hemorrhagic

Since these two types of stroke develop via different mechanisms, the treatment is accordingly different.

Important for the treatment of strokes is preventing the disease a long time in advance, in order to minimize chances of becoming permanently handicapped or dying.

• Treatment is done through various medications and brain surgery.

Medication and assistance during the acute phase are especially important for the development of the disease. The diagnostic challenges encountered in the initial stages make deciding on a medication course more difficult.

Treatments that physicians try to avoid

In the very first hours following the symptoms, physicians try to avoid employing the following treatments:

• Lumbar punctures, which may worsen the cerebral circulation disequilibrium
• The usage of potent vasodilators which may lead to a worsening of the vaso-paralysis and thus lower the flow of blood to the brain
• Using heparin and other types of anticoagulants which may favor hemorrhages

Rest is absolutely necessary. For patients who are exceedingly agitated and anxious, physicians may decide to use sedatives. Great care should be taken in choosing these medications.

Usually barbiturates such as chloral hydrate are used, whereas there is a contraindication toward using morphine and its derivatives.

Advice for patients

Patients are instructed to lie down on their side with their upper body slightly elevated (lateral decubitus), in order to prevent pulmonary complications and decubitus.

The mouth and eyes should be thoroughly cleansed. Great care should be taken with the respiratory tract, in order to avoid swallowing their tongue or aspirating their secretions, the patients are instructed to turn their head to the side.

A supply of oxygen is also made available to the patient. All pharyngeal and tracheal secretions are aspirated with a medical aspirator and in special cases a tracheotomy must be performed (using a scalpel to open the trachea from the neck, in order to allow the patient to breathe).

It is important to pay a lot of medical attention to the blood circulation condition of the patient. If the patient has indeed suffered a stroke, the amount of blood flowing to their brain is low, and should somehow be compensated for in order to avoid any serious consequences.

Medication is taken to bring arterial pressure to normal values, as well as antibiotics in order to prevent pulmonary infections, which often can become a direct cause of death.

Other Advices

• In the first 2-3 days of hospitalization, it is important to maintain a balance of electrolytes and liquids.
  After these days the patient may receive nourishment from the mouth, and if they cannot do this then a gastric tube (feeding tube) is inserted, through which the patient receives glucose and proteins.
• When there is urinary retention (the patient cannot pee) a catheter is placed.
• An examination of the fundus oculi (the interior surface of the eye opposite the lens and includes the retina, optic disc, macula, fovea, and posterior pole) is also performed.
• While a lumbar puncture is a debatable choice of treatment, if the diagnosis is clear, the test is unnecessary.

 

Methods to Treat a Stroke

Thrombolysis (Medical Compounds that Dissolve the Thrombus)

The medicine usually used for dissolving the thrombus is called Alteplase. This medication reestablishes blood circulation in the damaged part of the brain by dissolving the clot. Using such medication facilitates a process called thrombolysis.

Recommendation:
This type of medication should be used in the very first hours following the onset of the disease, and it is not recommended for use after 4-5 hours, since it is not clear how efficacious this therapy is at this delayed time.

• It is absolutely crucial to have correctly diagnosed the condition as an ischemic stroke, since if the stroke is hemorrhagic Alteplase is contraindicated for use.

Thrombectomy

Thrombectomy is an invasive procedure which is urgently used to treat an ischemic stroke. It consists in removing the thrombus (via aspiration or cutting it into smaller pieces) and restoring normal blood flow to the brain.

This procedure can only be employed if the thrombus is located in large arteries of the brain. The sooner the procedure is done, the more effective it is.

This procedure consists in inserting a catheter through the femoral artery in the thigh. Through there the catheter is threaded all the way to the brain. The thrombus is removed by aspirating it or by cutting it into smaller pieces. This entire procedure is conducted while using either local or general anesthesia.

Antithrombotics (Antiaggregants)

Many individuals regularly use aspirin, which has been shown to have a very effective antithrombotic influence. Using aspirin lowers the chances of a blood clot forming.

Other medications that may also be used either individually or in conjunction to aspirin include Clopidogral and Depiridamol.

Anticoagulants

Anticoagulants are drugs that reduce the risk for a blood clot. Preparations such as warfarin, edoxaban, rivaroxaban are commonly used for prolonged periods of time in order to prevent the formation of a thrombus.

Rivaroxaban is an especially useful drug, since patients can take it without getting the prothrombin index test (International Normalized Ratio (INR)).

• Rivaroxaban poses a very low risk for causing hemorrhage as compared to the other anticoagulants.

Since the other anticoagulants are more dangerous and more prone to causing hemorrhage, the INR test needs to be taken continuously on a regular basis. In order for a patient to be considered fully under the effect of the anticoagulant the prothrombin index needs to remain in the 25-40 range.

In normal individuals, meaning those who don’t use anticoagulants, the values obtained should remain within the norm 70-100.

• If the index is above 40, that means the patient is not considered fully under medication, and the risk for developing a thrombus increases.
• If the index is below 25, patients are at risk for hemorrhage.

Heparin, enoxaparin and other such anticoagulants are injectable drugs that are used for a short amount of time.

Anticoagulants may be used when:

1. The patient suffers from a heart rhythm disorder such as atrial fibrillation
2. When there is a family history for developing blood clots
3. When there is previous history for developing deep vein thrombosis of the legs.

Antihypertensives

These are a group of drugs which may be used individually or combined in order to maintain arterial tension within the normal range, and thus reduce the risk for stroke.

This group includes:

1. Thiazide diuretics (hydrochlorthiazide)
2. ACE Inhibitors (enalapril, lisinopril, perindopril, etc)
3. Calcium channel blockers (nifedipine, amlodipine, lercanidipine, felodipine)
4. Beta-blockers (atenolol, metoprolol, bisoprolol
5. ARB (angiotensin-2 blockers, such as valsartan, irbesartan, olmesartan, telmisartan)

Statins

This group of drugs is used to restore the balance of lipids in the blood. Lipid disorders in the blood may become the cause for forming atherosclerotic plaques, hence using such drugs is necessary to lower the risk for developing atherosclerosis.

By consequence, using these drugs can lower the risk for cardiovascular and cerebral disease.

• They are separated into statins (atorvastatin, pravastatin, simvastatin, fluvastatin) which are more favorable for lowering total cholesterol levels and fibrates (ciprofibrate, fenofibrate) which are used to lower triglyceride levels.

Carotid Endarterectomy

For patients suffering from a severe constriction of the carotid arteries of the neck, an invasive method may be used, by performing surgery to open the artery and manually remove the atherosclerotic plaque.

Tretament of Hemorrhagic Stroke

In a majority of cases, these patients need surgical treatment, which may be the only way to save the patient’s life.
Surgery involved repairing the damaged vessels in order to restore normal circulation to the brain.

• This procedure is called craniectomy (opening the skull in order to operate on the brain).

Surgery to treat Hydrocephalus

Surgery may be used in order to treat a complication that may occur as a result of a stroke, called hydrocephalus. This occurs due to an increase in cerebrospinal fluid pressure in the brain which manifests in headaches, nausa, vomiting, vertigo, weakness, etc.

In order to treat this, a tube is inserted into the brain in order to drain the fluid and relieve pressure from the brain.