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Diagnosis and Treatment
The First Critical Hour
If you, your friend or family member suddenly develops one or all of the following symptoms:
Face: Ask the person to smile. Does one side of the face droop?
Arms: Ask the person to raise both arms. Does one arm drift downward?
Speech: Ask the person to repeat a simple phrase. Is their speech slurred or strange?
Time: If you observe any of these signs, Call 911
The Ambulance notifies the AGH Emergency Department of the patient’s age, sex, time of stroke onset, along with an estimated arrival time to Emergency Room.
A page is sent to alert the Stroke team of the impending arrival of the stroke patient with the information obtained from the ambulance crew.
On arrival to AGH Emergency Department, the patient is assessed by the stroke team using the NIH Stroke Scale (NIHSS) (a tool used to measure the severity of the stroke). The stroke team also obtains medical history, reviews medications and completes blood work, EKG and speaks with the person who witnessed the stroke.
A CT scan of the brain is immediately performed and is read by a Board Certified Neurologist and/or Neuroradiologist.
Treatment options for acute stroke are determined by the location, severity of stroke (NIHSS score), type of stroke, and the patient’s medical history. Patients with ischemic stroke (clot in a blood vessel) are assessed to determine if they may benefit from intravenous rt-PA (clot buster). Patients may also be considered for procedures performed in Interventional Radiology where an Interventional Neuroradiologist may attempt to restore normal blood flow in the brain. Catheters are used to deliver clot busting medication directly into the clot and mechanical devices are used to remove blood clots.
A Hemorrhagic Stroke (blood vessel ruptures causing bleeding into or around the brain) can be due to high blood pressure (especially if untreated), or a brain aneurysm that bursts. Treatment will be determined by the location and severity of the hemorrhage and the bleeding site. The patient may require an urgent surgical procedure performed by neurosurgeons or a catheter-based procedure by Interventional Radiology to stop the bleeding.
If it is determined you have had a Transient Ischemic Attack (TIA), the symptoms may go away before you reach the AGH Emergency Room or shortly after (disappearing within 24 hours). This is a serious warning sign of a stroke. Up to 40% of people who have a TIA will go on to have an actual stroke. Treatment will depend on the cause of the TIA. A CT angiogram or ultrasound of the neck may be ordered to determine if there is a blockage of arteries in the neck or brain. Surgery may be required if a blockage is found. Lifestyle changes such as quitting smoking, low cholesterol diet, exercise, managing your blood pressure and/or diabetes may help reduce your risk of another TIA or stroke. Medication may be ordered to lower your cholesterol, and blood thinner such as aspirin.
It is important for you to keep a written list of all of the prescription and nonprescription (over-the-counter) medicines you are taking with dosages, as well as any products such as vitamins, minerals, or other dietary supplements.
Major Associated Treatments of Ischemic Stroke
Intravenous Recombinant Tissue Plasminogen Activator (IV tPA)
|A patient suffering from acute stroke undergoes intra-arterial stroke therapy.|
Activase was approved by the Food and Drug Administration (FDA) for the treatment of acute ischemic stroke in 1996. The drug is infused intravenously over one hour and must be initiated within three hours from onset of stroke symptoms. Well defined protocols and experience are required to rapidly identify and accurately select patients with acute stroke who are candidates for treatment. The administration of tPA for acute ischemic stroke improves the probability of having little or no residual neurologic disability by 30 percent. The complication rate of symptomatic intracerebral hemorrhage secondary to tPA is 6 percent. Despite this increased risk of bleeding there is no difference in mortality between patients treated with tPA and those who are not treated.
Stroke patients who are ineligible for treatment with IV tPA may benefit from interventional catheter- based treatments that include diagnostic cerebral angiography, carotid angioplasty/stenting, intracranial angioplasty/stenting, intra-arterial administration of thrombolytic drugs, and the use of recently FDA-approved catheter devices for mechanical embolectomy. Patients undergo urgent CT perfusion or MR perfusion imaging which are evolving imaging methods that help the stroke team to make decisions about whether a patient may benefit from intra-arterial stroke therapy. These services are provided at specialized tertiary stroke referral centers with experience in acute stroke treatments.
Carotid Angioplasty and Stenting (CAS)
Certain stroke or TIA patients who are determined to have significant stenosis (narrowing) of the carotid artery may benefit from interventional balloon angioplasty and deployment of specialized carotid stents. CAS has been demonstrated to be effective in stroke patients who are considered higher than usual risk for complications from carotid endarterectomy. Clinical trials are underway to determine the safety and benefit of CAS in stroke patients who are not at high risk of complications from carotid endarterectomy.
Carotid Endarterectomy (CEA)
CEA has been proven as an effective preventative surgical treatment for patients with stroke and TIA due to moderate/severe carotid stenosis. Carotid endarterectomy has been demonstrated to be superior to medical treatment in symptomatic patients with carotid stenosis greater than 70 percent. Select patients with symptomatic moderate-grade carotid stenosis and asymptomatic stenosis may also benefit from CEA.
Stroke Units and Organized Stroke Care
Stroke units have been shown to improve outcomes in stroke patients by providing coordinated evidence-based treatments resulting in reduced medical complications (i.e. pneumonia, deep vein thrombosis), early mobilization, improved functional outcomes, and reduced mortality. Care is provided by a dedicated multidisciplinary team including:
- Stroke neurologists and nurses
- Physical medicine and rehabilitation physicians
- Speech and swallow therapists for dysphagia evaluation and treatment
- Physical and occupational therapy for early mobilization
- Dietary professionals for nutritional assessment
- Clinical case managers