Emergency Treatment of Ischemic and Hemorrhagic Stroke: Guidelines

An acute stroke is a medical emergency arising due to partial or complete loss of blood supply to a part of the brain.

And whether ischemic or hemorrhagic, it should be treated as such – as an emergency.

The primary and immediate aim for the acute management of stroke patients is to stabilize the patient and to complete the diagnostic assessment, which includes laboratory and imaging tests, within the first 60 minutes of the patient’s arrival to the hospital.

Critical decisions can then be taken on the need for intubation, control of blood pressure, and determination of the patient’s eligibility for thrombolytic intervention.

In ischemic stroke, prognosis significantly improves if Alteplase IV r-tPA is administered within 3 hours after the onset of the symptoms, though it is best to use it within 90 minutes of the onset. This period can be extended in some patients to 4.5 hours.

Similarly, the emergency aid for a hemorrhagic stroke is explained below.

About 80 percent of the strokes are ischemic and only 20 percent are due to a hemorrhagic cause.

Ischemic strokes occur due to the partial or complete blockage of an artery in the brain disrupting the blood supply to the brain tissue distal to the blockage.

Hemorrhagic stroke occurs due to the rupture of an artery in the brain leading to bleeding in the brain and disrupting the blood supply to the brain tissue.

Why is time of essence in starting treatment?

Damage to the brain occurs rapidly and time is of the essence in delivering treatment for recovery in both types of stroke.

Two million brain cells die every minute during a stroke. This greatly increases the risk of irreversible brain damage, permanent disability, or death.

These ischemic changes caused by the stroke begin within seconds to minutes of the loss of oxygen and nutrients to the neurons (brain cells).

Prompt treatment vastly improves the chances of recovery and prognosis and minimizes the effects of the long-term complications.

Since the etiology of both the strokes differs, the management and treatments are different.

But, one thing is common and that is, the stroke patient is taken from the emergency directly to the stroke unit or the ICU to immediately commence treatment.

Immediate aim of stroke treatment

The main aim of the aggressive management of an acute stroke is:

  1. Stabilize the patient – meaning stabilize his vital signs (e.g. blood pressure, heart rate, etc.)
  2. Evaluate risk factors if possible
  3. Evaluate and assess the stroke. This is done through imaging studies and laboratory tests.

All this should be done ideally within 60 minutes after the patient has entered the facility.

Once the above studies have been completed, the doctor will decide on how to control the blood pressure in case of a hemorrhagic stroke or the risk/benefits of thrombolytic intervention in case of thrombotic stroke. The doctor will also decide whether the patient needs to be intubated.

Hypoglycemia, if present should be corrected with IV glucose and hyperglycemia if present should be treated with insulin. This is necessary. Both these conditions can mimic a stroke and can also aggravate the neural ischemia.

Fever, if present should be accordingly treated with acetaminophen.

Most stroke patients are hypertensive and blood pressure should be cautiously lowered to normal levels.

How is ischemic stroke treated?

The purpose of treating ischemic stroke is to dissolve or remove the clot that has obstructed the artery and restore blood flow to the affected brain tissue.

This is done either with the help of drugs or by mechanical means.

Treatment with drugs

Drugs to treat ischemic stroke are called clot-busters. They work mainly by dissolving the blood clots and opening up the occluded arterial lumen.

Aspirin

Aspirin is given immediately because it prevents further blood clots from forming and giving rise to another stroke. It is also indicated in heart risk patients to prevent myocardial infarction (MI).

Prescribing the right amount of aspirin dose carries much importance in view of its risky side effects.

According to the National Institute of Health, studies indicate that the most appropriate dose for the primary and secondary prevention of stroke and MI is 160 mg/day.

Tissue plasminogen activator (tPA)

tPA also called alteplase, is a very potent clot-busting medicine approved by the U.S. FDA for use in thrombolytic therapy. It comes in the form of an injection, which is given intravenously (into the vein of the arm).

Alteplase IV r-tPA is indicated when the ischemic stroke patient presents within 3 hours after the onset of the symptoms, though it is best to use it within 90 minutes of the onset. However, the 3 hour time window can be extended to 4.5 hours in some cases.

tPA acts by dissolving the clot that has occluded the artery and opening up the lumen of the artery, thereby restoring blood supply to the affected part of the brain.

As mentioned above, there is a time limit prescribed for the use of this clot-busting medication. Its timely use can save you from permanent disability and death. Studies have shown that tPA can reduce disability from stroke by about 30%

That is why it is so important to diagnose a stroke through its symptoms and signs and investigations and on slight suspicion, start treatment immediately.

Mechanical intervention

This procedure involves physical removal of a large blood clot from an artery in the brain. It is an endovascular procedure called mechanical thrombectomy and is performed in stroke patients who are eligible and fit certain criteria.

Trained doctors use a catheter to insert a wire-cage device called a stent retriever to remove a large blood clot. This procedure breaks the clot or physically removes it.

This procedure has to be performed within six hours of the onset of the symptoms and after the patient has been given intravenous tPA.

Doctors may also insert a catheter and inject tPA directly at the site of the clot, which has caused the stroke. This offers a slightly longer but limited window period than the treating with IV tPA.

Treatment of hemorrhagic stroke

A hemorrhagic stroke, also referred to as intracerebral stroke (ICH), is caused by the rupture of an artery in the brain. This leads to leakage of blood into the brain and an interruption of blood supply to the brain tissue distal to the site of the rupture.

This is a dire emergency and most experts agree that emergency treatment should be initiated rapidly as compared to ischemic stroke.

According to the National Stroke Association, about 17% of the strokes are due to hemorrhage, but they account for more than 30 percent of all deaths due to stroke.

Treatment options depend on the cause of the hemorrhagic stroke.

It could be high blood pressure, use of anticoagulant medications (blood thinners), head injury, or blood vessel malformation

The stroke patient after initial evaluation and treatment in the emergency is taken straight to the stroke unit or the intensive care unit (ICU) and monitored closely.

In the emergency, great emphasis is laid on first finding out the cause of the brain hemorrhage.

Basic life support measures are initiated. Controlling the intracerebral bleeding, preventing or treating the seizures, and reducing intracranial pressure are primary essential measures that are critical.

Guidelines

  • Management of the patient begins with stabilization of the vital signs.
  • Endotracheal intubation is required for those with a decreased level of consciousness or cannot maintain their airway, cannot breathe on their own without assistance, or both.
  • An urgent computed tomography (CT) scan is asked for
  • Blood sugar is checked and normalized it if raised.
  • Removal of hematoma through an open craniotomy will improve long-term prognosis.
  • Use of antihypertensive drugs to control the blood pressure if raised
  • Use of anticonvulsants to prevent seizure Benzodiazepines, such as lorazepam or diazepam, can be used for rapid seizure control
  • Stopping any medication that could increase bleeding (e.g., blood thinners such as warfarin, aspirin) and infusing blood clotting factors to stop bleeding if blood thinners are the cause.
  • Spinal tap helps to measure the intracranial pressure of the cerebrospinal fluid. If raised, controlling the intracranial pressure with the use of osmotic diuretics

Surgical treatment

Surgical intervention may be required to repair a ruptured artery and stop bleeding.

If the stroke is caused by an arteriovenous malformation (AVM), surgery may be required to repair the malformation.

Surgery may also be required to normalize the raised intracranial pressure. The raised pressure could be due to intracranial hematoma or cerebral edema.

Stroke recovery stats

  • 10% of stroke survivors recover almost completely
  • 25% recover with minor disability
  • 40% experience moderate to severe impairments
  • 10% require long-term care in a nursing home or other facility
  • 15% die soon after the stroke
468