How Stroke Is Treated
Stroke treatment is about halting the potential problems that a stroke can cause before the damage is done.
Overall, the key to stroke treatment lies in catching a stroke as early as possible, right after symptoms begin. Only highly trained emergency medical teams can administer stroke treatment due to the subtle signs and variations of stroke.
Blood thinners are given when a stroke is still in progress. When it is clear that a blood vessel is partially or completely obstructed, blood thinners can help prevent a stroke from developing by allowing some blood to flow, which is crucial to preventing or minimizing brain injury.
Blood thinners must be given by a trained medical team because potential side effects include bleeding in the brain, gastrointestinal system, or other areas of the body.
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 a hemorrhagic stroke, your stroke care team works quickly to identify any bleeding in the brain before deciding on whether you are a candidate for any of the following blood thinners.
In the case of ischemic stroke, a blood thinner may be administered with great care to avoid creating a hemorrhagic transformation of the stroke.
Tissue Plasminogen Activator
Tissue plasminogen activator (TPA) is a potent blood thinner that is administered intravenously for selected cases of acute progressive stroke. It goes by the name Activase (alteplase).
TPA can only be given when a well-trained medical team is ready to evaluate a stroke within the first few hours of stroke onset. Intravenous TPA administration has shown the most benefit when administered within the first three hours of the initial stroke symptoms.1
However, some research suggests TPA can be of help when used up to four and a half hours after symptoms start. If it is unclear when your stroke symptoms began, then intravenous TPA is not recommended.
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.
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 you have a stroke, you do have the right to refuse treatment with TPA. But, it is important to know that stroke teams do not casually administer this potent medication, and they rely on safety guidelines that have been developed to maximize stroke recovery and safety. 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.
TPA can also be injected directly into the artery where a stroke-causing blood clot is located 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 is a medication that you can receive intravenously. IV heparin can be used if you have an acute stroke if certain conditions are met.
These conditions include:
- A blood clot is believed to be newly formed
- Stroke symptoms are present (new onset)
- A brain hemorrhage has been ruled out
Heparin is not recommended if you have a risk of gastrointestinal bleeding or bleeding from a surgical or traumatic wound.
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 in your carotid artery.
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 48 hours of an ischemic stroke’s start to prevent further events.1
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 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 also meticulously watches the correlation between your neurological condition and your blood pressure as a means to determine and manage your best blood pressure in the days after your stroke.
Blood sugar levels can become erratic as a response to an acute stroke. Adding to this problem, in the days after a major stroke, you would be unlikely to want to eat as you regularly do.
Elevated or low blood sugar levels can interfere with healing after a stroke. That is why your stroke care team devotes consistent attention to stabilizing your blood sugar levels during this time.
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 by removing a portion of the skull (see craniectomy below.)
IV hydration in the setting of an illness 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.5
Nerves that require the right amount of electrolytes 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.
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.
Some strokes are hemorrhagic strokes, meaning that there is bleeding in the brain. Most bleeding from hemorrhagic strokes is not easily removed from the brain. Yet, sometimes, when a significant amount of blood is concentrated in a certain location, it is best if the blood is removed through surgery.
If you need brain surgery after a stroke, you or your loved ones will be given time to carefully consider this option, and you will be informed of the risks and benefits of the procedure.
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 skull is preserved and then re-planted within a short period of time, as the skull is an important component of brain protection for the long term.
In the aftermath of a stroke, most patients undergo physical and occupational therapy 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.
Rehabilitation is the best and most reliably effective method of promoting healing and recovery after a stroke.
If you or a loved one has recently had a stroke, the decisions about your stroke care can seem overwhelming. The good news is that stroke management has been carefully studied, and the medical community has been developing the most effective protocols for the best outcomes.
Often, changes in your neurological functioning can be subtle in the hours and days after a stroke. This means that your medical team will need to examine you frequently and repeatedly.
While these periodic neurological examinations may seem tedious and tiring at a time when all you really want to do is rest (or help your loved one rest and recover comfortably), your neurological examinations are crucial in guiding the safest and most effective treatment in the delicate days following an acute stroke.
Your medical team is available to explain the rationale behind all of the stroke treatment options, and they will ask for your final decision regarding major treatment issues. Gathering information and learning about stroke is the best way to take advantage of the resources available to you on your path to recovery.
- Prasad K, Kaul S, Padma MV, Gorthi SP, Khurana D, Bakshi A. Stroke management. Ann Indian Acad Neurol. 2011;14(Suppl 1):S82-96. doi:10.4103/0972-2327.83084
- Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11-20. doi:10.1056/NEJMoa1411587
- Gray CS, Hildreth AJ, Sandercock PA, et al. Glucose-potassium-insulin infusions in the management of post-stroke hyperglycaemia: the UK Glucose Insulin in Stroke Trial (GIST-UK). Lancet Neurol. 2007;6(5):397-406. doi:10.1016/S1474-4422(07)70080-7
- Wijdicks EF, Sheth KN, Carter BS, et al. Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(4):1222-38. doi:10.1161/01.str.0000441965.15164.d6
- Van der jagt M. Fluid management of the neurological patient: a concise review. Crit Care. 2016;20(1):126. doi:10.1186/s13054-016-1309-2
- Wang WH, Hung YC, Hsu SP, et al. Endoscopic hematoma evacuation in patients with spontaneous supratentorial intracerebral hemorrhage. J Chin Med Assoc. 2015;78(2):101-7. doi:10.1016/j.jcma.2014.08.013
- Demaerschalk BM. Alteplase Treatment in Acute Stroke: Incorporating Food and Drug Administration Prescribing Information into Existing Acute Stroke Management Guide. Curr Atheroscler Rep. 2016;18(8):53. doi: 10.1007/s11883-016-0602-5.
- Oostema JA, Carle T, Talia N, Reeves M. Dispatcher Stroke Recognition Using a Stroke Screening Tool: A Systematic Review. Cerebrovasc Dis. 2016;42(5-6):370-377. doi: 10.1159/000447459
- Powers WJ, Rabinstein AA, Ackerson T, et al; American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46-e110. doi: 10.1161/STR.0000000000000158.