Aspirin

This has a small beneficial effect if administered within 48 hours of onset of ischaemic stroke (Sandercock et al. 2003). It is an antiplatelet drug which reduces the ‘stickiness’ of the blood. It is given to the vast majority of people who have had an ischaemic stroke.

Thrombolysis

Recombinant tissue plasminogen activator (rt-PA) (a ‘clot-busting’ drug) is licenced for intravenous administration to patients with acute ischaemic stroke within 3 hours of onset of symptoms. It is given via a small drip placed into a vein, usually in the arm. On the basis of a recent trial, some physicians will now administer it up to 4.5 hours after onset of symptoms (Hacke et al. 2008). It significantly reduces the risk of death and disability (Wardlaw et al. 2010) by dissolving the blood clot in the artery which has caused the stroke. It is therefore not surprising that the main side effect of thrombolysis is bleeding into the brain, which occurs in about 1 in 30 patients. Overall, the net benefit of rt-PA is one more independent survivor for every 10 patients treated. Around 10–15% of all stroke patients are suitable for thrombolysis. The remaining patients will not receive thrombolysis for various reasons, e.g. time of stroke onset unknown (and so doctors cannot be sure that treatment can be administered within the narrow time window), stroke symptoms improving rapidly at the time of admission to hospital, very mild neurological symptoms, high risk of bleeding, anaemia or receiving anticoagulation with warfarin.

The sooner thrombolysis is given, the better the outcome. This is why there have been major public health campaigns to raise awareness of stroke, so that people with suspected stroke symptoms seek urgent medical attention.

Hemicraniectomy for ‘malignant middle cerebral artery territory infarction’ for ischaemic stroke

Younger patients (<65 years) with large middle cerebral artery territory infarcts are at high risk of fatal brain swelling. Surgical treatment to ‘lift’ part of the skull to provide space for brain swelling reduces mortality (Vahedi et al. 2007). Currently, very few patients require this treatment in clinical practice.

Mechanical retrieval of blood clot/intra-arterial thrombolysis for ischaemic stroke

Very small tubes, called catheters, can be inserted via an artery in the groin into the arteries in the brain, to extract blood clot. This procedure is performed under X-ray guidance by a specialist doctor called an interventional neuroradiologist. This procedure is considered if there are medical reasons why intravenous thrombolysis cannot be given, e.g. recent bleeding, recent stroke. Thrombolysis can also be administered directly into the blood clot through these intra-arterial catheters.

Specific management of haemorrhagic strokes

After haemorrhagic strokes, drugs which increase the risk of bleeding (e.g. aspirin and warfarin) will usually be discontinued for at least 1–2 weeks (Sacco et al. 2006). The effect of an anticoagulant is sometimes reversed (e.g. with vitamin K). If oral anticoagulants are considered to be essential for the long-term management of another condition (e.g. in patients with prosthetic heart valves), they may be restarted at some stage after the stroke.

Neurosurgery is very occasionally performed for haemorrhagic strokes to remove the bleeding, particularly if it has occurred in the cerebellum. Patients with aneurysmal subarachnoid haemorrhage require specialist neurological care and almost always undergo either clipping or coiling of the aneurysm to prevent further bleeding.

Stroke units for the management of both ischaemic and haemorrhagic stroke

Stroke patients who require hospital admission should be managed on a stroke unit. Organised inpatient (stroke unit) care is a term used to describe the focusing of care for stroke patients in hospital under a multidisciplinary team who specialise in stroke management (Stroke Unit Trialists Collaboration 2007). Further details of the multidisciplinary team are discussed later in this chapter.

A stroke unit may be based on a dedicated ward, with a mobile stroke team or within a generic disability service (Stroke Unit Trialists Collaboration 2007). Patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent and living at home 1 year after the stroke. This applies to both ischaemic and haemorrhagic stroke, to mild strokes and more severe strokes, and to stroke patients of all ages.

Stroke unit care is complex, dynamic and comprises a number of components (e.g. intensive interdisciplinary teamwork, responsiveness and specialist interventions), which can be difficult to pin down. This type of care is sometimes referred to as a ‘black box’.

Exactly which components of the ‘black box’ of stroke unit care are effective are not certain. Possible reasons for better outcomes in stroke units include early prescription of aspirin (Indredavik et al. 1999), better diagnostic procedures (e.g. carotid imaging and hence more rapid carotid endarterectomy), better or more focused nursing care, early mobilisation of patients, prevention of medical complications, more effective rehabilitation procedures (Langhorne and Dennis 1998), specially trained staff, team work and enhanced involvement of relatives (Indredavik et al. 1999).

Intravenous fluids

These may be required for patients who have dysphagia and who cannot swallow safely. Some patients may be dehydrated on admission, or may become dehydrated during their admission.

Feeding

Patients with acute stroke may be too drowsy to eat or drink safely, or may have dysphagia (Barer 1989). They are at risk of aspiration, i.e. breathing in foreign materials into the lungs, which can lead to inflammation and infection in the lungs. A modified texture diet (e.g. puréed food) and thickened fluids can be provided to reduce the risk of aspiration. Those at high risk of aspiration may require feeding via a nasogastric tube (a tube inserted into the stomach via the nose). Early feeding with a nasogastric tube leads to a small non-significant reduction in case fatality, though this is offset by a slight increase in the proportion of patients surviving with dependence (The FOOD Trial Collaboration 2005). If dysphagia improves over time, the nasogastric tube can be removed. If dysphagia persists, a more permanent method of artificial feeding may be required. The most common technique used is a percutaneous endoscopic gastroenterostomy (PEG) tube, inserted through the abdominal wall into the stomach.

It is unlikely that patients with PEG tubes will attend exercise programmes because these tubes are generally needed for patients with more severe strokes. Patients with modified consistency diets and/or thickened fluids may well attend exercise programmes; the exercise professional must be aware of this, so that normal consistency food or unthickened fluids are not given inappropriately during or after an exercise session.