Acute management refers to treatment that reduces the damage caused by the stroke in the early phase of the illness.
Thrombolysis (clot-dissolving treatment)
An injection called Actilyse (Tissue Plasminogen Activator or tPA) needs to be given as soon as possible after the onset of a stroke to dissolve the clot blocking the artery to restore the circulation and minimise the damage caused by the stroke.
This treatment can only be used in ischaemic strokes (infarcts) and has to be given within 4.5 hours of onset. A CT scan has to be done before the injection to make sure that there is no bleeding in the brain.
There are very strict criteria to select suitable patients for the treatment. This is because there are several potentially serious side effects including major haemorrhage into the brain. In Gloucester, this treatment is available 24 hours a day, 365 days a year. The number of patients treated in this manner is rising steadily and at present about 11% of stroke patients receive this treatment in Gloucestershire. Read more about Thrombolysis.
Early use of Asprin
Research has shown that aspirin given early (within 48 hour) after an infarct (ischaemic stroke) has a small beneficial effect on the stroke. Aspirin or other antiplatelet drugs are not used in brain haemorrhages.
Monitoring of physiological parameters and supportive treatment
Physiological parameters are things like body temperature, oxygen levels, fluid balance, blood pressure and blood sugar levels which are monitored after a stroke.
It is believed that keeping these parameters as near normal as possible will improve the outcome of the stroke. Patients who develop a high temperature after a stroke have their temperatures brought down with paracetamol, cooling and antibiotics if necessary.
Saline infusions are given to prevent dehydration and oxygen is used in patients who have a low oxygen level. If the blood sugar level is very high, insulin infusions are used to bring it down.
Blood pressure levels are monitored but usually not treated for about 2 weeks after a stroke. This is because, in the early days after an ischaemic stroke, the blood flow to the brain is dependent on the blood pressure and lowering the blood pressure too much can be harmful.
Patients who are on blood pressure tablets already are asked to continue these tablets. If the blood pressure is too high, if certain complications supervene, or in patients with cerebral haemorrhages, the blood pressure may have to be lowered early after a stroke.
Feeding after a stroke
50% of stroke patients are unable to swallow on admission to hospital and 11% still have swallowing problems six months post stroke. Swallowing is tested by Speech therapists after admission to hospital.
It is important that friends or relatives should not try to feed patients or try to give them water without checking with the nurse first. Patients are sometimes kept on a drip for a few days before tube feeding is attempted.
Nasogastric tube (NG) feeding:
When some one cannot swallow it is important to ensure that he or she receives appropriate nutrition and fluids by other means so that their strength is kept up. A nasogastric feeding tube, or "NG-tube", is passed through the nose, down the oesophagus (food pipe) and into the stomach.
Problems with NG feeding include displacement of the tube and aspiration of stomach contents into the air passages and lungs. The other major problem is that many patients are unable to tolerate the NG tube.
Percutaneous endoscopic gastrostomy (PEG) tube:
This is a form of feeding tube placed endoscopically directly through the skin into the stomach. The patient is sedated, and an endoscope is passed through the mouth and oesophagus into the stomach. The position of the endoscope can be visualized on the outside of the patient's abdomen because it contains a powerful light source.
A needle is inserted through the abdomen, visualized within the stomach by the endoscope, and a suture passed through the needle is grasped by the endoscope and pulled up through the oesophagus. The suture is then tied to the end PEG tube that will be external, and pulled back down through the oesophagus, stomach, and out through abdominal wall. The insertion takes about 20 minutes.
The tube is kept within the stomach either by a balloon on its tip (which can be deflated) or by a retention dome.
A PEG tube is placed if the patient's swallowing does not return after a few weeks. It is customary to continue with NG feeding for about 3 weeks or more and then try a PEG if more prolonged feeding is needed. Inserting a PEG tube can be associated with complications and risks and the doctor will explain all the risks and benefits before obtaining the patient's consent.
The patient will have to be fit enough to undergo the procedure and not all patients are able to have it.
There are advantages and disadvantages to the different methods. It is important that feeding continues as far as possible so that the energy needed for a general sense of well-being, as well as for rehabilitation, is maintained.
Some patients, however, may be too unwell to benefit from feeding. Sometimes the patient may have complications like pneumonia or may be too drowsy or restless to tolerate feeding. Patients often pull out NG tubes very frequently making feeding almost impossible. The circumstances of each patient are different and methods of feeding have to be chosen carefully. Some patients may chose to refuse feeding or other medical intervention.
Bleeding into the brain due to a burst blood vessel can sometimes be treated by an operation to evacuate the blood in the brain. This form of treatment is applicable to a very small proportion of haemorrhages and the decision to operate is made by specialist neurosurgeons. The patient may need to travel to a neurosurgical centre if surgery is needed.