Someone’s had a Stroke – what now?
Someone you know has had a Stroke.
This is a very frightening and confusing time for all involved: the person (who is now called the patient), their partner (who is now called their carer), their family and friends.
Depending on the severity of the Stroke there are many different things that can happen. The initial effects of the Stroke can range from mild disability through to severe disability and in the worst-case scenario even death.
Initially the person will be seen by the staff in Accident and Emergency and undergo a number of medical tests to establish the fact that they have had a Stroke.
It is important to determine whether they have had a Haemorrhagic Stroke, or Ischaemic Stroke, as medical treatment for these are quite different (See What is a Stroke?) The hospital may ask all types of questions and want information, but none of this will make much sense. You may not take in all of what is occurring, as you will be in a state of shock and anxiety.
“NO TWO STROKES ARE THE SAME”
Remember if the heart is the pump for your body the brain is the computer that controls all you do. It depends which part of the brain is affected as to what deficits or complications will occur. Therefore, damage to the brain in every Stroke will be different.
It is difficult to provide definite answers about expected progress at any stage of recovery. Medical tests will have been done and the results, particularly in the initial period, are not always conclusive. No one wants to take away hope or give unrealistic expectations. As the individual’s Stroke is assessed, it must be remembered that each person’s outcome and potential for recovery varies.
Stroke units Back to top
A Stroke is a medical emergency and rapid access to treatment and care from a specialised team of health professionals is vital. A Stroke Unit is a specialised area in an Acute Hospital setting, similar to that of a Cardiac Unit. The Stroke Unit brings together the specialist doctors, nurses and allied health professionals required to effectively diagnose, treat and rehabilitate the Stroke affected person.
Stroke Units are located in an ever-increasing number of NSW hospitals. They consist of at least 4 specialised beds in a specific area of a ward (or high dependency Unit). Patients have access to the specialised staff mentioned above as well as specialised technology required to be certain that a patient’s Stroke is diagnosed and treated correctly. This to ensure they survive the initial impact of the Stroke.
Every Stroke patient is treated individually and the care depends entirely on the severity and type of Stroke they have had.
Generally treatment for Stroke is divided into three distinct stages of care:
Stage One – Hospitalisation in an Acute Hospital or Stroke Unit. This will last about 10-14 days. This is high dependency care and the patient will only be discharged from this area when they have been medically stabilised.
During this stage the patient and the family will be going through a lot of emotional turmoil and grief. Will the patient live or die? Will they be able to return home? How will the family cope with someone who is disabled? What are the chances of another Stroke? Will they be able to manage financially?
It is important that a hospital Social Worker assists the family through this stage and the family can also contact the Stroke Recovery Association for user-friendly information and counselling.
Stage Two – Rehabilitation is ongoing care and treatment in a ward or hospital, which specialises in returning the Stroke affected person to maximum functioning. This period can last from 14 days to 6 weeks to 6 months. The length of stay is very much dependent on the progress of the patient and the severity of the Stroke. This will generally be reviewed on a weekly or fortnightly basis by the treatment team. It is a long process and exercise should continue when the person returns home.
During this stage the person may become depressed. Their life has altered so completely and they are unable to do what they used to do. Families might find that it is an effort to motivate them to do anything. They may have fears, and altered feelings about themselves, as well as losses in social activities. The person may see little purpose in living and express thoughts of death. (See Psychological Effects)
Stage Three – Discharge. This will happen once the person has been assessed by the medical team. Their stay in the Rehabilitation Centre will depend primarily on how they progress with their recovery. Staff will meet with them and their family at regular intervals to discuss discharge options. Their stay may be longer or shorter than the average, as everyone makes progress at his or her own pace. (See Going Home-What Now?) People affected by Stroke often find that all they want to do is return home. This is a wonderful time for the whole family, but the carer needs to be able to ask the family for assistance once the reality of coping has sunk in. The carer will be on 24-hour duty and will need some time to her or himself. It is important if possible, to ensure that the work does not just fall on one person.
Medical Tests Back to top
Tests are performed to determine the type, location, and cause of the Stroke and to rule out other disorders that may be responsible for the symptoms. There have been enormous breakthoughs over recent years in Stroke and medical tests will begin as soon as you arrive at the hospital in order to determine the most appropriate treatment.
It is important to speak with your Doctor to understand what tests are being conducted and to enquire about the results. The Medical team will determine what tests are required depending on the presenting symptoms and the condition of the patient. These are some of the tests which may be undertaken:
CT or CAT Scan: This is an X-ray imaging test done on the brain. It is used to determine if the Stroke was caused by bleeding (Haemorrhage) or a blockage (Ischaemic). They give the medical team a visual picture of the brain and they may use it to define the location and extent of the Stroke.
MRI (Magnetic Resonance Imaging) Scan: This is another imaging test which gives the medical team a very accurate and detailed picture of the brain. These are used to determine the presence, location and size of aneurysms and arteriovenous malformations, which are potential sources for Haemorrhagic Stroke. The patient is placed in a magnetic field, then the head is subjected to bursts of energy of a known frequency. The response of the brain cells to these bursts of energy is detected as signals that ultimately generate an image of the brain.
ECG (Electrocardiogram): This is used to check the electrical activity of the heart. It is used to check if your heartbeat is regular and is used to diagnose any heart conditions that may be linked to the Stroke.
Echocardiogram: This is a test that uses sound waves to create a moving picture of the heart. It is used in Stroke to determine if the Stroke may have been caused by a blood clot from the heart.
Carotid duplex: This is a procedure that uses ultrasound to look at the blood flow in the Carotid artery of your neck. It is used to check if there are any abnormalities in the blood flow, which may be caused by blood clots or other matter blocking the artery.
Heart Monitor: This is a device attached to your body to determine if a heart arrhythmia (such as Atrial fibrillation) may be responsible for your Stroke.
Blood work: This may be done to exclude immune conditions or abnormal clotting of the blood that can lead to clot formation. Blood tests, such as a complete blood count (CBC), blood sugar, electrolytes, liver and kidney function, and prothrombin time, a test that measures how long it takes your blood to clot, may be carried out. These tests are done to help your doctor make choices about your treatment and to check for conditions that may cause symptoms similar to Stroke.
For more information go to: www.nlm.nih.gov/medlineplus/ency/article/003799.htm
Treatment Back to top
A Stroke is a medical emergency. It is a life threatening situation
with a percentage of Strokes being fatal. Immediate treatment can save lives and reduce disability. Treatment varies, depending on the severity and cause of the Stroke. All Strokes require medical treatment. For the vast majority of Strokes hospitalisation is required, possibly including intensive care and life support.
Stroke treatment is changing with medical advancement occurring all the time. It is important, if a Stroke is suspected, to take the person to the emergency room immediately. Medical tests will be undertaken to determine if he or she is having a bleeding Stroke or a Stroke from a blood clot. Once the type and severity of the Stroke has been established by the Medical team, treament can begin.
The Hospital Stroke team will determine the most appropriate form of treatment and care for you based on the results of the medical tests they have undertaken. This may include:
- Stroke Unit or Hospital Care (Go to http://www.strokefoundation.com.au/stroke-care-units)
- Rehabilitation (See: Rehabilitation)
tPA (tissue plasminogen activator)
This is a relatively new treament for Stroke and is administered under very strict guidelines as to who is eligible to receive thrombolytic medicine. The most important thing is that the person be evaluated and treated by a specialised Stroke team within 3 hours of the start of the symptoms.
Thrombolytic medicine, tPA, breaks up blood clots and can restore blood flow to the damaged area. Research has indicated that people who receive this medicine are more likely to have less long-term impairment.
If the Stroke is caused by bleeding (Haemorrhagic) rather than clotting (Ischaemic), this treatment can make the damage worse – so care is needed to diagnose the cause of the Stroke.
Blood thinners such as heparin and coumadin are used to treat Strokes. Aspirin and other anti-platelet agents may be used as well.
Other medications may be needed to control associated symptoms.
- Analgesics (pain killers) may be needed to control severe headache.
- Anti-hypertensive medication may be needed to control high blood pressure.
- Nutrients and fluids may be necessary, especially if the person has swallowing difficulties. The nutrients and fluids may be given
through an intravenous tube (IV) or a feeding tube in the stomach. Swallowing difficulties may be temporary or permanent.
For Haemorrhagic Stroke, surgery is often required to remove pooled blood from the brain and to repair damaged blood vessels.
Life support and coma treatment are performed as needed.
When the carotid artery in the neck is partially blocked by a fatty build-up, called plaque, surgery called carotid endarterectomy might be used to remove the accumulated plaque.
Cerebral angioplasty is another technique in which balloons, stents and coils are inserted to treat some problems within the brain’s blood vessels. Its use depends on its safety and effectiveness.
The treatment for Haemorrhagic Stroke is quite different to Ischaemic Stroke:
- For small bleeds, they are often watched and allowed to heal on their own.
- In the case of a large bleed or if the Stroke extends or appears to be getting worse, surgery may be done to ‘decompress’ the brain
release the blood which has built up, causing swelling. This takes up space in your brain squeezing it against the skull. Surgery
is undertaken to drain or remove blood in or around the brain that was caused by a bleeding blood vessel.
- A Haemorrhagic Stroke may be caused by a brain aneurysm. If this occurs a surgeon may perform endovascular coil embolisation to repair the weak artery. A small coil is inserted into the aneurysm to block it off. The location of the aneurysm, its size and your general health are used to determine if the surgery can be performed.
- An arteriovenous malformation is a congenital disorder that causes an abnormal web of blood vessels and veins in the brain, brain stem, or spinal cord. The vessel walls of an arteriovenous malformation may become weak and leak or rupture. Surgery may repair abnormally formed blood vessels (arteriovenous malformations) that have caused bleeding in the brain.
After a Stroke Back to top
People of any age can have a Stroke and every Stroke is different.
The impact of a Stroke is far-reaching and may have an effect upon each member of a family.
After the acute phase of a Stroke is over, many people experience frustration and frequently suffer from depression, anger, resentment and a sense of powerlessness. Fatigue is also common. As the person who has had the Stroke enters the phase of rehabilitation, just how much recovery they will achieve cannot be accurately predicted. Recovery is often a long term process.
Before Leaving Hospital
Before the person who has had a Stroke is discharged from hospital it may be a good idea to talk to the hospital staff regarding Discharge Planning. This may include:
- Talking to the doctor about what happens when the person gets home. Should they see a regular doctor or a specialist? How often should they see the doctor? What progress should be expected?
- Having a Family Conference with the Doctor, Social Worker, Physiotherapist, Speech Pathologist and Occupational Therapist to decide what services and resources will be needed when the person gets home. If possible, speak to all of the above at the same time.
- Find out if the hospital offers Outpatient Services for Physiotherapy, Speech Pathology or Occupational Therapy.
- Include the whole family, so everyone is aware of what happens when the person gets home.
- Telephone the Stroke Association of NSW to get their free Stroke Information Kit or print the Information Sheets from this website.
- REMEMBER – try to continue physical exercises and speech practice when the person returns home. The more you do the better it is for you.