Diagnostic Tests and Treatment
Signs and Tests
In diagnosing a stroke, knowing how the symptoms developed is important. The symptoms may be severe at the beginning of the stroke, or they may progress or fluctuate for the first day or two (stroke in evolution). Once there is no further deterioration, the stroke is considered completed.
During the exam, your doctor will look for specific neurologic, motor, and sensory deficits. These often correspond closely to the location of the injury in the brain. An examination may show changes in vision or visual fields, abnormal reflexes, abnormal eye movements, muscle weakness, decreased sensation, and other changes. A "bruit" (an abnormal sound heard with the stethoscope) may be heard over the carotid arteries of the neck. There may be signs of atrial fibrillation.
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. These tests include:
- Head CT or Head MRI - used to determine if the stroke was caused by bleeding (hemorrhage) or other lesions and to define the location and extent of the stroke.
- ECG (electrocardiogram) - used to diagnose underlying heart disorders.
- Echocardiogram -- used if the cause may be an embolus (blood clot) from the heart.
- Carotid duplex (a type of ultrasound) - used if the cause may be carotid artery stenosis (narrowing of the major blood vessels supplying blood to the brain).
- Heart Monitor - worn while in the hospital or as an outpatient to determine if a heart arrhythmia (like atrial fibrillation) may be responsible for your stroke.
- Cerebral (head) Angiography - may be done so that the doctor can identify the blood vessel responsible for the stroke. Mainly used if surgery is being considered.
- Blood work may be done to exclude immune conditions or abnormal clotting of the blood that can lead to clot formation.
A stroke is a medical emergency. Physicians have begun to call it a "brain attack" to stress that getting treatment immediately can save lives and reduce disability. Treatment varies, depending on the severity and cause of the stroke. For virtually all strokes, hospitalization is required, possibly including intensive care and life support.
The goal is to get the person to the emergency room immediately, determine if he or she is having a bleeding stroke or a stroke from a blood clot, and start therapy -- all within three hours of when the stroke began.
Thrombolytic medicine, such as tPA, breaks up blood clots and can restore blood flow to the damaged area. People who receive this medicine are more likely to have less long-term impairment. However, there are strict criteria for who can receive thrombolytics. The most important is that the person be examined and treated by a specialized stroke team within three hours of when the symptoms start. If the stroke is caused by bleeding rather than clotting, this treatment can make the damage worse, so care is needed to diagnose the cause before giving treatment.
In other circumstances, blood thinners such as heparin and Coumadin are used to treat strokes. Aspirin may also be used. Other medications may be needed to control associated symptoms. Pain killers may be needed to control severe headache. Medicine 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 (gastrostomy tube ). Swallowing difficulties may be temporary or permanent.
For hemorrhagic stroke, surgery is often required to remove pooled blood from the brain and to repair damaged blood vessels.
The goal of long-term treatment is to recover as much function as possible and prevent future strokes. Depending on the symptoms, rehabilitation includes speech therapy, occupational therapy, and physical therapy. The recovery time differs from person to person.
Certain therapies, such as repositioning and range-of-motion exercises, are intended to prevent complications related to stroke, like infections and bed sores. People should stay active within their physical limitations. Sometimes, urinary catheterization or bladder/bowel control programs may be needed to control incontinence.
The person's safety must be considered. Some people with stroke appear to have no awareness of their surroundings on the affected side. Others show indifference or lack of judgment, which increases the need for safety precautions. For these people, friends and family members should repeatedly reinforce important information, like name, age, date, time, and where they live, to help the person stay oriented.
Caregivers may need to show the person pictures, repeatedly demonstrate how to perform tasks, or use other communication strategies, depending on the type and extent of the language problems.
In-home care, boarding homes, adult day care, or convalescent homes may be required to provide a safe environment, control aggressive or agitated behavior, and meet medical needs. Behavior modification may be helpful for some people in controlling unacceptable or dangerous behaviors.
Family counseling may help in coping with the changes required for home care. Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may be helpful. Legal advice may be appropriate. Advance directives, power of attorney , and other legal actions may make it easier to make ethical decisions regarding the care of a person who has had a stroke.
The long-term outcome from a stroke depends on the extent of damage to the brain, the presence of any associated medical problems, and the likelihood of recurring strokes.
Of those who survive a stroke, many have long-term disabilities, but about 10 percent of those who have had a stroke recover most or all function. Fifty percent are able to be at home with medical assistance while 40 percent become residents of a long-term care facility like a nursing home.
- Problems due to loss of mobility (joint contractures, pressure sores)
- Permanent loss of movement or sensation of a part of the body
- Bone fractures
- Muscle spasticity
- Permanent loss of brain functions
- Reduced communication or social interaction
- Reduced ability to function or care for self
- Decreased life span
- Side effects of medications