Drug therapy is a relatively recent approach to the treatment of stroke, and a tremendous amount of research is under way to find effective new drugs that can minimize stroke damage.

Emergency Treatment of Stroke

Much of the damage caused by a thrombotic or embolic stroke occurs in the first six hours. The primary areas of research have focused on the development of new clot-dissolving drugs and medications that make the brain more resistant to stroke (neuroprotective agents).

Drugs that dissolve clots are known as thrombolytic agents. Experimental data and pilot clinical studies suggest that if given within the first few hours after stroke onset, these drugs may dramatically minimize stroke damage.

• Thrombolytic Agents (tissue plasminogen activator [tPA]), widely used to dissolve clots that cause heart attacks, are also effective for dissolving artery-blocking clots in the brain during the critical early stages of stroke. Early administration of tPA after a stroke can reduce neurological damage significantly.
• Neuroprotective Agents – Medications that make the brain less susceptible to the damaging effects of a stroke are called neuroprotective agents.

Stroke Medication

A number of medications that help prevent stroke in high-risk patients, particularly those who have had a previous TIA or minor stroke, are under investigation. These drugs fall into two major categories: anticoagulants (such as warfarin or ximelgatran) and antiplatelet agents (such as aspirin, dipyridamole and clopidogrel).

• Anticoagulants may be given orally or intravenously. These drugs work by thinning the blood and preventing clotting. They are also used for treatment and prevention of deep vein thromboses and pulmonary emboli.
• Antiplatelet Agents work by preventing or reducing the occurrence in the blood-stream of a phenomenon known as platelet aggregation. When there is damage or injury to a blood vessel, platelets (one type of blood particle) migrate to the scene to initiate a healing process. Large numbers of platelets clump together (aggregation) and form what is essentially a plug. This aggregation can sometimes result in formation of a thrombus (blood clot) that may totally block the artery or break loose and block a smaller artery. By preventing this from occurring, antiplatelet agents can reduce the risk of stroke in patients who have had TIAs or prior ischemic strokes. Studies are under way to determine the most effective ways to administer these agents.

Strokes are usually diagnosed by studying images of the brain (brain imaging). This can also be helpful in determining the risk of a transient ischaemic attack (TIA).

Even if the physical symptoms of a stroke are obvious, brain imaging should be carried out to determine:

• if the stroke has been caused by a blocked artery or a burst blood vessel
• which part of the brain has been affected
• how severe the stroke is

Different treatment is required for each type of stroke so a rapid diagnosis will make treatment more straightforward.

Exams and Tests

Time is critical when diagnosing a stroke. A quick diagnosis-the sooner, the better-may enable your doctor to use medicines that can lead to a better recovery.

The first priority will be to determine whether you are having an ischemic or hemorrhagic stroke. This distinction is critical because the medicine given for an ischemic stroke (caused by a blood clot) could be life-threatening if the stroke is hemorrhagic (caused by bleeding). Your doctor will also want to rule out other conditions that have symptoms similar to a stroke and to check for complications.

The first test after a stroke is typically a computed tomography (CT) scan of the brain, which is a series of X-rays of your brain that can show whether there is bleeding. This test will help your doctor diagnose whether the stroke is ischemic or hemorrhagic. Magnetic resonance imaging (MRI) may also be done to find out the amount of damage to the brain and help predict recovery.

Other initial tests recommended for ischemic stroke include:

• Electrocardiogram (ECG, EKG) to check for heart problems, including arrhythmias and atrial fibrillation.
• 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). These tests are done to help your doctor make choices about your treatment and to check for conditions that may cause symptoms similar to a stroke.

If your doctor suspects or if other tests show narrowing of a carotid artery, he or she may want you to have a carotid ultrasound/Doppler scan to evaluate blood flow through the artery. Your doctor may also request magnetic resonance angiogram (MRA), CT angiogram, or carotid angiogram.

If your doctor believes the stroke may have been caused by a problem with your heart, an echocardiogram or Holter monitoring or telemetry test may be done.

Guidelines recommend that risk factors for heart disease also be assessed after a stroke to prevent disability or death from a future heart problem. This is because many people who have had a stroke also have coronary artery disease.

A stroke is caused by an interruption in the flow of blood to the brain. The two main reasons that this blood flow stops are:

• A narrowing, hardening, or weakening of blood vessels
• A thickening or clot of the blood

Narrowing of the arteries is usually the result of fatty deposits that have built up on the artery walls. The narrowed diameter of blood vessels mean that the blood flow to major organs such as the brain is constricted. If one of these fatty deposits (also called plaques) breaks off, the artery wall, a blood clot forms where the plaque has detached. If it is big enough, this clot blocks the artery causing the blood supply to the brain be cut off.

People who have pre-existing medical conditions that affect blood circulation, such as high blood pressure (hypertension), diabetes, carotid artery disease, or heart disease, have an increased risk of having a stroke.In addition, if you’ve had a stroke or mini-stroke before you’re more likely to experience another.

Besides pre-existing medical conditions, lifestyle and genetic factors play a role in whether you’re at risk of a stroke or not.

Ischaemic Strokes

Ischaemic strokes occur when blood clots block the flow of blood to the brain. Blood clots typically form in areas where the arteries have been narrowed or blocked by fatty cholesterol-containing deposits known as plaques. This narrowing of the arteries is caused by atherosclerosis.

Haemorrhagic strokes

Haemorrhagic strokes (also known as cerebral haemorrhages or intracranial haemorrhages) usually occur when a blood vessel in the brain bursts and bleeds into the substance of the brain (intracerebral haemorrhage). In about 5% of cases, the bleeding occurs on the surface of the brain (subarachnoid haemorrhage).

Fixed risk factors

These are genetic risk factors that cannot be changed, and include:

• Sex: Men are more likely to have strokes than women
• Age: Strokes are more common after the age of sixty-five, with the risk continuing to rise with further aging
• Family history: If you have a close relative who has had a stroke your risk of having one yourself is increased
• Ethnic background: People from certain ethnic backgrounds including Asian, African, and African-Caribbean communities are at a greater risk of a stroke

Variable risk factors

These are lifestyle factors that can be changed, and include:

• Smoking: Chemicals in tobacco can damage your arteries; damaging blood vessel walls and also causing blood pressure to increase
• Obesity: Carrying extra weight can place strain on your heart, arteries, and circulation
• A poor diet: You should eat a balanced diet low in salt and saturated fats
• Being inactive: If able, you should engage in regular physical exercise to increase your heart capacity and stimulate circulation
• Excessive consumption of alcohol: You should aim to drink in moderation and should avoid binge drinking

In some cases, strokes happen to people without any obvious risk factors being present.

If you or someone you know experiences any of the warning signs listed below, it is extremely important to seek emergency help right away. Call 999 (UK) or 911 (USA) immediately even if you think that you are getting better or if the symptoms seem to disappear.

If the symptoms last for more than 10 to 15 minutes, appear frequently or seem to get worse, ask the emergency responders for urgent transportation to the nearest appropriate emergency medical facility.

Unfortunately, patients often do not seek help for a day or more after the first symptoms appear. By that time, it is usually too late for new treatments to be effective. Recognizing and responding to the warning signs of stroke – as soon as they appear – gives the patient the best chance for an optimal recovery.

Even if the symptoms of a stroke disappear while you are waiting for the ambulance to arrive, you or the person having the stroke should still go to hospital for an assessment. Symptoms that disappear may mean you have had a transient ischaemic attack (TIA) and you could be at risk of having a full stroke at a later stage.

After an initial assessment, you may need to be admitted to hospital to receive a more in-depth assessment and, if necessary, for specialist treatment to begin.

Recognising the Signs and Symptoms of a Stroke

The signs and symptoms of a stroke vary from person to person but they usually begin suddenly. As different parts of your brain control different parts of your body, your symptoms will depend upon the part of your brain that has been affected and the extent of the damage.

The main stroke symptoms can be remembered with the word FAST: Face-Arms-Speech-Time.

• Face: the face may have dropped on one side, the person may not be able to smile or their mouth or eye may have drooped
• Arms: the person with suspected stroke may not be able to lift one or both arms and keep them there because of arm weakness or numbness
• Speech: their speech may be slurred or garbled, or the person may not be able to talk at all despite appearing to be awake
• Time: it is time to dial 999 immediately if you see any of these signs or symptoms

It is important for everyone to be aware of these signs and symptoms. If you live with or care for somebody in a high-risk group, such as someone who is elderly or has diabetes or high blood pressure, being aware of the symptoms is even more important.

Symptoms in the FAST test identify about nine out of 10 strokes.

Other signs and symptoms may include:

• numbness or weakness resulting in complete paralysis of one side of the body
• sudden loss of vision
• dizziness
• communication problems, difficulty talking and understanding what others are saying
• problems with balance and coordination
• difficulty swallowing
• sudden and severe headache, unlike any the person has had before, especially if associated with neck stiffness
• blacking out (in severe cases)

Mini Stroke or Transient Ischaemic Attack (TIA)

The symptoms of a transient ischaemic attack (TIA) are the same as for a stroke but only last from between a few minutes to a few hours, then completely disappear. However, never ignore a TIA as it is a serious warning sign that there is a problem with the blood supply to your brain.

There is about a one in 10 chance that those who have a TIA will experience a full stroke during the four weeks following the TIA. If you have had a TIA, you should contact your GP, local hospital or out-of-hours service, as soon as possible.

A stroke can happen to anyone. Know the warning signs.

Warning Signs of Stroke

The most common sign of stroke is sudden weakness of the face, arm or leg, most often on one side of the body. Other warning signs can include:

• Sudden numbness of the face, arm, or leg, especially on one side of the body
• Sudden confusion, trouble speaking or understanding speech
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden severe headache with no known cause

Who is at Risk from Stroke?

People who are over 65 years of age are most at risk from having strokes, although 25% of strokes occur in people who are under 65. It is also possible for children to have strokes.

If you are south Asian, African or Caribbean, your risk of stroke is higher. This is partly because of a predisposition (a natural tendency) to developing diabetes and heart disease, which are two conditions that can cause strokes.

Smoking, being overweight, lack of exercise and a poor diet are also risk factors for stroke. Also, conditions that affect the circulation of the blood, such as high blood pressure, high cholesterol, atrial fibrillation (an irregular heartbeat) and diabetes, increase your risk of having a stroke.

Strokes can be Treated and Prevented

Strokes can usually be successfully treated and also prevented. Eating a healthy diet, taking regular exercise, drinking alcohol in moderation and not smoking will dramatically reduce your risk of having a stroke. Lowering high blood pressure and cholesterol levels with medication also lowers the risk of stroke substantially.

See the Prevention section for more information about reducing the risk of having a stroke.

Strokes can be treated using a combination of medicines and, in some cases, surgery.

However, many people will require a long period of rehabilitation after a stroke and not all will recover fully.