Initial Treatment

Until recently, the treatment of stroke was restricted to basic life support at the time of the stroke and rehabilitation later. Now, however, new and experimental treatments are being used that are proving to be very beneficial when administered as soon as possible after the onset of the stroke. If significant symptoms appear in people at risk for stroke, calling 911 is the best way to achieve prompt medical service (as opposed to calling the family doctor first).

As soon as the patient enters the hospital, diagnostic tests -- particularly a CT scan -- should be obtained to help determine whether the stroke is ischemic or hemorrhagic. The patient should receive treatment to support basic life functions and to reduce stress, pain, and agitation. Maintaining a healthy electrolyte balance (the ratio of sodium, calcium, and potassium in the body's fluids) is critical. Hospital staff should watch carefully for increased pressure on the brain, which is a frequent complication of hemorrhagic strokes but can also occur a few days after ischemic strokes. A number of medications may be given during a stroke to reduce this risk. Early symptoms of increased brain pressure are drowsiness, confusion, lethargy, weakness, and headache.

Drug Therapies

Generally drugs that are being tested for treating strokes use one of two approaches: breaking up the blood clots or protecting brain cells from further damage.

Drugs for Prevention of Further Clotting

Aspirin or intravenous heparin is commonly used to prevent more clots from forming and for maintaining blood flow after an ischemic stroke. Studies indicate that, in general, aspirin is more effective than heparin. Heparin also has a risk for a serious blood condition called thrombocytopenia. New forms of heparin are being investigated that may be effective and carry fewer risks. Unfortunately, one called low-molecular-weight heparin, which had showed promise, failed in a large scale study to improve neurological outcome or decrease the risk of recurrent stroke. Moreover, it resulted in a significantly higher risk of bleeding and serious brain hemorrhage. For most people with atrial fibrillation, warfarin (Coumadin) is used first. It should be noted that warfarin significantly increases the risk of hemorrhage and has no effect against large clots that are already present.

Thrombolytics

Clot-busting, or thrombolytic, drugs, normally used for breaking up existing clots in people who have had heart attacks, are now being used for stroke. At this time the only thrombolytic drug that might have any benefit for stroke is t-PA. It is administered within three hours of a stroke (but not after that period), patients who are given t-PA have a significantly better chance for functional improvement compared with patients who do receive the drug. T-PA, however, does carry a slightly higher risk for death from hemorrhage. Before t-PA is given, A CT scan must first confirm that the stroke is not hemorrhagic, which adds to delay in receiving the drug. Unfortunately, more than 50% of stroke patients arrive at the hospital more than three hours after an attack. Patients taking aspirin or other blood thinners or who have clotting abnormalities should not receive t-PA. Recent studies indicate that t-PA may be appropriate in more patients than previously thought, including older people and those with high blood pressure.

Nerve-Cell-Protecting Drugs

Researchers are working to develop medications that may slow down or prevent the process of cell death. Many such drugs are focusing on the excitatory amino acids that play an important role in damaging cell membranes and opening nerve cell channels in the brain, thus allowing the in-flow of destructive amounts of calcium. One of these amino acids, glutamate, is a particularly potent nerve cell killer and has provoked great interest. Another drug, citicoline, has shown promise in improving function in stroke victims. Another approach is to block an enzyme known as PARP, which may play a key role in cell death during a stroke. A number of other drugs are in various stages of development.

Calcium Channel Blockers for Hemorrhagic Stroke

One of the most common and serious dangers after a hemorrhagic stroke is spasm of the blood vessels near the ruptured site, which closes off oxygen to the brain. Calcium causes contraction of the smooth muscles of the blood vessels, and calcium-channel blockers are drugs that relax the blood vessels. One, nimodipine (Nimotop), has been tested in a number of trials with considerable success. The drug works best if it is administered within six hours of the stroke. It is not useful for ischemic stroke.

Surgical Treatment

Carotid endarterectomy is often performed in people who have suffered a stroke. Major studies have found that endarterectomy may be superior to drug therapy for reducing the risk of another stroke in some patients, particularly those whose arteries had narrowed by more than 70%. People whose carotid artery showed a narrowing of less than 30% did better using drug therapy. For those in between, more research needs to be done. The long-term benefits of surgery also included improvements in vision, speech, swallowing, functioning of arms and legs, and general quality of life. It should be noted that the studies showing such high benefit of surgery versus drug therapy were done in institutions experienced with such operations. There is a temporarily increased risk of stroke after surgery. Anyone who chooses any invasive procedure for diagnosing, treating, or preventing stroke should be sure that both the surgeon and the hospital in which it is performed have a history of no more than 4% incidence of stroke after the operation.