Early treatment of stroke consists of determining whether the patient has had an ischaemic or haemorrhagic stroke. This is acheived by carrying out either
a CT scan or an MRI scan. The national standard is that every patient should receive such a scan within 24 hours of onset of the stroke. Unfortunately this
is not been met, in 2006 only 42% of patients were scanned within 24 hours which is worse than the 59% achieved in 2004.
If an ischaemic stroke has occurred
then the priority is to clear the blockage. This is best achived by means of thrombolysis using alteplase (which has now been approved by the National
Institute for Clinical Excellence) but currently only 1% of ischaemic stroke patients receive this therapy compared with 20-30% abroad. The
alternative is to give the patient aspirin- this may be given rectally if the patient has problems swallowing. Alteplase must be given within three hours
of the stroke occurring in order to have any significant benefit. The NICE guidance approves the use of alteplase providing thre following conditions are
met:
- Treatment must be started within three hours of the onset of the stroke;
- Treatment can only take place after the prior exclusion of intercranial haemorrhage by appropriate imaging techniques
- Treatment must be given by a doctor who is specialised in neurological care;
- Alteplase should only be administered by physicians trained and experienced in the use of thrombylitc techniques and with the facilities to monitor
the use of such techniques
- It can only be used by physicians who are trained and experienced in the management of acute stroke;
With haemorrhagic strokes surgery may be required to isolate the burst vessel from the rest of the circulatory system.
The Royal College of Physicians have made the following recommendations for the management of people who have had an ischaemic stroke-
Longer term treatment consists of a variety of rehabilitation interventions which should be tailored to individual needs. These may include:
- speech therapy;
- physiotherapy;
- dietitian;
- occupational therapy;
- psychologist although the Royal College of Physicians describes the provision of psychology services for stroke patients as "diabolical".
Exercise is considered especially important to enable patients to recover the use of limbs that may have been afffected.
People recovering from an ischaemic stroke may be given anti-platelet drugs in addition to aspirin in order to reduce the possibility of further clots.
Anticoagulants like warfarin may be used if the patient has a blood clotting disorder or abnormal arteries.
The treatment of stroke has been the subject of much recent debate sparked in large part by an article in the British Medical Journal by Professor
Hugh Markus which pointed out the poor performance of the UK in treating strokes when compared with other countries. He pointed to the low
thrombolysis rate and the inability of hospitals to undertake scans within the first 24 hours as indicators of where serious improvements can be made. Some
of this poor performance can be attributed to stroke's "Cinderella" status within the medical profession as it has never been seen as an integral part of
neurology services. Some sobering reading is available fro the National Audit Office's
report "Reducing brain damage,
faster access to better care" which sets out in quite graphic terms the absolute need to be able to respond to a stroke with more urgency and the
structural and organisational barriers to achieving this.
