The stroke: what should you do?

You are having lunch with your grandmother when she suddenly slumps to one side. She is still conscious but doesn’t seem to be able to talk, despite appearing to want to say something. The suddenness of the problem is characteristic of a stroke. What should you do?

RECOGNISE THE SYMPTOMS

You should know the signs of a stroke, as early diagnosis and treatment are vital in most cases. If the blood supply to part of the brain stops as a result of a stroke, the symptoms appear almost immediately and this gives the first major clue to the diagnosis. The symptoms of a stroke may include: a sudden weakness or numbness of the face, arm or leg on one side of the body; sudden difficulty in speaking or understanding speech; and sudden blurring or a loss of vision (particularly in one eye).
The symptoms usually come on abruptly – within seconds for many people – and this is so unexpected that people can usually remember exactly what they were doing when the stroke came on. A stroke can also occur during sleep, and many people discover the stroke symp­toms on waking up.

CALL FOR HELP

A stroke should be treated as a medical emergency and you should call for help immediately. Those involved in stroke medicine feel that speed is increasingly important in the assessment of a stroke. This is because some treat­ments appear to offer the prospect of substantial benefit, but only if given very quickly.
Make sure the person will not injure him- or herself (for example, by falling off a chair) and call your family doctor (general practitioner or GP). Outside normal working hours, most GPs provide an emer­gency service by grouping several doctors together in a cooperative. These out-of-hours coops are there to provide help in just this situation.
Your GP may advise you to call a ‘999’ ambulance immediately. If, for any reason, you cannot contact a GP, telephone for an emergency ambulance yourself. If you use an ambulance, make sure someone who witnessed the stroke travels with the patient, so that they can tell the doctor on duty exactly what happened.
When the GP arrives, he or she will usually ask the witnesses (if any) a few questions and then assess the patient. Sometimes, the symptoms improve quickly, and there is complete recovery within minutes or hours. This type of attack is quite common and is called a transient ischaemic attack or TIA (see ‘Types of strokes’). TIAs are important because they act as an advance warning that there is trouble with the blood supply, not only to the brain (caus­ing a risk of a stroke), but also to the heart (causing a risk of a heart attack). People who have a TIA are far more likely to have problems with their circulation than some­one who has never had an attack. The risk of a stroke or a heart attack in someone who has had a TIA is about 10 per cent (1 in 10) in the next 12 months. The good news is that something can be done and, with some sensible changes in lifestyle and good med­ical care, this risk can be substantially lowered.
If the person’s condition has not improved by the time your doctor sees him or her, there are a number of options available. If the person with the suspected stroke has become disabled (for example, he or she is unable to stand or walk), then admission to hospital should be considered. Sometimes your family doctor may want to treat him or her at home and, in some places, there are now special hospital outpatient clinics available for those with a minor stroke or TIA.

GOING TO HOSPITAL

Hospital care is needed for most patients with a stroke, and initial hospital care has many advan­tages. On arrival at the hospital, the patient will be assessed in the emergency room (or admission unit). A nurse will see the patient very soon after admission to note the severity of the problem and to alert the medical team. This nurse, called a triage nurse, makes sure that patients get the appropriate priority by assessing their health and determining how quickly they need to be treated. If a major road accident has just occurred, there may be some delays in assessment while other crises are being dealt with. In the past, patients with a stroke had not been consid­ered a medical priority, but this is starting to change with the introduction of new stroke treatments.

Patients who have had a suspected stroke will not normally be allowed to eat or drink until it has been confirmed that they have a safe swallow mechanism. Many patients with a stroke can choke if they are fed with fluids and food in the early stages. This swallowing difficulty usually recovers quickly.

Hospital diagnosis

When the hospital doctor assesses the patient, it is important to get a witnessed account (if available) from people who saw what happened. The doctor will ask several questions and then perform a full examination. Blood tests are taken to find out what caused the stroke and to look for abnormalities, such as too much sugar in the blood which indicates diabetes.

Diabetes is associated with abnormally high levels of glucose in the blood­stream, which hastens the onset of hardening and furring up of the arteries (atherosclerosis) and increases the risk of a stroke.
Most patients will also have an electrocardiogram (ECG), which is a method of recording the electrical activity of the heart by attach­ing wires to the chest, arms and legs. The ECG can show evidence of heart disease that may have caused the stroke.

A chest X-ray is also useful for many patients because it can show dilation of the heart, which can occur with long-standing untreated high blood pressure, and may some­times detect a dilated swelling (aneurysm) of the body’s major artery, the aorta.

The doctors need to assess which type of stroke has occurred: either a blood vessel has become blocked (an ischaemic stroke) or a blood vessel has burst (an intra­cerebral haemorrhage). To determine this, a brain scan has to be performed. The most widely used type of scan is the CT (computed tomography) scan.

But a different technique, called magnetic reso­nance imaging (MRI), is becoming more widely available. An MRI scan gives a better cross-sectional image of soft tissues and does not use X-rays, so the patient is not exposed to radiation. These brain scans can show whether or not the stroke was caused by a bleed. If no blood is seen, doctors can be quite confident that the stroke has been caused by a blockage in the blood supply to the brain. This information is very useful because future medical care depends on the stroke type. For example, blood-thinning treatment is not suitable for people whose stroke was caused by a bleed because this would make the bleeding worse.
After the initial assessment and tests, the patient may have to be admitted to hospital. The main reasons for admission are to continue investigating the cause of the stroke, to give urgent treat­ment and to provide the care needed if the stroke has caused some disability. One of the biggest revolutions in stroke med­icine in the last 10 years has been research showing that organised stroke care (for example, stroke teams or units) can save lives and get more people back to their own home. As a result of this information, many health authorities are developing stroke units in major hospitals.

IMMEDIATE TREATMENT

Exciting new treatments are emerging for the acute stroke. Some treatments may now actually reverse the stroke, by dissolving the offending blood clot in the brain, leading to a complete recov­ery. Until recently, there was no effective pill or injection for a stroke, but the last 10 years has seen a huge increase in stroke research. As a result of major clinical trials, some medicines have been shown to be very effective.

Aspirin

Two large clinical trials have demonstrated that aspirin, in a dose of about 160–300 milligrams (mg) a day, is helpful for most people with a stroke. Before treat­ment, it is important for doctors to check that the stroke has not been caused by a bleed (as aspirin could make this worse) by performing an early brain scan. Aspirin works by reducing the stickiness of the blood cell fragments (platelets) that clump together to form a clot. It therefore reduces the risk of a new clot forming and reduces the chance of an early second stroke. It may even help stop the initial stroke getting worse.
Aspirin treatment is not very powerful. About 100 people need to be started on aspirin to prevent one death (or one person becom­ing disabled) in the first few weeks after the stroke. However, this very modest treatment benefit is worthwhile because aspirin is sim­ple to take, has few side effects and is very cheap. Immediate aspirin treatment started in the early phase of stroke could save an estimated four lives a year in a single hospital alone (see ‘Life after a stroke’).

Thrombolytics

Thrombolytic treatment (or ‘clot­busting’ treatment) has been stud­ied for the past few years. It is the standard treatment for blocked blood vessels in the heart (to treat a heart attack), and it is logical to try it for a blocked blood vessel in the brain (an ischaemic stroke). Clot-buster drugs dissolve the stringy protein (fibrin) that binds a clot together so that it breaks up. The treatment is given directly into a vein and must be given as soon as possible after the clot formed – and preferably within three hours.
Unfortunately, the results of the stroke clinical trials of thrombolytic treatment have been mixed. Some trials have had to stop early because there were too many seri­ous side effects, such as major bleeding in the brain. Other stud­ies have been more promising. In particular, one trial from America had a good result using a treat­ment called tissue plasminogen activator (now called alteplase).
Alteplase has now been grant­ed a licence in Europe but the licence is very restrictive and few people will be treated. This deci­sion was not easy for the licensing authorities and they have insisted that all treatment be carefully monitored in a special register and that a further randomised con­trolled trial of thrombolytics be carried out. The licence will then be reviewed in a few years when these data are available. The current evidence certainly suggests that thrombolytics may be effec­tive for a much larger group of patients with stroke. To help resolve these questions, several randomised controlled trials of ‘clot busters’ are under way or in the planning stage. The results of these research projects should improve our knowledge. However, this treatment is difficult to imple­ment. Hospitals must have a stroke unit with a consultant stroke expert available and have access to brain scanning on a 24-hour basis. At the moment there are simply too few such expert centres in the UK (and elsewhere) to offer this treatment to all those who may benefit. The good news is that stroke service provision is improving and the nec­essary expertise may become more widely available.

Heparin and warfarin

These are both anticoagulant drugs. Anticoagulant drugs act by preventing the formation of the protein-based clotting factors that are essential for normal blood clotting. Warfarin has no immedi­ate effect on existing blood clots as it takes two to three days to work. However, it can be used to prevent further blood clots in cerebral thrombosis and, there­fore, to reduce the risk of a second stroke or TIA (see ‘Life after a stroke’). Heparin is now rarely used in stroke man­agement or treatment as it has been shown to cause bleeding in the brain, triggering another stroke or haemorrhage.

Primary intracerebral haemorrhage

There are now promising new treatments emerging for stroke resulting from a brain haemorrhage. Preliminary data from a trial of a blood-clotting agent look very promising but a larger confirmatory study is likely to take place before treatment is widely available. Unfortunately, a trial of routine surgery to remove the brain haemorrhage was disappointing and neurosurgery is still applicable for only a small number of patients. Despite this setback, there is now more optimism that a successful medical or surgical treatment is around the corner.

Randomised controlled trials

As there are currently no perfect treatments for a stroke, further clinical trials are needed to assess the best way to manage people with this condition. It is likely that many people with a stroke will, in the next few years, be asked to join a clinical trial.
People differ so much from each other, in so many ways, that doctors find it very difficult to pre­dict who is going to do well (or badly) with a particular treatment. If the treatment is very new, enthusiastic doctors and their patients may think that the treat­ment is working, when in fact it is causing harm.
Over the last 50 years, scien­tists have developed a method of testing new medical treatments (or management strategies) called the randomised controlled trial. The idea behind this design is really quite straightforward. If the new treatment works, groups of people given the new treatment will do better than a similar group of people given the standard treatment.
As doctors are not very good at predicting who will do well and who will do badly, the two groups of patients are not chosen by the doctor but by a mathematical method called random allocation. Random allocation provides the best chance of creating two very similar groups of people. If all the people in one of these groups are then allocated the new treatment and these people, on average, do better than the group allocated the standard treatment, the differ­ence is likely to be the result of the new treatment. Unfortunately, the randomised controlled trial is not foolproof because small trials can sometimes produce misleading results by the play of chance. It is a sobering thought that over 40,000 people with stroke had to be studied to identify the small benefit of aspirin for the acute stroke attack.

Consent and clinical trials

Doctors have to follow strict rules laid down by their local ethics committees when involving people in clinical trials. This protects the patient from unethical doctors. The most important part of the ethics of clinical trials is that patients understand that they are in a research trial and also the pros and cons of the different treat­ments under study. Not all good ideas work, but the design of clini­cal trials helps to reduce any un­expected hazard to a minimum.

To provide evidence that the researchers have explained the trial properly, patients usually sign a consent form. This can be diffi­cult if the patient has just had a stroke because their thinking may not be clear or they may be unable to write or understand speech. Most ethics committees have agreed that a close relative (or perhaps even an independent person) can give permission if the patient is not in a position to do so. Some people have great con­cerns about this. Legally, no one other than the patient can decide to accept or reject a treatment. However, a treatment for some types of strokes would never be found if a signed consent form was compulsory from everyone. Most groups of experts and laypeople on ethics committees have therefore agreed that, under very strict conditions, some peo­ple with a stroke can be included in clinical trials, even if they are unable to give consent, provided that their family (or an independent expert) are happy with the project.