Maryland Stroke Alliance

When a stroke happens a patient and their loved ones experience profound anxiety, fear and confusion.  It can be difficult to remember anything that happens once a brain attack occurs.  The following will describe the journey a patient takes when a stroke happens.

In the Field

When a patient experiences a stroke the signs and symptoms occur within seconds, this is why health care providers call a stroke a Brain Attack.  Often the family must call 911 to have the patient transported to the Emergency Room.  This is the very best thing a person can do when they witness someone having symptoms of a stroke.  When you call 911 Emergency Medical Services personnel respond.  This may include paramedic or Emergency Medical Technicians.  These people are usually referred to as EMS personnel. EMS providers are trained to care for stroke patients.  Also, in the state of Maryland they are instructed to transport the stroke patient to the emergency department of the closest stroke center.

Once a stroke occurs there is a medication that can be infused which may help decrease the deficits from stroke.  The medication is called tissue plasminogen activator, most people call this drug TPA.  TPA is a medicine that is administered as an IV infusion over one hour.  TPA must be administered within 3 hours of when the patient first has stroke symptoms.  TPA is a FDA approved drug and is the only drug at this time which may lessen the disability from stroke.  Field providers are taught to act very quickly because they are taught “Time is Brain”.  Once a stroke is suspected the field provider will act very quickly to get a patient evaluated for possible TPA.

Now things will happen very quickly.  No one can delay.  Many things will happen all at once.  In the field the stroke patient will be placed on a stretcher.   An intravenous line (IV) is usually placed in the arm and fluids run into the IV line. Oxygen will be administered with small hosing in the nose or an oxygen face mask.  The blood pressure and heart rate are checked very frequently.  Heart leads will be placed on your chest to assess your heart rhythm, this is called cardiac monitoring.  A neurological exam is performed to look for stroke symptoms.  It is most important you try to confirm the exact time when the stroke patient experienced symptoms of stroke.  Because, remember, TPA can only be administered within three hours of the symptoms happening.  EMS people will ask you for your telephone numbers, including cell phone numbers.  This is so Emergency room doctors can contact family.

Emergency Department of a Primary Stroke Center

In the Emergency Room things can seem overwhelming.  The nurses and doctors caring for the stroke patient must act quickly.  Everyone on the stroke team knows their job.

All at once the stroke patient will have blood drawn from their arm and sent to the lab right away.  Blood work results must be obtained before TPA can be administered.

Also, the patient will be whisked away to the CT scan machine to have pictures taken of the brain.  A CT of the brain is performed to make sure there is no blood in the brain.  If blood is present in the brain TPA cannot be given.  A doctor and nurse will ask when the stroke started.  This will be asked many times by many people.  Remember, TPA cannot be given if the stroke happened more than three hours ago.  Also, doctors will perform a neurological examination.  This examination will help the doctor determine where the stroke happened and the severity of the stroke.

Many things must be evaluated before TPA can be given.  The following are good reasons why TPA can be given: stroke symptoms are <3 hours, the stroke is an ischemic stroke, and stroke symptoms are not resolving.  Many other factors determine if you can get TPA.

The following are some common reasons why you cannot get TPA:

1. Stroke symptoms have been present more than 3 hours
2. the stroke patient doesn’t want TPA
3. blood sugar levels are too low
4. the stroke is called by bleeding
5. the stroke patient has had major surgery within the last 14 days
6. there is a recent history of stroke or serious head trauma
7. the stroke patient is using anticoagulation and the INR is >1.7

These are just some of the reasons why TPA can or cannot be given

When a Stroke Patient Gets IV tPA

When a patient gets TPA there are many things the nurses and doctors do during the infusion.  Prior to the administration of TPA the patient will need two IV lines.  Vital signs will be taken.  Then TPA will be infusing into the IV line over one hour.  The nurse will take vital signs very frequently.  The stroke patient will be asked to let the nurse know if they feel sick with nausea and headache.  These symptoms may indicate a worrisome response to IV TPA.  During the infusion the doctors and nurses will check the patient’s neurological status.  When the infusion is over the patient will need to be monitored in a critical care unit.

One side effect of TPA may be bleeding into the brain.  The patient needs to be observed for any changes and vital signs will be taken very frequently.  After 24 hours of getting TPA, the patient will be evaluated by many therapists, including speech, occupational and physical therapists.    The reason is because we want to evaluate the stroke patient as soon as possible so a recovery plan can be developed.

Stroke Tests

There are many tests a stroke patient may receive during their stay in the hospital.

Some are described here:

1. CT scan: This test that takes images of the brain to determine the location and size of stroke
2. MRI/MRA: These tests take images of brain tissue and blood vessels.  The test is performed with a machine that has a giant magnet.  This is why a checklist is performed to make sure people do not have metal in their bodies.  Some people with a pacemaker or certain types of stents cannot have a MRI/MRA.  The MRI/MRA machine can cause some people to have claustrophobia.  In this case the doctors will prescribe some relaxation medicines which may help the patient have the test.
3. Carotid Duplex: this is a test which uses ultrasound technology to measure blood flow in the carotid arteries.  The purpose of this test is to see if the carotid arteries are blocked getting less blood to the brain. 
4. Transthoracic Ultrasound: Sometimes this is known as a TTE.  This test uses ultrasound technology to assess the chambers and valves of the heart, how much blood gets pumped out of the heart, and to look for blood clots.

Hospital Care

After TPA hospital care is geared to prepare the patient for discharge to home or transfer to a rehabilitation facility.  During the hospital stay in the stroke center the patient will have the following performed:

1. a test to make sure the patient can swallow to make sure the patient can take medicines and eat
2. receive physical, speech and occupational therapies
3. receive medicine to help prevent another stroke like aspirin or blood thinners
4. have all risk factors for stroke identified and treated
5. have an evaluation by a social worker to see if the patient or family needs resources
6. see a neurologist: a specialist of the brain
7. have tests performed as mentioned before: MRI/MRA, CT scan, TTE and Carotid Duplex
8. given medicine to help prevent blood clots in the leg
9. have stroke prevention teaching and taught when to call 911

Rehabilitation and Recovery

Recovery will depend on the size and location of the stroke.  Everyone on the stroke team works together to determine where a patient goes after a stroke.   Sometimes where a patient can go is determined by insurance benefits.  Some patients will go home. Some patients will require the expert care provided in rehabilitation centers.  Everyone will need to follow up with their primary care provider to have all of their health needs evaluated.

Your office visit (what questions to ask)

• What type of stroke did I have?
• What were my test results?
• What are my risk factors?
• What is my treatment plan?
• What can I do to prevent another stroke?
• What medications should I be taking?
• What can I do to help me deal with feelings of (sadness, depression, loss or anger)?
• May I resume sexual relations?
• When can I return to work?
• When can I drive?