The First 24 to 48 Hours

If you or a loved one is having a stroke, it is incredibly important that you receive medical attention right away. Immediate treatment can minimize the long-term impact of stroke: stroke can be disabling or life-threatening. During the first 24-48 hours, your doctors and nurses will be working together to stabilize your condition to prevent further worsening of the stroke and early recurrence of new strokes. Listed below are some of the treatments you may receive.

An ischemic stroke occurs when a blood vessel supplying oxygen and nutrients to the brain is blocked. To treat an ischemic stroke, doctors work to open the blockage and quickly restore blood flow to the brain.

If you arrive within four-and-a-half hours of the onset of the stroke, you might receive a medication called IV tPA (intravenous tissue plasminogen activator). This is a protein that your body makes to break up clots. However, in the setting of an ischemic stroke, your body may not make enough of this protein: doctors treat you with this medication to supplement your body’s ability to dissolve the clot causing stroke symptoms. This medication is FDA-approved and is the standard-of-care for people with ischemic stroke presenting to the hospital early. Occasionally, some people have increased risk for bleeding complications, so the doctors will help you determine if you are eligible for this treatment. This treatment is proven to reduce long-term disability related to stroke.

If your stroke is due to a blockage of a large artery, you might receive a treatment called mechanical thrombectomy or intra-arterial therapy. This is a catheter based treatment: a minimally invasive surgery involving a wire that is threaded up to the arteries of the neck and head with a snare that entraps the clot and removes it from the blood stream. This is performed by a neurosurgeon, neurologist, or interventional radiologist trained in this procedure. This procedure is also FDA-approved and is the standard-of-care for people with ischemic stroke due to large artery occlusions.

Besides these two treatments, you may be given a pill medication to help reduce further clot formation and the development of new strokes. These antiplatelet medications include aspirin and clopidogrel (Plavix). Sometimes, a stronger blood thinner may be started, whether as a pill or as an infusion (a continuous fluid medication delivered through an intravenous line or IV).

It is also important to make it easier for your heart to deliver blood with oxygen and nutrients to the brain: this includes increasing the volume of fluid in your blood stream and minimizing the work needed to pump blood to the brain. You will likely be given intravenous fluids through an IV and also be asked to lie in bed at a low angle (usually 30 degrees or less) to minimize the need for the heart to fight against gravity when moving blood to the head. Additionally, your blood pressure will be allowed to rest at a higher level than usual: your brain is asking your heart for more oxygen and nutrients. In other words, elevated blood pressure after stroke is a temporary, protective response to help restore blood flow to the brain and prevent further worsening of the stroke.

Because your body is temporarily more prone to developing blood clots, you may be at risk for developing blood clots in the legs or pelvis. This can be dangerous if the blood clots travel from your legs or pelvis to your lungs, making it difficult to breathe normally. To prevent blood clots from forming in the legs, you will be asked to wear sequential compression devices (inflatable wraps placed around your calves that periodically squeeze the legs) and will have heparin injections (a low dose blood thinner) under the skin.

An intracerebral hemorrhage occurs when a weakened blood vessel ruptures and spills blood into the brain tissue. To treat an intracerebral hemorrhage, doctors quickly identify factors that worsen bleeding and minimize the effect of each one.  

The three main factors that exacerbate bleeding in the brain are uncontrolled hypertension, a coagulopathy (an increased tendency to bleed), and abnormal blood vessels.

If your blood pressure is very high, the doctors will start medications to reduce the blood pressure and maintain it at a lower, safer level.

Coagulopathies may be related to medications (such as Coumadin/warfarin) or medical conditions (such as liver disease): if abnormalities are suspected based on known medication use or identified by laboratory testing, you may receive treatments that reverse the effects of these medications or conditions. These treatments include purified blood products such as prothrombin complex concentrates, fresh frozen plasma, and cryoprecipitate, or medications such as vitamin K.

If a blood vessel abnormality is identified, the vascular malformation may be surgically treated to prevent further bleeding. Many of these surgeries are minimally invasive procedures using wire catheters.

Once the bleeding in the brain stops, treatment focuses on supporting the body while it absorbs the blood. If the bleeding is extensive and life threatening, our neurosurgery team may perform a surgery to remove the blood or temporarily remove part of the skull to relieve pressure on the brain.

During the first few days after stroke, early complications are common. The chances of complications occurring can be reduced through careful coordination of care at a stroke center, but not all complications are completely preventable. Whether at your bedside or behind the scenes, your doctors and nurses are working together to watch for complications and minimize their impact on your health if they do occur.

The following are some of the early complications that can occur after stroke:

• Dysphagia or difficulty swallowing – Stroke often causes loss of the ability to swallow safely. When that happens, food and fluid can go into the lungs instead of into the stomach, causing injury to the lungs and life threatening difficulty with breathing. Our Speech and Language Pathologists and nurses help assess your swallowing ability. If you have difficulty swallowing safely, we have to avoid giving you food or fluid by mouth until you can safely swallow again. This may involve temporary placement of a nasogastric tube, a thin tube that is threaded through the nostril to the stomach. If the difficulty with swallowing is expected to last weeks or months, then we may recommend temporary placement of a gastrostomy (aka “PEG tube”) to provide nutrition directly to the stomach during the early part of your recovery from stroke. These feeding tubes are usually temporary measures with the expectation that you will be able to regain the ability to swallow in the long term.
• Aspiration or accidental swallowing of food particles into the lungs – When aspiration occurs, an infection of the lung can develop, or you may develop difficulty with breathing. If an infection develops, we may need to treat you with antibiotics. If you are having significant difficulty with breathing, we may need to provide respiratory support, whether with minor measures such as a nasal cannula (a thin plastic tube delivering oxygen to the nostrils) or with more intensive measures such as a ventilator (a machine providing temporary support for breathing).
• Urinary tract infection, an infection in the bladder or urethra – Sometimes, a person with a stroke may have a minor bladder infection preceding the stroke that is discovered at the beginning of the hospitalization. Occasionally, a urinary catheter needs to be placed early during the course of a hospitalization for stroke. In most cases, we try to remove the urinary catheter as quickly as possible. Urinary catheters can increase the risk for bladder infections. In either case, it is important to treat these infections with antibiotics to prevent worsening of strokes (resulting from fever or the diversion of the body’s resources to fight the infection instead of repairing the brain).
• Fever – An elevated body temperature is common after stroke. Sometimes this is related to an infection, or it can be due to the stroke itself. High temperatures can worsen the stroke, so we often will treat fevers with acetaminophen (Tylenol) or cooling blankets.
• Hyperglycemia or high blood sugar – Glucose often rises in the blood stream when the body is sick: the extra energy is needed to fight the illness. However, too much glucose in the blood stream can worsen the stroke. We may periodically check your blood sugar (with a “finger stick”) and give you small doses of insulin to keep your blood sugar in a moderate range during the hospitalization, even if you do not have diabetes.
• Brain swelling – Severe strokes often result from injury to a large part of the brain. When this occurs, the injured brain tissue can sometimes become swollen and cause collateral injury to other parts of the brain spared by the stroke. This can be a life threatening situation: to treat this, we may move you to the Neurocritical Care unit, treat you with medications and other care measures to reduce swelling, and potentially suggest a surgery to help reduce collateral injury from the swelling.
• Deep vein thrombosis – With ischemic strokes and intracerebral hemorrhages, the body can be more prone to forming blood clots, particularly if your body is partly paralyzed. Clots forming in the deep veins of the legs and pelvis can be dangerous: besides causing swelling and pain in those locations, they can travel to the lungs and cause difficulty breathing. To prevent this, we ask you to wear sequential compression devices (wraps around the calves) while in bed and also will give you heparin injections under the skin.