When a person has symptoms of a TIA or stroke, the doctor will evaluate the symptoms, get a medical history and do a physical examination. To determine the type of stroke and the extent of the damage, any of the following tests may be ordered:
Electrocardiogram (EKG) – This test is used to test for the electrical activity of the heart. Pads with a sticky back are placed on your chest, legs and arms, and a recording of the heart beat is made.
Echocardiogram – An echocardiogram is a moving picture of the heart using sound waves. The technologist will place gel on your chest and take pictures of your heart from different angles.
The test is used to:
- measure the thickness of the heart walls,
- see how well the heart pumps,
- check the size of the heart and its chambers,
- check how blood flows from one heart chamber to the next through the valves,
- check for abnormal fluid,
- detect blood clots, tumors in the heart and leaks or
- narrowing of valve openings.
Transesophageal Echocardiogram – This test is done to better see the heart. A sound wave tube is swallowed, and the heart is seen from behind rather than through the chest wall. This can provide more detailed pictures of the heart, especially when looking for a blood clot.
Blood Flow Tests
Carotid Doppler – Carotid arteries are vessels that run along the sides of the neck. They carry blood to the brain and eyes. These arteries can become clogged with fatty deposits known as plaque. This test uses sound waves to see if there is a blockage in the carotid arteries. A gel will be put on the side of your neck, and a small probe will then be placed on top of the area to be checked.
Transcranial Doppler – A Transcranial Doppler study is a test to see blood flow in vessels inside the head using sound waves. A gel will be put on both sides of your temples, over both closed eyelids and to the base of your head. A wand is then gently placed over those areas, and a recording is made of the sound waves.
Cerebral Arteriogram (or Angiography) – This test uses X-rays to see how the blood flows or if there are blockages in the arteries that supply blood to the brain. A tube is put in an artery in the groin, and dye is injected so that the vessels can be seen when X-rays are taken.
CT scan (Computed Tomography), or CAT scan – This test uses radiation to create a picture of the brain and blood vessels. It is usually done in the emergency department to find out the type of stroke you have.
MRI (Magnetic Resonance Imaging) – This test uses a large magnetic field to produce an image of the brain. The image is sharper and more detailed than a CT scan. With this test you will need to lie quietly for about 30 minutes. If you have a pacemaker, you should not have an MRI. Also notify your nurse if you have any metal implants in your body. If you have problems being in a closed space, you can have some medicine to relax you before the test.
MRA (Magnetic Resonance Angiography) – This test detects blood vessel changes such as a blockage, narrowing or an aneurysm. An MRA has the same procedure as the MRI.
Anticoagulant medications work by interfering with production of certain blood components necessary for forming blood clots.
Antiplatelet medications work by keeping platelets, a component of blood, from sticking together. When platelets stick together they form clots.
Arteriovenous Malformations (AVM) can be surgically removed through a craniotomy. Small AVMs can be obliterated with a laser (gamma) knife. Treatment depends on the size and location of the AVM.
Carotid Endarterectomy is surgery that removes harmful fatty deposits (plaque) from your carotid arteries. A cut is made in the side of the neck, and the carotid artery is opened. The plaque is removed, and then the artery is closed up. This surgery depends upon the amount of blockage caused by the plaque. It may or may not be performed during your hospital stay for a TIA or stroke. Patients are usually discharged the day after the surgery.
Although stroke rehabilitation is increasingly successful at prolonging life, a stroke can be a disabling or fatal condition. People who have had a stroke may consider discussing health care and other legal issues that may arise near the end of life. Many people find it helpful and comforting to state their health care choices in writing with an advance directive while they are still able to make and communicate these decisions.
Advance directives can include the ability to refuse treatment in specific situations. The three main types of advance directives are:
- Do not resuscitate orders (DNRs)
- Living wills
- Durable power of attorney for health care (DPA)
Do not resuscitate orders (DNRs) typically request that no extraordinary measures be used to save your life. Extraordinary measures include cardiopulmonary resuscitation (CPR), use of an electrical shock to stop a fatal abnormal heart rhythm (defibrillation), intubation (placement of a breathing tube down your throat), or the use of lifesaving drugs. People with DNR orders will only be given drugs that make them more comfortable in their last moments. You may request that you be identified as a DNR if you wish to avoid expensive, uncomfortable, or invasive medical care that probably will not improve your long-term prognosis and may increase your discomfort.
Living wills are written documents that contain specific instructions about the type of treatment you wish to receive at the end of your life. Unlike a DNR order, which applies to a specific moment when you require resuscitation, living wills apply to more general situations.
One of two broad conditions must be triggered:
- You have slipped into a permanent coma.
- You are unable to make decisions about the type of care you wish to receive.
Merci Retriever is another option that extends the treatment time to six to eight hours after stroke symptoms. In this procedure, a catheter is placed into the groin and threaded up to the blocked artery in the brain. A tiny flexible wire that resembles a cork screw device is then coiled into the clot and removed through the catheter.
If your condition gets worse, you may want to think about palliative care. Palliative care is a type of care for people who have illnesses that do not go away and often get worse over time. It is different from care to cure your illness, called curative treatment. Palliative care focuses on improving your quality of life - not just in your body, but also in your mind and spirit. Some people combine palliative care with curative care.
Palliative care may help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term illness, make future plans around your medical care, or help your family better understand your illness and how to support you.
If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.
Recovery and Rehabilitation
Recovery after stroke often occurs more quickly in the first months, then continues slowly and steadily over years. Rehabilitation programs are designed to help you improve your abilities and learn new skills.
Depending upon your specific needs, you may or may not need therapies after discharge.
Therapies can be provided in your home, in a rehabilitation setting, in an outpatient setting or in a skilled nursing facility. That determination is made prior to your discharge.
It will be important to your recovery that you take your medications as prescribed and practice lifestyle changes to reduce your risk of having another stroke.
If you drove before your stroke happened, you will need your doctor’s permission to continue driving. You may also need to have a driver evaluation prior to driving again.
TPA (tissue plasminogen activator) is a thrombolytic drug that works by dissolving a clot. Although this is a proven therapy for stroke, only a limited number of patients will receive this therapy because of the short amount of time that it can be safely administered once a stroke has occurred. To receive this medication intravenously (IV), the patient must be treated within three hours of acute onset of stroke symptoms. If a patient’s stroke symptoms are more than three hours, but less than six hours, the drug may be given intra-arterially (IA), directly into the clot. Patients who receive IA tPA are taken to a special angiography lab where a temporary catheter is placed and threaded to the clot. Research studies have shown that people who arrive in the emergency room quickly enough after stroke to receive tPA have a better chance of functional recovery than those who do not receive it. In addition to the time limit of three to six hours, patients must meet other criteria in order to decrease the chance of bleeding after the medication is given. Patients who receive tPA will be closely monitored for 24 hours following the administration of the drug to observe for hemorrhage. A CT of the brain will be repeated the following day.
Treatment for Hemorrhagic Stroke
Aneurysms are usually treated in one of two ways:
Clipping: Clipping an aneurysm involves attaching a spring loaded clip to the neck of the aneurysm. To get the aneurysm, the neurosurgeon must go through the skull with a procedure called a craniotomy. A craniotomy means a piece of bone will be removed from the skull during the surgery. The aneurysm is clipped, the bone reattached, and the skin sutured closed.
Coiling: Sometimes an aneurysm is not in an area where a clip can be applied, so an alternate therapy called coil embolization or coiling is used to get into the blood vessel. In contrast to surgery, endovascular coiling does not require open surgery. Instead, the physician inserts a catheter (small plastic tube) into the femerol artery in the patient’s leg and navigates it through the blood vessels into the head and into the aneurysm. Tiny platinum coils are threaded through the catheter into the aneurysm. A small electrical current heats the coils and allows them to expand and block off the aneurysm. The catheter is then taken out, and the patient is sent to intensive care to be observed for spasm.