Stroke: the first hours

1. Call an ambulance; don’t drive them yourself

   The ambulance team starts the assessment on the way, warns the hospital ahead, and knows which hospital offers the right treatment. Some cities have ambulances with a CT scanner on board.

2. Note the last time you saw them well

   It is the single most important fact for the team. If they woke up with the symptoms, what matters is the last time they were seen normal before sleep, not the time they woke.

3. Give no food, water or medicine by mouth

   Not even aspirin. The stroke may be a bleed rather than a blockage, and aspirin makes bleeding worse. Swallowing may also be affected, so food or water can go into the lungs.

4. Gather their medicines, or photograph the boxes

   Especially blood thinners. Add what you know about their illnesses, and whether they were walking and looking after themselves before; this feeds into the treatment decision.

Hospitals aim to do the first brain scan within about 25 minutes of arrival. Before and during it:

• A blood sugar check: because low sugar can mimic a stroke exactly.
• A neurological score (the NIHSS): it measures speech, strength, vision and sensation, and is repeated after treatment.
• A CT or MRI scan: the first question is whether there is bleeding, because treating a bleed is the opposite of treating a blockage.
• Imaging of the arteries, and sometimes of blood flow: to see whether a large artery is blocked, and whether part of the brain can still be saved.

A low score doesn’t always mean a minor stroke; weakness of the hand someone writes with, or loss of speech, can be disabling despite a small number. That is why the team asks: does this symptom disrupt their life?

Dissolving the clot through a vein

A medicine that breaks down the clot: either tenecteplase as a single injection, or alteplase as an injection followed by an hour-long drip. It is usually given within 4.5 hours of the last time the person was seen well, and for some people up to 9 hours, or when the time is unknown, if MRI or blood-flow imaging shows that the stroke is recent and that part of the brain can still be saved.

Before it is given, very high blood pressure is brought down, because high pressure raises the risk of bleeding with the medicine.

Removing the clot through a catheter

A thin tube goes in through an artery in the groin or wrist up to the brain, and pulls the clot out. It is used when the blockage is in a large artery. It is now possible up to 24 hours in selected patients depending on the scans, for some people with fairly large strokes, for blockage of the basilar artery at the back of the brain, and for some people who had mild disability before the stroke.

If a patient needs both treatments, the team doesn’t wait to see whether the first works before starting the second.

Why didn’t my relative get this treatment?

For many reasons: the stroke may be a bleed; the timing or scans may fall outside where benefit has been shown; the bleeding risk may be high; or the symptoms may be mild and not disabling. In a mild, non-disabling stroke, trials haven’t shown benefit from clot-dissolving medicine, and two antiplatelet medicines for three weeks, then one, are often the better choice.

Nothing by mouth before the swallow test

Many people’s swallowing is affected by a stroke, and food or water can go into the lungs and cause pneumonia. That is why swallowing is tested before any food, drink or tablets by mouth. Give them nothing by mouth, not even a sip of water, until the team says so.

Blood pressure and sugar

You may notice that the blood pressure is high and the team isn’t rushing to lower it. That is often deliberate: the injured brain needs enough blood flow, and lowering pressure sharply can do harm. After clot-dissolving or clot-removal treatment, pressure is kept below a set limit, but pushing it much lower isn’t better. Sugar is controlled too, but not driven too low, because low sugar is more dangerous.

The stroke unit and rehabilitation

Care on a dedicated stroke unit improves outcomes. Rehabilitation, meaning physiotherapy and speech and swallowing therapy, starts early once the person is stable. In the first one to two days that usually means gentle, gradual steps: sitting up in bed, then on the edge of the bed, then standing. Hard, strenuous exercise in the first 24 hours isn’t better and may do harm, especially after a bleed or a large stroke. Ask the team what your relative can safely do, and how you can help.

If a new symptom appears

If you notice new weakness, increasing drowsiness, or new trouble speaking, tell the nurse at once. You know your relative better than any monitor.

Call an ambulance for a child with a sudden severe headache with vomiting and drowsiness, a new seizure on one side of the body, confusion or trouble speaking, vision problems, or difficulty walking or balancing.

Stroke in children can look like migraine, seizures or head injury, which is why MRI and imaging of the arteries are preferred. Some children can be treated with clot-dissolving medicine or clot removal, in centres with experience.

Questions you can ask

Choose what matters now, add your own, then copy or print them.

1. Is it a blockage or a bleed?
2. Did they have clot-dissolving or clot-removal treatment? If not, why not?
3. What is the most likely cause, and which tests are still to come?
4. When will swallowing be tested, and when can they eat and drink?
5. Which medicines will they take to prevent another stroke, and for how long?
6. When does rehabilitation start, and who follows it up after discharge?
7. Which signs mean we should tell you straight away?

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