As soon as the symptoms of stroke or paralysis are seen, immediate treatment should be started in a hospital by an expert physician or a neurologist. Delay can be dangerous. If possible, while taking the patient to the intensive care unit, the CT scan should be done on the way, if the facility is available in that city. If the patient is very serious he should be admitted immediately in an ICU (intensive care unit).
If the patient is serious and also has edema of the brain along with paralysis, emergency treatment should be initiated in ICU or even at home to prevent him from going into coma. The doctor should ensure that BP, pulse and respiration are maintained at normal levels. If the patient gets a convulsion, it should be immediately brought under control and if he is suffering from blood pressure, diabetes etc then they should also be controlled immediately. In short every minute counts.
Treatment of Paralysis : Six Major Aspects
i. Thrombolytic therapy.
ii. Antithrombic therapy.
iii. Neuroprotective therapy.
iv. Therapy for complications.
vi. Supportive therapy: Physiotherapy, etc.
It is an undisputed fact that in case of thromboembolism, if immediate treatment is given with latest special techniques, in the first 3 to 6 hours of paralysis, then in many cases
i. entire blocked artery opens up;
ii. the clot in the artery (thrombus) melts;
iii. the damage to the brain cells can be prevented or reduced.
Thus incipient paralysis as well as its complications can be prevented. Major research has been conducted on Thrombolytic therapy in which a drug called rt-PA is given through intravenous or intraarterial route within 1 to 3 or 1 to 6 hours. Several other similar drugs are under research e.g. Prourokinase, Urokinase. The results are really very good, but this therapy requires a fully equipped hospital having special equipment and facilities (CT scan, Angiography etc.). These treatments are moderately expensive, costing about Rs.60,000 to Rs.90,000. In addition, 4 to 7 % of the patients suffer from brain hemorrhage as a side effect. But in effect the death rate does not increase due to this side effect. Considering all the options, this is still the best available recent therapy. It is the only treatment approved by FDA for acute stroke treatment in USA. In foreign countries public awareness about stroke is very high and hence the person suffering from one is immediately taken to a hospital within 1 to 2 hours. Due to the availability of the coverage of the stroke therapy through insurance policy abroad, particularly USA, this therapy is extensively used. We hope that the same happens in India too and the attitude of the people towards insurance changes for the better.
Because of constraints, only time will tell whether this therapy will reach the common man and give desired results. Though our doctors are well aware of this therapy, there are many practical problems in our country. The other therapies available till now cannot cure paralysis beyond six hours after the stroke, as they can not rejuvenate the brain cells, which have died due to lack of blood and oxygen.
This therapy is easily available in our country and it aims to stop the clot formation in the blood vessels. It includes anticoagulant drugs like, heparin, low molecular heparin, drugs of antiplatelet group, like aspirin, dipyridamol, abciximab and drugs of fibrinolytic group, like ancrod. Their use, checks further damage. However, they can lead to side effects like hemorrhage and therefore they need to be administered in the right dose with proper investigations. Ticlopidine, Clopidogrel etc. may not be very effective in the initial stages of paralysis but they are successful in preventing future paralytic attacks.
About 10% to 15% of patients suffer from a strange situation called stroke-in-evolution. It is called strange because even after taking the necessary medications after the initial symptoms of stroke, the paralysis keeps on advancing for 2 to 4 days and eventually the entire side is completely paralyzed. This situation arises when the clot is obstructing the blood vessel gradually and the antithrombotic or antiplatelet drugs are not sufficient enough to offer complete protection against the disease. This can create amisunderstanding between the patient and the doctor, as condition of the patient worsens in spite of the treatment. So patients should be informed about this possibility from the beginning of treatment. If the paralysis is advancing, a second CT scan should be done to rule out hemorrhage.
In the case of thrombosis, during the initial days the blood pressure should not be brought down rapidly, because this causes a decrease in the blood supply of the brain increasing paralysis further. The neurologists usually do not give any drug to reduce blood pressure (In the first 7 days of a paralysis related to thrombosis) if the systolic B.P. is around 200 and the diastolic is around 110 (except in a fresh case of heart attack or angina or any other specific reason).
In cases of stroke, theoretically during the first 6 to 24 hours, chemicals should be given which provide nutrition and oxygen to the cells for a longer period, remove metabolic disturbances, protect the cell walls, and prevent the cells from breaking and dying (due to lack of blood and oxygen). There are about 30 to 40 types of drugs for this purpose (Nimodipine, Citicholine, Piracetam, MK-801), which have undergone various laboratory trials. But for reasons unknown, it has been seen that when they are administered to the patients, they do not give the expected results. There are some scientific reasons also for this failure and so better drugs are being developed which can prevent cell damage and keep the cells intact and alive for a longer period even if there is a deficiency of blood and oxygen.
During paralysis there can be various complications which increase the severity of the disease like swelling in the brain, unconsciousness, seizures, fever, pneumonia, increase or decrease of the water proportion in the body, bloating of the stomach, retention of urine and fluctuations in the levels of sodium or potassium. The doctor should constantly monitor the condition of the patient minutely so that the patient gets well soon. If a patient gets respiratory distress or goes into a coma due to excessive edema of brain, the patient should be kept on a ventilator and his/her life can be saved.
In certain cases (2 to 5%) of paralysis, one may require the help of a neurosurgeon who may be able to save the life of a patient and reduce the damage of the brain cells by emergency operations like craniotomy-duraplasty, emergency carotid bypass and embolectomy etc. In a stroke due to hemorrhage, sometimes the skull is opened and the clots are removed (if the drugs are unable to improve the patient’s condition and if it is possible to remove the clot).
Along with the treatment, it is essential that the patient gets proper nutrition and fluids along with vitamin supplements. If necessary, antibiotics can be administered. All these are included in supportive treatment.
Within 1 to 2 days of a stroke the doctor usually consults a physiotherapist, who makes the patient undergo limb and chest (respiration) exercises. Physiotherapy is recommended for at least 20 to 40 minutes, 4 to 6 times daily. It is imperative for the relatives of the patient to learnthese exercises and help the patient with them. The exercise provides various benefits to the patient. Basically this helps in preventing the stiffness and improves the movement of the limbs. It also prevents congestion of the chest due to cough, hence prevents pneumonia.
In order to prevent the recurrence of stroke, drugs of antiplatelet group like aspirin, dipyridamole, ticlopidine, clopidogrel, etc. are given for a long period of time. The doctor decides the right drug\drugs, their dosage etc. according to the condition of the patient and the possibility of recurrence of the disease. In some cases oral anti-coagulant drugs like, warfarin, acetrom etc. (which require meticulous monitoring and are risky) are also prescribed.
Ultra Sound Technique Doppler is used to examine the blood vessels (carotid and vertebral artery) situated in the neck, and if Carotid artery shows 60 to 70 % block then it is advisable to consult a neurosurgeon or a vascular surgeon who can remove the obstruction by surgical treatment. The surgery called Carotid Endartrectomy is not yet as popular in our country. It is increasingly becoming popular and its results are also good. The risk of surgery is not more than 1 to 2%. As angioplasty is being done instead of bypass surgery of the heart, similarly carotid angioplasty is gradually reducing the necessity of Endartrectomy.
Thus the combination of drugs, surgery, physiotherapy and treatment of the causes of stroke (like blood pressure, diabetes) can treat stroke permanently. The treatment can be said to be successful only if the patient is rehabilitatedphysically, mentally, socially, financially and professionally.
It is responsibility of a doctor not only to treat the patient, but also guide him about the various aspects of health and also explain the various warning symptoms (T.I.A),, risk factors, first aid, importance of immediate treatment etc. The role of a familey doctor is vital in every case of paralysis.
At the same time the patient should make changes in his/ her life style. He/She should avoid sedentary life and do exercise regularly. The patient should follow the advice of the doctor and take medicines regularly, lead a simple life without any stress and make positive changes in his attitude:
A disciplined life, mental soundness, moderate exertion, regular exercise as well as yoga and the necessary medicines along with regulation of blood pressure and diabetes, can largely avoid stroke (and heart diseases too). Public awareness is very much necessary. This can prevent the damage (of various kinds) to a person, family, society as well as the country, to a great extent.
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