Stroke Patient Care: 24-Hour Attention Needed?

A stroke is a life-threatening condition that requires immediate medical attention and can cause severe disabilities. The faster a stroke patient receives treatment, the better their chances of recovery. The first few hours after a stroke are crucial and can be very scary and fast-paced for the patient and their loved ones. The type of care and length of hospital stay depend on the patient's needs and vary on a case-by-case basis. While some patients may require 24-hour care, especially in the initial stages after a stroke, others may not need the same level of constant care.

The importance of immediate treatment

Immediate treatment is crucial for stroke patients as it can significantly impact their recovery and reduce the risk of long-term damage or disability. The first few hours after a stroke are critical, as the speed of treatment can determine the outcome for the patient. Here's why immediate treatment is essential:

Minimising Brain Damage

Time is of the essence when it comes to treating strokes. For every minute the brain is deprived of necessary blood flow, 1.9 million brain cells die. Therefore, the sooner the blood flow to the brain can be restored, the better the chances of recovery. This is why it is so important to recognise the signs of a stroke and seek emergency care as soon as possible.

Diagnosing the Type of Stroke

The first step in immediate treatment is to accurately diagnose the type of stroke. There are two main types: ischemic and hemorrhagic. Ischemic strokes are caused by blood clots blocking blood flow in the brain, while hemorrhagic strokes are due to ruptured blood vessels. A quick diagnosis helps determine the appropriate treatment plan.

Administering Medication

In the case of ischemic strokes, clot-busting medications such as tissue plasminogen activator (tPA) are often used to break up blood clots and restore blood flow. These drugs are most effective when administered as soon as possible, ideally within 3 to 4.5 hours of the onset of symptoms. The faster the medication is given, the more effective it is at reversing damage and improving outcomes.

Preventing Complications

Starting treatment early helps prevent further complications. For example, if a patient is unable to move around, immediate treatment can help prevent deep vein thrombosis (DVT) from forming in their legs. It also reduces the risk of pressure injuries to the skin. Additionally, a swallowing test is crucial before administering any liquids, food, or medication to prevent complications such as inhaling food or dehydration.

Initiating Rehabilitation

Immediate treatment also means that rehabilitation can begin sooner. The first few days after a stroke are crucial for stabilising the patient and starting their recovery process. A team of healthcare providers will work with the patient to assess their abilities and develop strategies and therapies to support their recovery. This may include physical therapy, occupational therapy, and speech-language therapy to address any physical, cognitive, or emotional symptoms.

Stabilising the patient

Stabilising a stroke patient is a critical process that requires immediate care and attention. Here are some key steps and considerations for stabilising a stroke patient:

Initial Emergency Care

The first few hours after a stroke are crucial and can be very overwhelming for both the patient and their loved ones. The primary goal during this time is to stabilise the patient's condition and prevent further damage to brain cells. This involves managing their breathing, heart function, blood pressure, bleeding, and swallowing, among other symptoms. A brain scan, typically a CT (computed tomography) scan, is performed to identify the type and location of the stroke, helping healthcare professionals choose the best treatment options.

Treatment Options

The type of treatment depends on whether the stroke is ischemic or hemorrhagic. Ischemic strokes, caused by blood clots, are often treated with clot-busting medications such as tissue plasminogen activator (tPA) or alteplase, which must be given within a few hours of the onset of symptoms to be most effective. Hemorrhagic strokes, on the other hand, involve bleeding in the brain and are treated by controlling the bleeding, reducing blood pressure, and sometimes requiring surgery to fix damaged arteries or lower pressure in the brain.

Monitoring and Managing Risk Factors

During the patient's hospital stay, the medical team will continuously monitor and manage risk factors to prevent further complications. This includes prescribing blood thinners or anti-platelet medications like ASA (acetylsalicylic acid or Aspirin) to prevent more clots in the case of ischemic strokes. Regular blood pressure checks are also crucial, and medication may be prescribed if it is high. Additionally, the team will assess the patient's risk of falling due to weakness and balance problems, working with the patient and their family to ensure a comprehensive understanding of the risk and fall prevention strategies.

Rehabilitation Planning

Once the patient is stabilised, the focus shifts to rehabilitation and recovery. The medical team will assess the patient's abilities and develop strategies and therapies to support their recovery journey. This includes speech, swallowing, and walking evaluations, as well as identifying any issues with bowel and bladder control. The team will also consider the patient's ability to resume day-to-day activities and plan for their discharge, which may involve inpatient rehabilitation, long-term care, or returning home with outpatient rehabilitation services.

Diagnosis and treatment options

Diagnosis

The first few hours after a stroke are critical for diagnosis and treatment. The healthcare team will work quickly to determine the type of stroke and prevent further damage to brain cells. Diagnosis involves stabilising the patient, making a diagnosis, and providing early treatment.

Stabilisation involves managing breathing, heart function, blood pressure, bleeding, swallowing, and other symptoms. A diagnosis is made through a physical exam, medical history, and test results. Brain scans, such as CT or MRI scans, are used to determine the type and location of the stroke. Blood tests and other imaging tests may also be used to rule out other health problems and identify the best treatment options.

Treatment Options

The type of treatment depends on the type of stroke. Treatment options include medication, surgery, and rehabilitation.

Medication

For an ischemic stroke caused by a blood clot, doctors may administer clot-busting medication to reopen blocked arteries and reduce long-term effects. This must be given as soon as possible, ideally within 4.5 hours of the onset of stroke symptoms. Endovascular thrombectomy (EVT) is a common procedure where doctors insert a thin tube through an artery to remove large clots and restore blood flow.

For ischemic strokes, doctors may prescribe blood thinners or anti-platelet medications to prevent further clots. If the stroke is caused by blocked carotid arteries, surgery may be required.

Surgery

For a hemorrhagic stroke, a neurosurgeon may be needed to control bleeding in the brain, fix a damaged artery, or lower brain pressure.

Rehabilitation

Rehabilitation typically starts within 24 hours of a stroke and involves a team of specialists, including physiatrists, neurologists, physical and occupational therapists, speech-language pathologists, and nurses. Therapy sessions are conducted daily, and sometimes hourly, to evaluate damage and promote recovery.

Rehabilitation focuses on activities of daily living (ADL), such as bathing or preparing food. Patients are encouraged to discuss activities important to them with their care team to set personalised recovery goals.

Rehabilitation psychologists and neuropsychologists can address the cognitive and emotional impacts of a stroke and create plans to improve cognitive function and develop resilience.

The first three months after a stroke are critical for recovery, with most patients making significant improvements during this period. However, improvements are still possible after six months, albeit at a slower pace.

Recovery and rehabilitation

The road to recovery after a stroke varies from person to person, depending on the severity of the stroke, the area of the brain affected, and the individual's overall health. However, there are some general milestones and guidelines that can help patients and their families understand what to expect during the recovery process.

In the Hospital

During the initial days and weeks after a stroke, the focus is on stabilising the patient and preventing further complications. This includes managing vital functions like breathing, heart function, blood pressure, and swallowing. A brain scan, typically a CT (computed tomography) scan, is performed to determine the type and location of the stroke, guiding subsequent treatment decisions.

The type of stroke—whether ischemic (caused by a blood clot) or hemorrhagic (caused by a ruptured blood vessel)—dictates the course of treatment. Ischemic strokes are often treated with clot-busting medications like tissue plasminogen activator (tPA) or alteplase, which must be administered within 3 to 4.5 hours of the onset of symptoms. Hemorrhagic strokes, on the other hand, involve controlling bleeding in the brain and reducing blood pressure.

The patient's rehabilitation plan is formulated during their hospital stay. The stroke care team, consisting of physiatrists, neurologists, physical and occupational therapists, speech-language pathologists, and nurses, work together to address the patient's specific needs. The typical length of a hospital stay after a stroke is around 5 to 7 days, during which therapy sessions are conducted intensively, up to six times per day.

After Leaving the Hospital

After being discharged from the hospital, the patient's journey towards recovery continues. They may continue their rehabilitation in an inpatient rehabilitation unit, a subacute rehabilitation facility, or at home with outpatient clinic visits. The decision depends on the patient's level of functional impairment and the intensity of therapy they can tolerate.

The first three months after a stroke are considered the most crucial for recovery. During this period, patients typically make significant improvements and may complete an inpatient rehabilitation program or progress in their outpatient therapy sessions. The goal of rehabilitation is to restore function as closely as possible to pre-stroke levels or develop compensation strategies to overcome any remaining impairments.

Long-Term Recovery

Even after the initial months, improvements are still possible, albeit at a slower pace. Most stroke patients reach a relatively steady state after six months, with some achieving a full recovery while others experience ongoing impairments, known as chronic stroke disease. Continuing follow-up care with a multidisciplinary team, including a primary care physician, rehabilitation physician, therapists, neurologist, and rehabilitation psychologist, is crucial to support long-term recovery and prevent future strokes.

While recovery can be a challenging and uncertain process, starting rehabilitation as soon as possible and maintaining a dedicated approach can maximise the chances of a positive outcome. Each small milestone, such as needing less assistance with a task, represents a significant step in the patient's journey back to independence.

Discharge and aftercare

The typical length of a hospital stay after a stroke is five to seven days. During this time, the stroke care team will evaluate the effects of the stroke and determine the rehabilitation plan. Before leaving the hospital, the patient's provider will test how well they can speak, swallow, and walk. The provider and patient will then work together to set up a rehabilitation plan. Team members will assess how the stroke has affected the patient's ability to resume day-to-day life and will work with the patient to plan the next step in their recovery—whether that be returning home, going to inpatient rehabilitation, or moving to long-term care or another living situation.

If the patient is discharged to return home, they may continue their rehabilitation at an inpatient rehabilitation unit or independent rehabilitation facility if they can benefit from being monitored by a physician and can tolerate three hours of therapy per day. They may also continue their rehabilitation at a subacute rehabilitation facility if they require a slower course of rehabilitation with one to two hours of therapy daily. If the patient has family support to assist with daily activities, they can go home and continue their rehabilitation with visits to an outpatient rehabilitation clinic as needed.

The first three months after a stroke are the most important for recovery, and patients will see the most improvement during this time. The goal of rehabilitation is to restore function as closely as possible to pre-stroke levels or develop compensation strategies to work around functional impairments. For example, a patient might learn to hold a toothpaste tube in a way that allows their strong hand to unscrew the cap. During the first three months after a stroke, patients may experience spontaneous recovery, where a skill or ability that seemed lost returns suddenly as the brain finds new ways to perform tasks.

Some patients will experience setbacks in the months after a stroke, such as pneumonia, a heart attack, or a second stroke. These challenges can have significant physical, mental, and emotional effects, and rehabilitation might need to be put on hold. It is important for patients to work with their care team to adjust their rehabilitation goals when there are setbacks.

Even after six months, improvements are still possible, but they will be much slower. Most stroke patients reach a relatively steady state at this point, with some making a full recovery and others experiencing ongoing impairments, also called chronic stroke disease. Whether a full recovery is possible depends on several factors, including the severity of the stroke, how fast the initial treatment was provided, and the type and intensity of rehabilitation. It is crucial for patients to continue following up with members of their care team, including their primary care physician, a rehabilitation physician (physiatrist), physical, occupational, and speech therapists, a neurologist, and a rehabilitation psychologist.

Frequently asked questions