Current Management Of Stroke

Introduction

Stroke is a major public health problem globally and surviving patients have very high risks of recurrence (Wolfe et al, 2010). It is the third-largest cause of death in England(Raithatha et al, 2013). The World Health Organization defines stroke as “a rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin” (Coupland et al, 2017). However, the American Stroke Association has developed a new definition of stroke which besides clinical definition includes “infarction of the brain, spinal cord, or retinal cell death due to ischemia, based on pathological, imaging, or other objective evidence of cerebral, spinal cord, or retinal focal ischemic injury in a definite vascular distribution” (Sacco et al, 2013).

The majority of the Stroke cases is ischaemic (87%) while others (15%) are haemorrhagic( Doberstein et al,2017). In haemorrhagic stroke, following the break of an artery in the brain, there is increase in volume of the haemorrhage over time leading to an elevated intracranial pressure (Mikulik and Wahlgren 2015). In ischaemic stroke, there is occlusion of a cerebral artery, followed by a reduction in blood flow to the distant tissue and subsequent death of the compromised cells in a few hours. The brain tissue is intricately sensitive to ischemia, and about 1.9 million neurons die every minute that blood is not supplying the brain tissue. Time is brain (Saver 2006). Coronary heart disease (CHD) and stroke are projected to maintain their ranking as the top two causes of death worldwide by 2020 thus routine examination of patients’ blood pressures should be done to prevent CHD and stroke(Hamzat et al 2010). Modifiable risk factors are hypertension, diabetes mellitus and cardiac diseases. About 30% of patients die within a year of developing a stroke, with 50% of survivors suffering from a long-term disability. An analysis of patients from the third International Stroke Trial (IST-3) revealed that about one-third were alive and independent at six months post stroke events (The IST-3 Collaborative Group, 2012).

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Clinical presentation

Accurate diagnosis and classification will assist physicians in management and prediction of outcome in stroke cases. The National Institute for Health and Clinical Excellence (NICE) in United Kingdom recommends the use of a validated recognition tool called ‘Recognition of Stroke In the Emergency Room’ (ROSIER) for a rapid diagnosis of stroke. Its’ sensitivity is 93%. It can be used to assess blood sugar, visual field, documentation of a history of seizures, level of consciousness, and also focal neurological weakness and speech problems (Raithatha et al, 2013). The neurological symptoms depend on the site and the size of the lesion. Larger infarcts are associated with worse prognosis. The symptoms include hemiparesis, sensory dysfunction, dysarthria, facial asymmetry and impaired vision. The level of function is usually graded between 0 and 6 on the modified Rankin scale (mRS) score, with 0 signifying normal functional status and 6 showing lethal outcome. Patients that maintain self-care for activities of daily living corresponds to an mRS score of 0–2. A score of 0–1 is usually classified as a perfect functional outcomes.

Computed tomography scan of the brain is the most common form of clinical imaging procedure used in the treatment of stroke. Diffusion-weighted magnetic resonance imaging (MRI) is very effective in evaluation of cerebral changes in ischaemic stroke. Serum Troponin level is elevated in stroke conditions and might be useful in prognostication (Raithatha et al, 2013).

Management

To improve outcome in management of stroke, it is expedient to intervene in the acute phase of stroke to improve the size of the stroke lesion, which becomes irreversible over the first few hours after the onset of symptoms. Ischaemic changes can be reversed only by early restoration of blood flow. Modern treatment approaches require excellent organization in terms of early identification of stroke symptoms, as well as highly specialized and efficient in-hospital care to achieve early restoration of blood flow.

Thrombolysis

In management of stroke, intravenous thrombolysis was effective in reversal of neurological deficit, but the therapy is not currently used in many places. This is useful in patients presenting within 4.5 h of onset of acute ischaemic stroke. Intravenous recombinant tissue plasminogen activator (alteplase-t-PA) is administered. Although it has been established that rtPA given within the first 3h is beneficial, rtPA given up to 6 hour post symptom onset might also be beneficial(Lindley et al, 2012)

Hemicraniectomy

After medical treatment, many patients have perpetual neurologic deficits such as hemiplegia, aphasia, and visual loss. Surgery for restoration of function are important to complement medical treatment. Procedures such as Stem cell transplantation, neuro-modulation and cortical stimulation techniques, and brain-computer interface technologies are likely to improve neuro- restoration and are subjects of future research (Doberstein et al, 2017). For patients who did not respond well to medical management, decompressive surgery has been recommended for those with space occupying hemispheric infarction. The justification for this therapy is to create compensatory space to house the enlarging brain, consequently controlling intracranial pressure, and averting tissue injury(Juttler et al, 2007).

Decompressive surgery for malignant cerebral infarcts, at least in patients under the age of 60 years, is now also well-documented. Endovascular thrombectomy is recommended for anterior circulation stroke due to large-vessel occlusion. In this case, a rapid assessment is very important and management should start in six hours. The blood pressure should be monitored carefully during the procedure and hypotension should be treated aggressively as the need arises (McMahon et al, 2019). Stroke patients below 60 who has malignant middle cerebral artery region infarction should have decompressive hemicraniectomy (Raithatha et al, 2013).

In the DESTINY (Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery) study by Juttler et al, they chose a sequential design which could be adjusted as the study progresses. Intention to treat analysis was used to avoid bias. However, combining per-protocol analysis with intention to treat analysis is usually recommended for a non-inferiority trial while the DESTINY trial was closer to a superiority trial. This study showed that hemicraniectomy significantly reduces death and improve outcome in respondents

Secondary prevention

Secondary prevention of stroke will require effective management of risk factors like diabetes mellitus, hypertension, smoking and hyperlipidaemia. After an episode of stroke, the risk of recurrence, death, and use of health services is high. Secondary prevention of stroke is very important to avoid complications associated with stroke. To achieve a good secondary prevention of stroke, surviving patients need to be followed up adequately including proper management of risk factors of recurrence.

Wolfe et al conducted a cluster randomized control trial to evaluate the impact of intervention in secondary prevention of stroke. Groups of patients were randomized to receive or not to receive intervention (Wolfe et al, 2010). Randomization of groups of patients in different practice areas would improve the external validity of the study. Analysis was performed by the use of intention to treat by taking into consideration all randomized respondents from the beginning of the study including those who did not complete the study. The fact that patients were not blinded would introduce bias into the study. From the study, no improvement in risk factor management was found which created room for further studies to be carried out in this area.

Very early mobilization was defined by Langhorne et al as the beginning of sitting, standing and walking out of bed after stroke within 24 hours of stroke event based on severity of stroke. However, despite being a very big study with high external validity, the earlier the patients started mobilization the worse their conditions. Therefore there is a need to know who to target for early mobilization and the characteristics of early mobilization. In other to evaluate the effect of early mobilization of patients with stroke, Herisson et al conducted a randomized controlled trial of patients after stroke events. The first group seated out of bed one calendar day after a stroke event while the second group was seated out of bed on the third calendar day. No significant difference was found between the two groups, however there is need to conduct a bigger study because the sample size used in this study was relatively small (Herisson et al, 2016).

Conclusion

Although a lot have been done in stroke research which has led to improvement in patients’ management, there is room for more studies in both medical and surgical management of stroke because the mortality is still relatively high.

References

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