DescriptionAn in-depth report on the causes, diagnosis, treatment, and prevention of stroke.
Alternative NamesAtrial Fibrillation; Transient Ischemic Attacks
Patients should begin all measures, including any medications and life-style changes needed to prevent another stroke. For those whose stroke was ischemic, aspirin, warfarin, or both will usually be prescribed.
Using a neurologist as the primary physician after a stroke, rather than some other specialist or primary care doctor, significantly increases the chance for survival. In any case, patients or their families should be persistent in requesting the best care possible during this important early period.
Being treated initially in a stroke unit instead of a general ward plays a strong role for better long-term quality of life. Rehabilitation services aimed at patients living at home are also very effective in improving independence. Unfortunately, Medicare cuts are making it difficult to obtain adequate rehabilitation. Patients or their families should seek patient advocates or support associations.
Reducing the Risk for Non-Neurologic Complications after a Stroke
In addition to problems brought on by neurologic damage, stroke patients are also at risk for other serious problems that reduce their chances for survival. They include the following:
Measures should be taken to monitor and treat patients for these important problems.
Candidates for Rehabilitation
In all, 90% of stroke survivors experience varying degrees of improvement after rehabilitation. With current cost cutting, there is pressure to send elderly stroke victims directly to a nursing home rather than try rehabilitation first, although one study found that patients were three times more likely to return home from rehab units than from nursing homes. Not all patients, however, need or benefit from formal rehabilitation:
Positive factors that help predict good candidates for rehabilitation:
Factors that might predict a poor response to rehabilitation:
Factors that do not rule out rehabilitation:
Some Approaches to Rehabilitation
Physical therapy should be started as soon as the patient is stable, as early as two days after the stroke. Some patients will experience the fastest recovery in the first few days but many will continue to improve for about six months or longer. Because stroke affects different parts of the brain, specific approaches to managing rehabilitation vary widely among individual patients:
Drug Therapy for Rehabilitation
Drug therapy can sometimes help relieve specific effects of stroke:
Certain drugs commonly taken for conditions associated with stroke may actually slow recovery. They include drugs used for high blood pressure, including clonidine and prazosin, anticonvulsant drugs, the antipsychotic drug haloperidol, and the common anti-anxiety drugs benzodiazepines.
Managing the Emotional Consequences
The Emotional State of the Patients. Strong motivation with the goal of independence after rehabilitation is important for recovery. Unfortunately, depression is very common after a stroke, both as a direct and indirect result of the stroke:
If depression is prolonged, it can impair recovery. One study showed that people who suffered strokes and became depressed were three times more likely to die within ten years than stroke victims who were not depressed. There is a significantly increased risk of suicide in patients with stroke, especially in women and those under age 60.
Antidepressants, particularly fluoxetine (Prozac) and similar so-called SSRI drugs, have been beneficial in relieving post-stroke crying and to improve recovery in general, and mood in particular, in patients who are depressed. Antidepressants may also help restore mental abilities.
Some physicians also recommend agents called tricyclic antidepressants, including amitriptyline (Elavil) and nortriptyline (Pamelor). In one 2000 study nortriptyline (Pamelor) not only improved mood but also had positive effects on mental functioning, suggesting perhaps that some dementia associated with stroke may actually be due to depression. Tricyclics may also be useful for neurologic emotionalism.
Anxiety disorder is also common and debilitating. Some research, in fact, indicates that many patients suffer from feelings identical to post-traumatic stress syndrome. The two disorders often overlap, but drug treatments for each differ and may offset the other.
It should be noted that many drugs for psychologic disorders affect the central nervous system and can actually delay rehabilitation. Skilled professional help is needed to determine the most effective and safest treatments.
The Emotional State of the Caregiver. The caregiver's emotions and responses to the patient are critical. Patients do worse when caregivers are depressed, over-protective, and not knowledgeable about the stroke. Unfortunately, in one study, over half of the caregivers themselves were depressed, particularly if the stroke victims were left with dementia or abnormal behavior.