Stroke consultation at Mayo Clinic
To determine the most appropriate treatment for your stroke, your emergency team needs to evaluate the type of stroke you're having and the areas of your brain affected by the stroke. They also need to rule out other possible causes of your symptoms, such as a brain tumor or a drug reaction. Your doctor may use several tests to determine your risk of stroke, including:
Physical examination. Your doctor will ask you or a family member what symptoms you've been having, when they started and what you were doing when they began. Your doctor then will evaluate whether these symptoms are still present.
Your doctor will want to know what medications you take and whether you have experienced any head injuries. You'll be asked about your personal and family history of heart disease, transient ischemic attack or stroke.
Your doctor will check your blood pressure and use a stethoscope to listen to your heart and to listen for a whooshing sound (bruit) over your neck (carotid) arteries, which may indicate atherosclerosis. Your doctor may also use an ophthalmoscope to check for signs of tiny cholesterol crystals or clots in the blood vessels at the back of your eyes.
- Blood tests. You may have several blood tests, which tell your care team how fast your blood clots, whether your blood sugar is abnormally high or low, whether critical blood chemicals are out of balance, or whether you may have an infection. Managing your blood's clotting time and levels of sugar and other key chemicals will be part of your stroke care.
- Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create a detailed image of your brain. A CT scan can show a hemorrhage, tumor, stroke and other conditions. Doctors may inject a dye into your bloodstream to view your blood vessels in your neck and brain in greater detail (computerized tomography angiography).
- Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and magnets to create a detailed view of your brain. An MRI can detect brain tissue damaged by an ischemic stroke and brain hemorrhages. Your doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow (magnetic resonance angiography, or magnetic resonance venography).
- Carotid ultrasound. In this test, sound waves create detailed images of the inside of the carotid arteries in your neck. This test shows buildup of fatty deposits (plaques) and blood flow in your carotid arteries.
- Cerebral angiogram. In this test, your doctor inserts a thin, flexible tube (catheter) through a small incision, usually in your groin, and guides it through your major arteries and into your carotid or vertebral artery. Then your doctor injects a dye into your blood vessels to make them visible under X-ray imaging. This procedure gives a detailed view of arteries in your brain and neck.
Echocardiogram. An echocardiogram uses sound waves to create detailed images of your heart. An echocardiogram can find a source of clots in your heart that may have traveled from your heart to your brain and caused your stroke.
You may have a transesophageal echocardiogram. In this test, your doctor inserts a flexible tube with a small device (transducer) attached into your throat and down into the tube that connects the back of your mouth to your stomach (esophagus). Because your esophagus is directly behind your heart, a transesophageal echocardiogram can create clear, detailed ultrasound images of your heart and any blood clots.
Emergency treatment for stroke depends on whether you're having an ischemic stroke blocking an artery — the most common kind — or a hemorrhagic stroke that involves bleeding into the brain.
To treat an ischemic stroke, doctors must quickly restore blood flow to your brain.
Emergency treatment with medications. Therapy with clot-busting drugs must start within 3 hours if they are given into the vein — and the sooner, the better. Quick treatment not only improves your chances of survival but also may reduce complications. You may be given:
- Aspirin. Aspirin is an immediate treatment given in the emergency room to reduce the likelihood of having another stroke. Aspirin prevents blood clots from forming.
Intravenous injection of tissue plasminogen activator (TPA). Some people can benefit from an injection of a recombinant tissue plasminogen activator (TPA), also called alteplase. An injection of TPA is usually given through a vein in the arm. This potent clot-busting drug needs to be given within 4.5 hours after stroke symptoms begin if it's given in the vein.
TPA restores blood flow by dissolving the blood clot causing your stroke, and it may help people who have had strokes recover more fully. Your doctor will consider certain risks, such as potential bleeding in the brain, to determine if TPA is appropriate for you.
Emergency procedures. Doctors sometimes treat ischemic strokes with procedures that must be performed as soon as possible, depending on features of the blood clot:
- Medications delivered directly to the brain. Doctors may insert a long, thin tube (catheter) through an artery in your groin and thread it to your brain to deliver TPA directly into the area where the stroke is occurring. The time window for this treatment is somewhat longer than for intravenous TPA but is still limited.
- Mechanical clot removal. Doctors may use a catheter to maneuver a tiny device into your brain to physically break up or grab and remove the clot.
However, recent studies suggest that for most people, delivering medication directly to the brain (intra-arterial thrombolysis) or using a device to break up or remove clots (mechanical thrombectomy) may not be beneficial. Researchers are working to determine who might benefit from this procedure.
Other procedures. To decrease your risk of having another stroke or transient ischemic attack, your doctor may recommend a procedure to open up an artery that's narrowed by fatty deposits (plaques). Doctors sometimes recommend the following procedures to prevent a stroke. Options will vary depending on your situation:
Carotid endarterectomy. In a carotid endarterectomy, a surgeon removes plaques from arteries that run along each side of your neck to your brain (carotid arteries). In this procedure, your surgeon makes an incision along the front of your neck, opens your carotid artery and removes plaques that block the carotid artery.
Your surgeon then repairs the artery with stitches or a patch made from a vein or artificial material (graft). The procedure may reduce your risk of ischemic stroke. However, a carotid endarterectomy also involves risks, especially for people with heart disease or other medical conditions.
- Angioplasty and stents. In an angioplasty, a surgeon gains access to your carotid arteries most often through an artery in your groin. Here, he or she can gently and safely navigate to the carotid arteries in your neck. A balloon is then used to expand the narrowed artery. Then a stent can be inserted to support the opened artery.
Emergency treatment of hemorrhagic stroke focuses on controlling your bleeding and reducing pressure in your brain. Surgery also may be performed to help reduce future risk.
Emergency measures. If you take warfarin (Coumadin) or anti-platelet drugs such as clopidogrel (Plavix) to prevent blood clots, you may be given drugs or transfusions of blood products to counteract the blood thinners' effects. You may also be given drugs to lower pressure in your brain (intracranial pressure), lower your blood pressure, prevent vasospasm or prevent seizures.
Once the bleeding in your brain stops, treatment usually involves supportive medical care while your body absorbs the blood. Healing is similar to what happens while a bad bruise goes away. If the area of bleeding is large, your doctor may perform surgery to remove the blood and relieve pressure on your brain.
Surgical blood vessel repair. Surgery may be used to repair blood vessel abnormalities associated with hemorrhagic strokes. Your doctor may recommend one of these procedures after a stroke or if an aneurysm or arteriovenous malformation (AVM) or other type of vascular malformation caused your hemorrhagic stroke:
- Surgical clipping. A surgeon places a tiny clamp at the base of the aneurysm, to stop blood flow to it. This clamp can keep the aneurysm from bursting, or it can prevent re-bleeding of an aneurysm that has recently hemorrhaged.
- Coiling (endovascular embolization). In this procedure, a surgeon inserts a catheter into an artery in your groin and guides it to your brain using X-ray imaging. Your surgeon then guides tiny detachable coils into the aneurysm (aneurysm coiling). The coils fill the aneurysm, which blocks blood flow into the aneurysm and causes the blood to clot.
- Surgical AVM removal. Surgeons may remove a smaller AVM if it's located in an accessible area of your brain, to eliminate the risk of rupture and lower the risk of hemorrhagic stroke. However, it's not always possible to remove an AVM if its removal would cause too large a reduction in brain function, or if it's large or located deep within your brain.
- Intracranial bypass. In some unique circumstances, surgical bypass of intracranial blood vessels may be an option to treat poor blood flow to a region of the brain or complex vascular lesions, such as aneurysm repair.
- Stereotactic radiosurgery. Using multiple beams of highly focused radiation, stereotactic radiosurgery is an advanced minimally invasive treatment used to repair vascular malformations.
Stroke recovery and rehabilitation
Following emergency treatment, stroke care focuses on helping you regain your strength, recover as much function as possible and return to independent living. The impact of your stroke depends on the area of the brain involved and the amount of tissue damaged.
If your stroke affected the right side of your brain, your movement and sensation on the left side of your body may be affected. If your stroke damaged the brain tissue on the left side of your brain, your movement and sensation on the right side of your body may be affected. Brain damage to the left side of your brain may cause speech and language disorders.
In addition, if you've had a stroke, you may have problems with breathing, swallowing, balancing and vision.
Most stroke survivors receive treatment in a rehabilitation program. Your doctor will recommend the most rigorous therapy program you can handle based on your age, overall health and your degree of disability from your stroke. Your doctor will take into consideration your lifestyle, interests and priorities, and the availability of family members or other caregivers.
Your rehabilitation program may begin before you leave the hospital. It may continue in a rehabilitation unit of the same hospital, another rehabilitation unit or skilled nursing facility, an outpatient unit, or your home.
Every person's stroke recovery is different. Depending on your condition, your treatment team may include:
- Doctor trained in brain conditions (neurologist)
- Rehabilitation doctor (physiatrist)
- Physical therapist
- Occupational therapist
- Recreational therapist
- Speech therapist
- Social worker
- Case manager
- Psychologist or psychiatrist
One way to evaluate the care of patients diagnosed with stroke is to look at the percentage of patients receiving the timely and effective care measures that are appropriate. The goal is 100 percent.
The graph below displays the percentage of eligible Mayo Clinic patients diagnosed with stroke receiving all of the appropriate care measures.
Stroke core measure
Timely and effective care
The following table reflects the timely and effective care measures for stroke.
|Timely and Effective Care for Stroke Patients
||Explanation of Care
|Percent of ischemic and hemorrhagic stroke patients who received venous thromboembolism (VTE) prophylaxis the day of or the day after hospital admission
||Stroke patients are at increased risk of developing venous thromboembolism (deep vein blood clots). Clinical practice guidelines for the prevention of VTE recommend the use of preventive therapies in at-risk patients.
|Percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge
||An antithrombotic agent is a drug that reduces the formation of blood clots. Studies suggest that antithrombotic therapy should be prescribed at hospital discharge following an ischemic stroke to reduce stroke mortality and morbidity.
|Percent of ischemic stroke patients with atrial fibrillation or atrial flutter who are prescribed anticoagulation therapy at hospital discharge
||Anticoagulation therapy is a course of drug therapy in which medications are administered to a patient to slow the rate at which the patient's blood clots. Nonvalvular atrial fibrillation is a common arrhythmia and an important risk factor for stroke. Arrhythmia means that the heart's normal beating rhythm is interrupted. The administration of anticoagulation therapy is an effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients.
|Percent of acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours of time last known well
||The goal is to quickly get rid of any blood clot(s) to restore function to the area that is impacted by a stroke, such as the brain. This may be achieved by administering the t-PA drug intravenously to eligible patients within three hours of stroke onset.
|Percent of ischemic stroke patients who received antithrombotic therapy by the end of hospital day two
||An antithrombotic is a medication that prevents blood clots. Studies at this time suggest that antithrombotic therapy should be administered within 2 days of symptom onset in acute ischemic stroke patients to reduce stroke mortality and morbidity.
|Percent of ischemic stroke patients with an LDL greater than or equal to 70 mg/dL, or LDL not measured, or who were on a lipid-lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge
||Statin drugs are medications used to reduce serum level of lipids such as cholesterol. The reduction of LDL cholesterol, through lifestyle modification and drug therapy when appropriate, is recommended for the prevention of recurrent ischemic stroke, heart attack, and other major vascular events.
|Percent of ischemic or hemorrhagic stroke patients, or their caregivers, who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke
||Patient education should include information about the event (e.g., cause, treatment, and risk factors), the role of various medications or strategies, as well as desirable lifestyle modifications to reduce risk or improve outcomes. Family/caregivers will also need guidance in planning effective and realistic care strategies appropriate to the patient's prognosis and potential for rehabilitation.
|Percent of ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services
||Stroke is a leading cause of serious, long-term disability in the United States. Early rehabilitation interventions initiated following stroke can enhance the recovery process and minimize functional disability. The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function.
|Appropriate care measure (ACM)
||The ACM is a pass-fail measure at the individual patient level that asks whether an eligible patient has received all of the appropriate care for the condition for which he or she is being treated.
Carotid Endarterectomy Mortality Rate
See related graph.
Carotid Stenting Mortality Rate
See related graph.
Comprehensive Stroke Measure
See related graph.
Comprehensive Stroke – Post Thrombolysis Revascularization Rate
See related graph.
Comprehensive Stroke – Timeliness of IV t-PA Therapy
See related graph.
For additional information and data visit Medicare Hospital Compare.
For additional information about quality at Mayo Clinic visit Quality Measures.
Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this disease.
Coping and support
A stroke is a life-changing event that can affect your emotional well-being as much as your physical function. You may experience feelings of helplessness, frustration, depression and apathy. You may also have mood changes and less of a sex drive.
Maintaining your self-esteem, connections to others and interest in the world are essential parts of your recovery. Several strategies may help you and your caregivers, including:
- Don't be hard on yourself. Accept that physical and emotional recovery will involve tough work and that it will take time. Aim for a "new normal," and celebrate your progress. Allow time for rest.
- Get out of the house even if it's hard. Try not to be discouraged or self-conscious if you move slowly and need a cane, walker or wheelchair to get around. Getting out is good for you.
- Join a support group. Meeting with others who are coping with a stroke lets you get out and share experiences, exchange information and forge new friendships.
- Let friends and family know what you need. People may want to help, but they may not know what to do. Let them know how they can help, such as by bringing over a meal and staying to eat with you and talk, or attending social events or religious activities.
- Know that you are not alone. Nearly 800,000 Americans have a stroke every year. Approximately every 40 seconds someone has a stroke in the United States.
One of the most frustrating effects of stroke is that it can affect your speech and language. Here are some tips to help you and your caregivers cope with communication challenges:
- Practice will help. Try to have a conversation at least once a day. It will help you learn what works best for you, feel connected and rebuild your confidence.
- Relax and take your time. Talking may be easiest and most enjoyable in a relaxing situation when you have plenty of time. Some stroke survivors find that after dinner is a good time.
- Say it your way. When you're recovering from a stroke, you may need to use fewer words, rely on gestures or use your tone of voice to communicate.
- Use props and communication aids. You may find it helpful to use cue cards showing frequently used words, pictures of close friends and family members, or daily activities, such as a favorite television show or the bathroom.
Preparing for your appointment
A stroke in progress is usually diagnosed in a hospital. If you're having a stroke, your immediate care will focus on minimizing brain damage. If you haven't yet had a stroke, but you're worried about your future risk, you can discuss your concerns with your doctor at your next scheduled appointment.
What to expect from your doctor
In the emergency room, you may see an emergency medicine specialist or a doctor trained in brain conditions (neurologist), as well as nurses and medical technicians.
Your emergency team's first priority will be to stabilize your symptoms and overall medical condition. Then they will determine if you're having a stroke. Doctors will try to find the cause of your stroke to determine the most appropriate treatment.
If you're seeking your doctor's advice during a scheduled appointment, your doctor will evaluate your risk factors for stroke and heart disease. Your discussion will focus on avoiding these risks, such as not smoking or using illicit drugs. Your doctor also will discuss lifestyle strategies or medications to control high blood pressure, cholesterol and other stroke risk factors.
In some cases, your doctor may recommend certain tests and procedures. These will help the doctor to better understand your risk of stroke. They may also help treat underlying conditions that can increase your risk.
Aug. 15, 2017