Can Stroke Be Treated? Care Options and Concerns

Can a stroke be treated?

My mother suddenly experienced facial drooping and weakness in her left arm and leg, and was urgently taken to the hospital.
The doctor diagnosed her with a stroke and administered three doses of tissue plasminogen activator (tPA) and started an IV drip.
She was admitted to the hospital, but during her stay, she experienced recurrent stroke symptoms every day.
Each time, the nursing station was notified, and a nurse would come to assess her for weakness in her limbs (without administering any additional medication; every morning, the nurse would give her one dose of tPA).
After four days, I was really unsure what the purpose of staying in the hospital was, so I asked the doctor if she could be discharged.
To my surprise, the doctor said yes.
Upon discharge, the doctor informed me that my mother had complete occlusion of the right carotid artery and multiple infarcts in the brain.
I asked the doctor if medication could improve her condition, and the doctor shook his head, implying that my mother was too old (75 years) for surgery.
I then asked the doctor if we were just supposed to let her continue having strokes.
The doctor replied that it wasn't the case, and suggested adding another medication, clopidogrel, which left me stunned.
I asked the doctor: 1.
Should we not be concerned about the occurrence of stroke symptoms? 2.
If clopidogrel can prevent further strokes, then shouldn't it have been administered during her hospitalization when she experienced increasingly severe stroke symptoms?

Da Yu, 30~39 year old female. Ask Date: 2017/11/08

Dr. Hong Weibin reply Neurology

Currently, for the treatment of stroke, if a patient arrives at the hospital within 3 hours of the onset of acute stroke symptoms (calculated from the last time they were normal), thrombolytic therapy can be administered.
If the patient arrives within 4 to 6 hours (and in some cases, up to 8 hours for certain vessels), based on cerebral CT perfusion imaging (to determine the extent of ischemic necrosis), if the necrotic core is small but the ischemic area is large, endovascular thrombectomy can be performed (refer to https://youtu.be/UzTygYAagJQ).
If the time exceeds these limits, the current treatment options are limited to medication.
According to American treatment guidelines, the dosage of aspirin (Bayer) for preventing secondary strokes is 80-360 mg daily.
The acute phase of an ischemic stroke lasts approximately 5-7 days from the onset of symptoms.
During this acute phase, stroke symptoms may change at any time, necessitating hospitalization for observation.
After hospitalization, depending on the patient's condition, we may administer a higher dose of antiplatelet agents (Aspirin 300 mg/day) to prevent stroke deterioration, along with an appropriate amount of saline infusion.
A portion of patients (approximately 30-40% of all stroke patients) may initially present with mild stroke symptoms and are admitted to the hospital after being sent to the emergency department.
However, after 2-3 days of hospitalization, their symptoms may worsen, a phenomenon known as stroke in progression.
Symptoms that may worsen include a decline in consciousness (the patient, who was previously responsive, becomes increasingly lethargic, with minimal response to painful stimuli), deterioration in swallowing function (the patient, who could previously drink and eat without choking, now chokes easily and coughs after meals), and increased weakness in limbs (the previously affected side could be lifted off the bed or the patient could walk to the bathroom, but now they cannot lift their hand or move their foot).
The exact mechanism remains unclear.
Unfortunately, there are currently no effective treatment options for this condition.
Clinically, we can only increase the patient's intravenous fluids to maintain good circulation, administer higher doses of oral antiplatelet medications (Aspirin or other oral antithrombotic agents), or consider the patient self-paying for neuroprotective agents (Piracetam, 12 g/day, as there are no large-scale clinical trials confirming the efficacy of this medication for stroke symptom progression, thus it is not covered by insurance).
If the patient's consciousness deteriorates to the point of affecting respiratory function, we may arrange an emergency CT scan of the head to monitor changes in the brain and discuss with the family whether intubation is necessary to assist the patient through the critical period with a ventilator.
In cases of severe strokes, such as internal carotid artery occlusion, middle cerebral artery occlusion, and cerebellar infarction, which can lead to cerebral edema, severe cases may result in brain herniation.
Due to the constraints of the skull, there is limited space for cerebral edema, which can exert pressure on normally functioning brain tissue, such as the thalamus and brainstem, leading to a decline in consciousness.
If we wish to save the patient's life, we must urgently consult neurosurgery for a craniotomy or placement of a ventricular drain.
It is important to understand that surgery is a life-saving option, but its effectiveness in restoring the patient's consciousness and improving quality of life is uncertain.
If the patient has swallowing difficulties, a nasogastric tube may be required to assist with feeding.
If the patient has poor muscle strength, rehabilitation training will be necessary after the acute phase of the stroke to help restore muscle strength.
Based on your description, your mother's condition is likely indicative of stroke in progression.
Unfortunately, there are currently no effective treatments for this situation, and we can only wait for the patient to pass through the acute phase of the stroke before initiating rehabilitation.
Concurrent use of aspirin and clopidogrel is a strategy to prevent recurrent strokes, but it may carry a higher risk of bleeding (including intracranial hemorrhage, gastrointestinal bleeding, hemoptysis, hematuria, etc.).
Some foreign studies suggest that it is possible to use both antiplatelet medications (i.e., aspirin and clopidogrel) simultaneously, but using them for more than 90 days significantly increases the risk of bleeding for the patient.
Medical care often requires consideration of many factors (patient age, past medical history, treatment side effects, etc.), and it is not possible to account for every aspect.
Sometimes, physicians can only choose the method that poses the least harm to the patient, which may not necessarily be the most beneficial approach.
Wishing you a speedy recovery.

Reply Date: 2017/11/08

More Info

Stroke is a serious medical condition that requires immediate attention and appropriate treatment. Understanding the options for stroke care and addressing concerns about treatment can be crucial for both patients and their families.
When a stroke occurs, it is typically due to a blockage of blood flow to the brain (ischemic stroke) or a rupture of a blood vessel (hemorrhagic stroke). The immediate treatment for an ischemic stroke often involves medications such as tissue plasminogen activator (tPA), which can dissolve the clot and restore blood flow if administered within a specific time frame. In some cases, mechanical thrombectomy may be performed to physically remove the clot. For hemorrhagic strokes, the focus may be on controlling bleeding and reducing pressure in the brain.

In your case, it appears that your mother experienced multiple strokes during her hospital stay, which can be alarming. The fact that she was given a medication (likely a blood thinner or antiplatelet agent) and monitored for her symptoms indicates that the medical team was attempting to manage her condition. However, it is concerning that there was a lack of proactive treatment in response to the recurring stroke symptoms.
1. Addressing Stroke Symptoms: It is essential to take any signs of a stroke seriously. Symptoms such as facial drooping, weakness in one arm or leg, and speech difficulties should prompt immediate medical evaluation. If your mother was experiencing these symptoms repeatedly, it would be reasonable to expect a more aggressive approach to her treatment. Communication with the healthcare team is vital; if you feel that your mother's condition is not being adequately addressed, you should advocate for her care.
2. Use of Medications: The use of medications like 保栓通 (which I assume refers to an antiplatelet or anticoagulant medication) can indeed help prevent further strokes by improving blood flow and reducing clot formation. If the physician suggested adding this medication, it indicates that they recognize the risk of further strokes. However, the decision to start or change medications should be based on a thorough assessment of the patient's overall health, potential benefits, and risks, especially considering her age and medical history.

3. Discharge Planning: If the physician deemed it appropriate for your mother to be discharged, it is crucial to understand the rationale behind this decision. Discharge should not mean that the patient is left without a plan for ongoing care. You should inquire about follow-up appointments, rehabilitation options, and any necessary lifestyle changes that can help manage her condition.
4. Second Opinions: If you are dissatisfied with the care your mother is receiving, seeking a second opinion from another neurologist or stroke specialist can provide additional insights and treatment options. In many healthcare systems, obtaining a second opinion is a common practice and can help ensure that all potential treatment avenues are explored.

5. Rehabilitation: After a stroke, rehabilitation is often necessary to help regain lost functions and improve quality of life. This may include physical therapy, occupational therapy, and speech therapy, depending on the specific deficits your mother is experiencing.

In summary, stroke treatment is multifaceted and requires a collaborative approach between healthcare providers and family members. It is essential to advocate for your loved one, ensure that all symptoms are taken seriously, and explore all available treatment options. If you feel that your mother's care is lacking, do not hesitate to seek further evaluations or alternative opinions to ensure she receives the best possible care.

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