Physician scientists have now discovered that a series of surprisingly simple treatments—performed in the first 24 to 48 hours after a stroke—can prevent additional brain damage and help reduce the risk for disability and complications, including cognitive impairments.
Important: The recommendations described in this article apply only to patients who have had an ischemic stroke (caused by a blood clot). Almost 90% of all strokes are ischemic. Unless it’s otherwise noted, these recommendations do not apply to patients who have suffered a hemorrhagic (bleeding) stroke.
Most important treatments following stroke…
Maintain or raise blood pressure. It sounds counterintuitive because high blood pressure is one of the main risk factors for stroke—and because most stroke patients have a spike in blood pressure of about 20 points. But studies have shown that higher-than-normal blood pressure can help patients recover faster, with less brain damage.
Giving blood pressure–lowering drugs in the hospital can cause a decrease in cerebral perfusion pressure (a measurement of blood flow to the brain) that can increase damage.
Recommended: As a general rule, your blood pressure should not be lowered immediately after a stroke, even if you have existing hypertension. As long as your blood pressure reading is below 220/120 (normal is about 120/80), it should be left alone.
In some patients, particularly those with a blockage in a major blood vessel, it might be advisable to actively raise blood pressure with a vasopressive medication, such as phenylephrine (Neo-Synephrine).
Exceptions: Blood pressure may still need to be lowered in patients who have had a hemorrhagic stroke (caused by bleeding in the brain) or in those who are taking clot-dissolving drugs. Raising blood pressure in patients who are actively bleeding or at risk for bleeding can potentially cause more bleeding.
Reduce body temperature. Fever is common in stroke patients due to infection or the stroke itself, with up to 25% having a temperature of 100.4°F or higher within 48 hours after being admitted to the hospital. A fever is dangerous because it increases the metabolic demands of damaged brain tissue—energy that should go toward healing. It also triggers the release of inflammatory substances that can cause additional damage.
Recommended: Acetaminophen (Tylenol) and hydration. Cooling blankets may be used for fever above 101°F. An experimental treatment called therapeutic hypothermia involves rapidly lowering body temperature with a cooled saline solution given intravenously.
Rehydrate. Dehydration is common in stroke patients because fever and other complications can reduce the body’s fluids. If you’ve had a stroke and are dehydrated, your risk of forming additional blood clots is increased by fivefold. Reason: Dehydration reduces the volume of blood in the body. This, in turn, reduces blood pressure and increases the tendency of blood to clot.
Recommended: Intravenous (IV) saline solution for at least 24 to 48 hours.
Lower the bed. When the head of the bed is raised, the increased elevation can decrease cerebral blood flow, particularly when the stroke affects the middle cerebral artery, which is common in ischemic stroke.
Important finding: Studies suggest that lowering the head of the bed from 30 degrees to 15 degrees increases blood flow through the middle cerebral artery by 12%. There’s an additional 8% increase when the bed is flat.
The trade-off: Many patients aren’t comfortable when the bed is completely flat. They also have more trouble swallowing, which increases the risk that they’ll get pneumonia after inhaling (aspirating) foreign material from the mouth. Therefore, the head of the bed should initially be elevated to about 15 degrees. If the patient doesn’t improve, the bed can be lowered.
Use an insulin drip. It’s common for stroke patients to have high blood sugar because of preexisting diabetes or prediabetes. In addition, the stroke itself can temporarily raise blood sugar (in fact, any major stressor in the body can raise blood glucose levels). High blood sugar, or hyperglycemia, is associated with a 2.7-fold increase in poor outcomes following stroke. Poor outcomes could include language difficulties, paralysis, cognitive impairments, etc.
Recommended: Stroke patients should be tested for hyperglycemia immediately after arriving in the hospital emergency department and then as frequently as needed. If blood sugar is higher than 155 mg/dL, insulin should be administered intravenously.
Important: To help prevent stroke-related complications that are worsened by elevated blood sugar, these patients should not be given saline that contains glucose—even if they could benefit nutritionally from the additional sugar.
Give a statin quickly. Stroke patients routinely have their cholesterol tested in the hospital.
Recommended: There’s no need to wait for the results before giving patients a cholesterol-lowering statin drug, such as atorvastatin (Lipitor) or pravastatin (Pravachol).
Reason: Even if your cholesterol is normal, statins reduce the inflammatory brain damage that’s caused by stroke. Giving these medications quickly can help patients recover more promptly. Continuing statin therapy (if you have high cholesterol and are already taking a statin) can help prevent a subsequent stroke.
Start activity early. Hospitalized patients who are physically active to any degree—even if it is just sitting up in bed—improve more quickly and have fewer complications than those who are initially immobile.
Other benefits: Physical activity also reduces the risk for pneumonia, deep-vein thrombosis, pulmonary embolism and bedsores.
Recommended: Some form of activity within hours after having a stroke if the patient is neurologically stable. We encourage patients to spend as little time in bed as possible even if their mobility is impaired and to do as much as they can tolerate.
Important: Activity should always be carefully guided by nurses, therapists or other members of the hospital team to avoid injury.