Hemorrhagic Stroke – Causes, Symptoms, Diagnosis, Treatment

hemorrhagic stroke

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Hemorrhagic Stroke is due to bleeding into the brain by the rupture of a blood vessel. Hemorrhagic stroke may be further subdivided into intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). ICH is bleeding into the brain parenchyma, and SAH is bleeding into the subarachnoid space. Hemorrhagic stroke is associated with severe morbidity and high mortality.[2] Progression of hemorrhagic stroke is associated with worse outcomes. Early diagnosis and treatment are important in view of the usual rapid expansion of hemorrhage, causing sudden deterioration of consciousness and neurological dysfunction.

Pathophysiology

The common sites of the bleed are the basal ganglia (50%), cerebral lobes (10% to 20%), the thalamus (15%), pons and the brain stem (10% to 20%), and the cerebellum(10%)(fig.1,2,3). The hematoma disrupts the neurons and glia. This results in oligaemia, neuro-transmitter release, mitochondrial dysfunction, and cellular swelling. Thrombin activates microglia, causes inflammation and edema.

The primary injury is due to the compression by the hematoma and an increase in the intracranial pressure(ICP).

Secondary injury is contributed by inflammation, disruption of the blood-brain barrier (BBB), edema, overproduction of free radicals such as reactive oxygen species (ROS), glutamate-induced excitotoxicity, and release of hemoglobin and iron from the clot.

Usually, the hematoma enlarges in 3 hours to 12 hours. The enlargement of hematoma occurs in 3 hours in one-third of cases. The Perihematomal edema increases in 24 hours, peaks around 5–6 days, and lasts up to 14 days. There is an area of hypoperfusion around the hematoma. The factors causing deterioration in ICH are an expansion of hematoma, intraventricular hemorrhage, perihematomal edema, and inflammation. Cerebellar hematoma produces hydrocephalus by compression of the fourth ventricle in the early stage.

Non-aneurysmal spontaneous subarachnoid hemorrhage may be either perimesencephalic or non-perimesencephalic SAH. In perimesencephalic SAH, bleeding is mainly in the interpeduncular cistern. Physical exertion such as Valsalva maneuver producing increased intrathoracic pressure, and elevated intracranial venous pressure, is a predisposing factor for perimesencephalic nonaneurysmal SAH (PM-SAH). There is diffuse blood distribution in non-perimesencephalic SAH (NPM-SAH).

Types of Hemorrhagic Stroke

  • Anterior Cerebral Artery (ACA) Infarction – There is significant collateral blood supply in the ACA territory. So, pure ACA strokes are rare. The ACA distribution involves mainly Broca’s area, primary motor, primary sensory and pre-frontal cortex. So patients present with motor aphasia, personality issues, and contralateral leg weakness and numbness. Hand and face are usually spared.
  • Middle Cerebral Artery (MCA) Infarction – The MCA has the main trunk (M1) and it divides into two M2 Branches. The M1 (horizontal branch) supplies the basal ganglia and M2 (Sylvian branches) supplies part of the parietal, frontal and temporal lobes. As MCA supplies a wide territory it is extremely important to rule out MCA occlusion. The MCA syndrome causes contralateral arm and facial numbness and weakness, gaze deviation towards the affected side. Aphasia in the left-sided lesions and neglect in the right-sided lesions.
  • Posterior Cerebral Artery (PCA) Infarction – The PCA mainly supplies occipital lobe, thalamus and some portion of the temporal lobe. The classic presentation of PCA stroke is homonymous hemianopsia. Apart from this hypersomnolence, cognitive issues, the chemosensory loss can be seen when the deep PCA is involved. Some times there is bilateral infarction of distal PCAs producing cortical blindness and the patient is unaware of the blindness and denies it. This is called Anton-Babinski syndrome.
  • Cerebellar Infarction – The patients with cerebellar strokes present with ataxia, dysarthria, nausea, vomiting, and vertigo.  Lacunar strokes are due to occlusion of small perforating vessels and can be a pure motor, pure sensory and ataxic hemiparetic strokes. In general, these strokes don’t impair memory, cognition, level of consciousness or speech.

Causes of Hemorrhagic Stroke

Hypertension is the most common cause of hemorrhagic stroke.
  • Longstanding hypertension produces degeneration of media, breakage of the elastic lamina, and fragmentation of smooth muscles of arteries.
  • Lipohyalinosis, fibrinoid necrosis of the subendothelium, microaneurysms, and focal dilatations are seen in the arterioles. The microaneurysms are named as Charcot-Bouchard aneurysms.
  • The common sites of origin of hypertension-induced intracerebral hemorrhage are the small penetrating arteries that originate from basilar arteries or the anterior, middle, or posterior cerebral arteries.
  • Small artery branches of 50 to 700 μm in diameter often have multiple sites of rupture associated with layers of platelet and fibrin aggregates.
  • Hypertensive change causes non-lobar intracranial hemorrhage (ICH). Acute hypertension, as seen in eclampsia, also can cause ICH, known as postpartum ICH.
Cerebral amyloid angiopathy (CAA)

It is an important cause of primary lobar intracerebral hemorrhage in older adults.

  • It is characterized by the deposition of the amyloid-β peptide in the capillaries, arterioles, and small- and medium-sized arteries in the cerebral cortex, leptomeninges, and cerebellum.
  • This causes ICH in elderly people, commonly associated with variations in the gene encoding apolipoprotein E.
  • A familial syndrome can occur in young patients, typically associated with mutations in the gene encoding amyloid precursor protein.
  • The incidence of CAA increases with age to the extent that around 50% of those aged more than 70years have CAA. Recurrent hemorrhages can occur due to CAA.
Other Important Causes
  • Cigarette smoking and moderate or heavy alcohol consumption and chronic alcoholism.
  • Chronic liver disease also increases the chance of ICH due to coagulopathy and thrombocytopenia.
  • Decreased low-density lipoprotein cholesterol and low triglycerides are also considered to be risk factors.
  • Dual antiplatelet therapy has an increased risk of ICH than monotherapy.
  • Sympathomimetics such as cocaine, heroin, amphetamine, ephedrine, and phenylpropanolamine carry an increased risk of a cerebral hemorrhage.
  • Cerebral microbleeds (CMBs) associated with hypertension, diabetes mellitus, and cigarette smoking increase the risk of ICH.
  • Old age and male sex. The incidence of ICH increases after 55 years of age. The relative risk after 70 years is 7.
  • The tumors which are more prone to bleed are glioblastoma, lymphoma, metastasis, meningioma, pituitary adenoma, and hemangioblastoma.

The usual causes of spontaneous subarachnoid hemorrhage (SAH) are ruptured aneurysm of a cerebral artery, arteriovenous malformation, vasculitis, cerebral artery dissection, dural sinus thrombosis, and pituitary apoplexy. The risk factors are hypertension, oral contraceptive pills, substance abuse, and pregnancy.

Intracranial hemorrhage of pregnancy (ICHOP-intracerebral or subarachnoid hemorrhage) occurs with eclampsia. It is due to the loss of cerebrovascular autoregulation.

Symptoms of Hemorrhagic Stroke

The American Stroke Association has suggested the acronym ACT FAST to recognize the early symptoms of a stroke. They include:

  • F (Face) – A droop or an uneven smile on a person’s face.
  • A (Arms) – Arm numbness or weakness – Elicited by asking the patient to lift the arms
  • S (Speech difficulty) – Slurred speech or difficulty in understanding speech
  • T (Time) – If any of the above features are present, even if transient, it is time to call the emergency helpline (911).
The additional symptoms of stroke to be watched for are
  • Sudden Numbness
  • Sudden Confusion
  • Sudden Trouble Seeing
  • Sudden Trouble Walking
  • Sudden Severe Headache
The stroke can be quantified by the NIHSS scale which includes the following
  • Visual function
  • Level of consciousness
  • Sensation and neglect
  • Motor function
  • Cerebellar function
  • Language

A high score suggests proximal vessel occlusion.

Features of middle cerebral artery stroke
  • Contralateral hemiparesis and hypesthesia (Weakness of arm& face is worse than in the lower limb)
  • Gaze towards to side of lesion
  • Ipsilateral hemianopsia
  • Receptive or expressive aphasia is dominant hemisphere is affected
  • Agnosia
  • Inattention, neglect
Features of anterior cerebral artery stroke
  • Speech is preserved but there is disinhibition
  • Mental status is altered
  • Judgment is impaired
  • Contralateral cortical sensory deficits
  • Contralateral weakness greater in legs than arms
  • Urinary incontinence
  • Gait apraxia
Posterior cerebral artery stroke
  • Cortical blindness
  • Contraletarl homonynous heminopsia
  • Altered mental status
  • Visual agnosia
  • Memory impairment
Vertebral/basilar artery stroke
  • Nystagmus
  • Vertigo
  • Diploia and visual field deficits
  • Dysarthria
  • Dysphagua
  • Syncope
  • Facial hypersthesia
  • Ataxia
Intracerebral hemorrhage

Symptoms almost always occur when the person is awake. Symptoms tend to appear without warning, but they can develop gradually. Symptoms worsen over a period of 30 to 90 minutes. Symptoms can include

  • Sudden weakness
  • Paralysis or numbness in any part of the body
  • Inability to speak
  • Inability to control eye movements correctly
  • Vomiting
  • Difficulty walking
  • Irregular breathing
  • Stupor
  • Coma
Subarachnoid hemorrhage

When caused by a ruptured aneurysm, symptoms can include:

  • A very severe headache that starts suddenly (Some people describe it like a “thunderclap.”)
  • Loss of consciousness
  • Nausea and vomiting
  • Inability to look at bright light
  • Stiff neck
  • Dizziness
  • Confusion
  • Seizure
  • Loss of consciousnes

Diagnosis of Hemorrhagic Stroke

History and Physical

The common presentations of stroke are headache, aphasia, hemiparesis, and facial palsy. The presentation of hemorrhagic stroke is usually acute and progressing. Acute onset headache, vomiting, neck stiffness increases in blood pressure, and the rapidly developing neurological signs are the common clinical manifestations of hemorrhagic stroke. Symptoms can lead to the extent and location of hemorrhage.

  • Headache is more common in a large hematoma.
  • Vomiting indicates raised intracranial pressure and is common with cerebellar hematoma.
  • Coma occurs in the involvement of the reticular activating system of the brainstem.
  • Seizure, aphasia, and hemianopia are seen in lobar hemorrhage. A prodrome consisting of numbness, tingling, and weakness may also occur in lobar bleed.
  • Contralateral sensorimotor deficits are the features in hemorrhage of the basal ganglia and thalamus.
  • Loss of all sensory modalities is the main feature of thalamic hemorrhage.
  • Extension of thalamic hematoma into midbrain can cause vertical gaze palsy, ptosis, and unreactive pupil.
  • Cranial nerve dysfunction with contralateral weakness indicates brainstem hematoma.
  • Usually, pontine hematoma produces coma and quadriparesis.

Cerebellar hemorrhage produces symptoms of raised ICP, such as lethargy, vomiting, bradycardia. Progressive neurological deterioration indicates the enlargement of hematoma or an increase in edema.

The stroke exam is a multi-person coordinated rapid exam.  While staff obtain vitals, attach telemetry, and obtain IV access, the physician performs a rapid neurological evaluation.  National Institutes of Health Stroke Scale (NIHSS) is routinely used to get the baseline evaluation. The exam has to be rapid as “time is brain.”  One must examine the following items:

  • The level of consciousness (alert and responsive, arouses to noxious stimuli, comatose…)
  • Language (fluency, naming, comprehension, repetition)
  • Dysarthria (slurring) which may be picked up in the history
  • Motor (subtle arm weakness can be picked up by performing a pronator drift)
  • Visual field deficits
  • Eye movement abnormalities (in general if a gaze preference is present, the eyes deviate towards the side of the lesion)
  • Facial paralysis (asking the patient to smile)
  • Ataxia (finger to nose)

With a good history and physical exam, we can localize the stroke. There are various stroke syndromes.

The clinical features of subarachnoid hemorrhage are severe headache described as a thunderclap, vomiting, syncope, photophobia, nuchal rigidity, seizures, and decreased level of consciousness. Signs of meningismus such as Kernig sign (pain on straightening the knee when the thigh is flexed to 90 degrees) and Brudzinski sign (involuntary hip flexion on flexing the neck of the patient) may be positive.

Imaging

This is followed by a rapid, concise, history and exam such as the NIHSS which is administered simultaneously as the patient gets IV access, telemetry, and labs were drawn.  The patient should then get a stat non-contrasted head computed tomogram (CT) or a combination of head CT, CT Angiography, and perfusion imaging. “Time is brain,” and so we should not waste any time at all.  Ideally, rtPA should be prepared as imaging is occurring, and as soon as the non-contrasted head CT can be visualized, and a bleed is excluded, rtPA should be administered after discussing the risks and benefits, and excluding rtPA contraindications.  Time is critical, as only patients who get all the required studies within 4.5 hours qualify for potentially lifesaving thrombolysis.  After IV rtPA, the CT angiography should be reviewed to determine if the patient qualifies for endovascular therapy as well.

The earliest CT sign of stroke is
  • A hyperdense segment of a vessel (direct visualization of the intravascular thrombus/embolus)  – most often seen in the MCA (hyperdense MCA sign and MCA dot sign)
Interpretation of CT perfusion scan
  • Infarct core – Demonstrates matched defects in cerebral blood volume (CBV) and mean transit time (MTT)
  • Ischemic penumbra – Prolonged MTT, but preserved CBV
Interpretation of magnetic resonance imaging (MRI) scan
  • Early hyperacute – Increased diffusion-weighted image (DWI) signal and reduced apparent diffusion coefficient (ADC) values
  • Late hyperacute (>6 hours) – High T2 signal in fluid-attenuated inversion recovery (FLAIR) image

Again in 2018, a significant paradigm shift happened in stroke care. DAWN trial showed significant benefits of endovascular thrombectomy in patients with large vessel occlusion in the arteries of the proximal anterior circulation. This trial extended the stroke window up to 24 hours in selected patients using perfusion imaging. Due to this, we can treat more patients even up to 24 hours.

All patients should be treated with an antiplatelet agent and a statin, and be admitted for full stroke evaluation. Hypertension is often seen in acute stroke.  This should not be aggressively treated. A baseline electrocardiogram is recommended. The following labs would be indicated when a diagnosis of stroke is entertained:

  • Basic metabolic panel (BMP)
  • Complete blood count (CBC)
  • Cardiac markers
  • Coagulation profile: prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (aPTT)
  • Lipid Panel
  • Hemoglobin A1C

A transthoracic echocardiogram, telemetry monitoring, and neck vessel imaging are necessary to elucidate the etiology of stroke.

  • In the subacute phase – the hematoma may be isodense to brain tissue, and magnetic resonance imaging (MRI) may be necessary. The volume of the hematoma can be measured by the formula AxBxC/2, where A and B are the largest diameter and the diameter perpendicular to that. C is the vertical height of the hematoma. Intracerebral hemorrhage with a volume of more than 60 cc is associated with high mortality. The other poor prognostic factors are hematoma expansion, intraventricular hemorrhage, infra-tentorial location, and contrast extravasation on CT scan (spot sign). The paramagnetic properties of deoxyhemoglobin allow early detection of hemorrhage in MRI. Gradient echo (GRE) imaging is as good as CT in the detection of acute bleed. MRI can distinguish between the hemorrhagic transformation of infarct and primary hemorrhage. MRI can detect underlying causes of secondary hemorrhages, such as vascular malformations, including cavernomas, tumors, and cerebral vein thrombosis.
  • Extravasation of contrast in CT angiogram (CTA) – indicates ongoing bleeding and is associated with fatality. Multidetector CT angiography(MDCTA) is helpful to rule out the causes of secondary hemorrhagic stroke such as arteriovenous malformation (AVM), ruptured aneurysm, dural venous sinus (or cerebral vein) thrombosis (DVST/CVT), vasculitis, and Moya-Moya disease. (fig.4).
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Certain imaging characteristics help in the differentiation of the underlying disease.
  • Multiple hemorrhages of different ages in parieto-occipital lobes are seen in cerebral amyloid antipathy.
  • Hemorrhage in an arterial territory indicates hemorrhagic infarction.
  • Multiple stages of bleed in the same hematoma with a fluid level is seen in anticoagulation induced hemorrhage.
  • A combination of small ischemic and hemorrhagic lesions indicates vasculitis.
  • Hemorrhage in the presence of occlusion of arteries is the feature of Moyamoya disease.

Four- vessel digital subtraction angiography (DSA) – is necessary in the case of SAH. If the DSA is negative for aneurysm, a repeat study is needed to confirm. Repeat angiography is advisable at 1-week and 6-weeks intervals.

Blood investigations – such a bleeding time, clotting time, platelet count, peripheral smear, prothrombin time (PT) and activated partial thromboplastin time(aPTT) will detect any abnormality of bleeding or coagulation and any hematological disorder which can cause hemorrhage.

Liver function tests and renal function tests – are also needed to exclude any hepatic or renal dysfunction as a cause. The investigations to rule out vasculitis are the quantitative evaluation of immunoglobulins, thyroid antibodies, rheumatoid factor, antinuclear antibodies (ANA), anti-double-stranded DNA (ds-DNA antibodies), Histon antibodies, complement, anti-Ro [SS-A] and anti-La [SS-B-] antibodies, cytoplasmic staining and perinuclear staining antineutrophil cytoplasmic antibodies (c- and pANCA), and anti-endothelial antibodies.

  • Electrocardiogram (ECG),
  • troponin,
  • complete blood count,
  • electrolytes,
  • blood urea nitrogen (BUN),
  • creatinine (Cr), and
  • coagulation factors. An
  • ECG and troponin are suggested because stroke is often associated with coronary artery disease. A complete blood count can look for anemia or suggest infection.
  • Electrolyte abnormalities should be corrected. BUN and Cr should be monitored as contrast studies may worsen kidney function. Coagulation factors, including PTT, PT, and INR, should also be done as the elevated levels can suggest a cause of hemorrhagic stroke.

Treatment of Hemorrhagic Stroke

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.
  • Anticoagulants (eg: heparin) – these medications help to prevent blot clots from getting bigger and prevent new blood clots from forming
  • Vinpocetine  – a group of medicine to reached oxygen & nutrition to the hemorrhagic/ischemic area of the brain.
  • Vasodilator  – medicine for in ischemic stroke to really reached blood to the obstacle area of the brain.
  •  Prednisolone /methylprednisolone –  for the eradication of inflammation in the blood clots area of the brain.
  • NSAID –  for inflammation & removing pain.
  • Gaba Pentin & Pregabalin –  to recover damage nerve & inhabited the pain impulse to the brain.
  • Lipid-lowering agent  – to remove the excessive fat & plaque that are accumulated in the blood vessel in the body.
  • Thrombolytic therapy  – these medications dissolve blood clots allowing blood flow to be re-established
  • Antihypertensives drug  – in cases of hemorrhagic stroke these medications may be prescribed to help lower high blood pressure
  • Antidepressants  – a drug for better sleep & Removed anxiety.
  • Muscle Relaxant  – to improved muscle tone & avoid spasticity or bedsore.
  • The anti ulcer  – drug used to avoid constipation & normalizing the boil movement.
  • Medications of diuretic  – to reduce swelling in the brain and medications to treat underlying causes for the stroke eg: heart rhythm disorders may also be given.
  • 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.

There are many different opinions in the treatment of hemorrhagic stroke. There are many trails on the optimal management of hemorrhagic stroke – Antihypertensive Treatment in Acute Cerebral Hemorrhage(ATACH), Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial ( INTERACT ), Factor VIIa for Acute Hemorrhagic Stroke Treatment (FAST ) and Surgical Trial in Intracerebral Haemorrhage (STICH). The role of surgery in hemorrhagic stroke is a controversial topic.

  • Anticoagulation therapy –  COMPASS trial published in 2017 compared three antiplatelet regimens-  rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg once daily), rivaroxaban (5 mg twice daily), and aspirin (100 mg once daily) in patients with stable atherosclerotic disease (peripheral, coronary, symptomatic carotid artery disease, >50% asymptomatic carotid disease) and found the combination treatment group had a significantly lower risk of major adverse cardiovascular events than with aspirin alone, but a significantly higher risk of major bleeding. Combination treatment is not yet added to guidelines but there is a possibility that this could soon be part of treatment guidelines on secondary prevention of atherosclerotic stroke in select patients. Caution is recommended in patients with a high risk of bleeding.
  • Blood pressure (BP) Management – BP should be reduced gradually to 150/90mmHg, using beta-blockers (labetalol, esmolol), ACE inhibitor (enalapril), calcium channel blocker (nicardipine) or hydralazine. BP should be checked every 10-15 minutes. ATACH study observed a nonsignificant relationship between the magnitude of systolic blood pressure (SBP) reduction and hematoma expansion and 3-month outcome. But the INTERACT study showed that early intensive BP-lowering treatment attenuated hematoma growth over 72 hours. It has been found that high SBP is associated with neurological deterioration and death. The recommendation of the American stroke association (ASA) is that for patients presenting with SBP between 150 and 220 mmHg, the acute lowering of SBP to 140 mmHg is safe and can improve functional outcome. For patients presenting with SBP >220 mmHg, an aggressive reduction of BP with a continuous intravenous infusion is needed.
  • Management of Raised Intracranial Pressure (ICP) – The initial treatment for raised ICP is elevating the head of the bed to 30 degrees and osmotic agents (mannitol, hypertonic saline). 20 % mannitol is given at a dose of 1.0 to 1.5 g/kg.[2] Hyperventilation after intubation and sedation, to a pCO of 28 to 32 mmHg will be necessary if ICP increases further. ASA recommends monitoring of ICP with a parenchymal or ventricular catheter for all patients with Glasgow coma scale (GCS) <8 or those with evidence of transtentorial herniation or hydrocephalus.[21] The ventricular catheter has the advantage of drainage of cerebrospinal fluid (CSF) in the case of hydrocephalus. The aim is to keep cerebral perfusion pressure (CPP) between 50 to 70mmHg.
  • Hemostatic Therapy – Hemostatic therapy is given to reduce the progression of a hematoma. This is especially important to reverse the coagulopathy in patients taking anticoagulants. Vitamin K, prothrombin complex concentrates (PCCs), recombinant activated factor VII (rFVIIa), fresh frozen plasma (FFP), etc. are used. ASA recommends that patients with thrombocytopenia should receive platelet concentrate. Patients with elevated prothrombin time INR should receive intravenous vitamin K and FFP or PCCs. FFP has the risk of allergic transfusion reactions. PCCs are plasma-derived factor concentrates containing factors II, VII, IX, and X. PCCs can be reconstituted and administered rapidly. The FAST trial showed that rFVIIa reduced the growth of the hematoma but did not improve survival or functional outcome. rFVIIa is not recommended in unselected patients since it does not replace all clotting factors.
  • Antiepileptic Therapy – Around 3 to 17% of patients will have a seizure in the first two weeks, and 30% of patients will show electrical seizure activity on EEG monitoring. Those with clinical seizures or electrographic seizures should be treated with antiepileptic drugs. Lobar hematoma and the enlargement of hematoma produce seizures, which are associated with neurological worsening. Subclinical seizures and non-convulsive status epileptics also can occur. Continuous EEG monitoring is indicated in patients with a decreased level of consciousness. Otherwise, prophylactic anticonvulsant medication is not recommended, according to ASA guidelines.
  • Vitamin B therapy – helps in small vessel brain injury (due to a reduction in Homocysteine) but not large artery disease or cardioembolic disease. B-vitamins have a role in primary stroke prevention and are associated with a reduction in primary stroke risk between 7% to 11% in high vascular risk patients (but no reduction in cardiac events is reported). VITATOPS study showed secondary prevention benefits: a reduction in small artery ischemic strokes from 17% to 14% after the intervention, reduction in intracerebral hemorrhage from 18% to 12% after the intervention, reduction in recurrent TIAs from 14% to 10% after intervention and reduction in milder strokes from 22% to 18% after the intervention.
  • Homocysteine-Lowering Therapy – Elevated circulating homocysteine level has been postulated as a risk factor for CVD. However, an updated Cochrane review published in 2017 that included 12 trials (4 new trials since the last review in 2009) found no support for homocysteine-lowering therapy in the form of vitamin B6, B9, or B12 supplements, either alone or in combination, for preventing cardiovascular events (

Surgery

Minimally invasive surgery plus recombinant tissue plasminogen activator(rt-PA) for Intracerebral Hemorrhage Evacuation (MISTIE) was a randomized, prospective trial that tested image-guided catheter-based removal of the blood clot. It showed a reduction in perihematomal edema with clot evacuation.

  • The Clot Lysis – Evaluating Accelerated Resolution of IntraVentricularr Hemorrhage (CLEAR IVH) trial showed that low-dose rt-PA can be safely administered to stable intraventricular clots and can increase lysis rates. Decompressive craniectomy and hematoma evacuation are now being done more frequently for hemorrhagic stroke. Moussa and Khedr showed the improvement in outcome gained by adding decompressive craniectomy with expansive duraplasty to the evacuation of large hypertensive hemispheric ICH in a randomized controlled trial. Decompressive hemicraniectomy with hematoma evacuation is performed in patients with GCS scores of 8 or less and large hematomas with a volume greater than 60 ml. It reduces mortality and may improve the functional outcome.
Cerebroprotection
  • The secondary injury of hemorrhagic stroke comprises of inflammation, oxidative stress, and toxicity of erythrocyte lysates and thrombin. So, strategies to reduce these are being tried. Pioglitazone, misoprostol, and celecoxib are tried to reduce inflammatory damage. Edaravone, flavanoid, and nicotinamide mononucleotide can reduce oxidative stress. The iron chelator deferoxamine is also in the experimental phase. The safety and neuroprotective efficacy of the cell membrane component citicoline (cytidine-5-phosphocholine) has been shown in some studies. Rosuvastatin, a competitive inhibitor of the enzyme 3-hydroxy-3-methylglutaryl coenzyme A reductase, was associated with a better outcome in a trial. The calcium channel blocker nimodipine improves outcome in SAH by a neuroprotective effect.
General Care
  • Good medical care, nursing care, and rehabilitation are also of paramount importance. Dysphagia, aspiration, cardiac arrhythmias, stress-induced cardiomyopathy, cardiac failure, acute kidney injury, gastrointestinal bleeding, and urinary tract infection, etc. are common problems. Percutaneous endoscopic gastrostomy (PEG) may be needed to prevent aspiration. Screening for myocardial ischemia with electrocardiogram and cardiac enzyme testing is recommended in hemorrhagic stroke. Intermittent pneumatic compression and elastic stockings reduce the occurrence of deep vein thrombosis. Multidisciplinary rehabilitation is advised to reduce disability.

Rehabilitation

Physical, Occupational, or Movement Therapy
  • Several interventions to improve physical function in the upper or lower limbs and activities of daily living have been studied in LMICs. Studies examining physical therapy in LMICs showed that patient outcomes improved significantly over time, including as measured by the Barthel index, Mini-Mental State Examination, and Stroke Rehabilitation Assessment of Movement. The research to date demonstrates interest in examining the efficacy and effectiveness of physical rehabilitation and medicine; however, studies are often hampered by low quality and significant limitations.
  • No individual studies were identified for “rehabilitation of speech and language disorders,” and systematic reviews have not identified any studies from LMICs that meet inclusion criteria for specific questions related to speech and language or cognition. Given that an estimated 67 percent of stroke patients experience cognitive challenges, such as decreased attention and poor recall, this gap in the evidence requires attention from researchers.

Rehabilitation & Therapy in Advance Stage

1. Improving motor control

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a.Neurofacilitatory Techniques

  • In Stroke Physical Therapy these therapeutic interventions use sensory stimuli (e.g. quick stretch, brushing, reflex stimulation, and associated reactions) , which are based on neurological theories, to facilitate movement in patients following stroke (Duncan,1997). The following are the different approaches: –
i.Bobath
  • Berta & Karel Bobath’s approach focuses to control responses from the damaged postural reflex mechanism. Emphasis is placed on affected inputs facilitation and normal movement patterns (Bobath, 1990).
ii.Brunnstrom
  • Brunnstrom approach is one form of neurological exercise therapy in the rehabilitation of stroke patients. The relative effectiveness of Neuro-developmental treatment (N.D.T.) versus the Brunnstrom method was studied by Wagenaar and colleagues (1990) from the perspective of the functional recovery of stroke patients. The result of this study showed no clear differences in the effectiveness of the two methods within the framework of functional recovery.
iii.Rood
  • Emphasize the use of activities in developmental sequences, sensation stimulation, and muscle work classification. Cutaneous stimuli such as icing, tapping, and brushing are employed to facilitate activities.
iv. Proprioceptive neuromuscular facilitation (PNF)
  • Developed by Knott and Voss, they advocated the use of peripheral inputs as stretch and resisted movement to reinforce existing motor response. Total patterns of movement are used in the treatment and are followed in a developmental sequence.
  • It was shown that the commutative effect of PNF is beneficial to stroke patient (Wong, 1994). Comparing the effectiveness of PNF, Bobath approach and traditional exercise, Dickstein et al (1986)demonstrated that no one approach is superior to the rest of the others (AHCPR, 1995).

b. Learning theory approach

i. Conductive education
  • In Stroke Physical Therapy, Conductive education is one of the methods in treating neurological conditions including hemiplegic patients. Cotton and Kinsman (1984) demonstrated a neuropsychological approach using the concept of CE for adult hemiplegia. The patient is taught how to guide his movements towards each task-part of the task by using his own speech – rhythmical intention.
ii. Motor relearning theory
  • Carr & Shepherd, both are Australian physiotherapists, developed this approach in 1980. It emphasizes the practice of functional tasks and the importance of relearning real-life activities for patients. Principles of learning and biomechanical analysis of movements and tasks are important. (Carr and Shepherd, 1987)
  • There is no evidence adequately supporting the superiority of one type of exercise approaches over another. However, the aim of the therapeutic approach is to increase physical independence and to facilitate the motor control of skill acquisition and there is strong evidence to support the effect of rehabilitation in terms of improved functional independence and reduced mortality.
c. Functional electrical stimulation (FES)
  • FES is a modality that applied a short burst of electrical current to the hemiplegic muscle or nerve. In Stroke Physical Therapy, FES has been demonstrated to be beneficial to restore motor control, spasticity, and reduction of hemiplegic shoulder pain and subluxation.
  • It is concluded that FES can enhance the upper extremity motor recovery of acute stroke patient (Chae et al., 1998; Faghri et al., 1994; Francisco, 1998). Alfieri (1982) and Levin et al (1992) suggested that FES could reduce spasticity in a stroke patient. A recent meta-analysis of the randomized controlled trial study showed that FES improves motor strength (Glanz 1996). A study by Faghri et al (1994) has identified that FES can significantly improve arm function, electromyographic activity of posterior deltoid, the range of motion and reduction of severity of subluxation and pain of hemiplegic shoulder.
d. Biofeedback
  • Biofeedback is a modality that facilitates the cognizant of electromyographic activity in selected muscle or awareness of joint position sense via visual or auditory cues. In Stroke Physical Therapy the result of studies in biofeedback is controversial.
  • A meta-analysis of 8 randomized controlled trials of biofeedback therapy demonstrated that electromyographic biofeedback could improve motor function in stroke patient (Schleenbaker, 1993). Another meta-analysis study on EMG has shown that EMG biofeedback is superior to conventional therapy alone for improving ankle dorsiflexion muscle strength (Moreland et al., 1998. Erbil and co-workers (1996) showed that biofeedback could improve earlier postural control to improve impaired sitting balance.
  • A conflicting meta-analysis study by Glanz et al (1995) showing that biofeedback was not efficacious in improving range of motion in ankle and shoulder in a stroke patient. Moreland (1994) conducted another meta-analysis concluded that EMG biofeedback alone or with conventional therapy did not superior to conventional physical therapy in improving upper- extremity function in an adult stroke patient.

2. Hemiplegic shoulder management

  • Shoulder subluxation and pain of the affected arm is not uncommon in at least 30% of all patient after stroke (RCP, 1998) , whereas subluxation is found in 80% of stroke patients (Najenson et al., 1971). It is associated with severity of disability and is common in patients in a rehabilitation setting. Suggested interventions are as follows:

a. Exercise

  • Active weight-bearing exercise can be used as a means of improving motor control of the affected arm; introducing and grading tactile, proprioceptive, and kinesthetic stimulation; and preventing edema and pain. In Stroke Physical Therapy, Upper extremity weight bearing can be used to lengthen or inhibit tight or spastic muscles while simultaneously facilitating muscles that are not active (Donatelli, 1991). According to Robert (1992), the amount of shoulder pain in hemiplegia was related most to loss of motion. He advocated that the provision of ROM exercise (caution to avoid improvement) as treatment as early as possible.
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b. Functional electrical stimulation

  • Functional electrical stimulation (FES) is an increasingly popular treatment for the hemiplegic stroke patient. It has been applied in stroke physical therapy for the treatment of shoulder subluxation (Faghri et al.,1994), spasticity (Stefanovska et al., 1991) and functionally, for the restoration of function in the upper and lower limb (Kralji et al., 1993). In Stroke Physical Therapy, Electrical stimulation is effective in reducing pain and severity of subluxation, and possibly in facilitating recovery of arm function (Faghri, et al., 1994; Linn, et al., 1999).
c. Positioning & proper handling
  • In Stroke Physical Therapy, proper positioning and handling of the hemiplegic shoulder, whenever in bed, sitting and standing or during lifting, can prevent shoulder injury is recommended in the AHCPR & SIGN guidelines for stroke rehabilitation. In Stroke Physical Therapy, positioning can be therapeutic for tone control and neuro-facilitation of stroke patients (Davies, 1991). Braus et al 94 found shoulder-hand syndrome reduced from 27% to 8% by the instruction to everyone including family on handling technique.
d. Neuro-facilitation

e. Passive limb physiotherapy

  • Maintenance of full pain-free range of movement without traumatizing the joint and the structures can be carried out. In Stroke Physical Therapy, at no time should pain in or around the shoulder joint be produced during treatment. (Davies, 1991).
f. Pain relief physiotherapy
  • Passive mobilization as described by Maitland can be useful in gaining relief of pain and range of movement (Davies, 1991). In Stroke Physical Therapy other treatment modalities such as thermal, electrical, cryotherapy etc. can be applied for shoulder pains of musculoskeletal in nature.
g. Reciprocal pulley
  •  The use of reciprocal pulley appears to increase the risk of developing shoulder pain in stroke patients. It is not related to the presence of subluxation or to muscle strength. (Kumar et al., 1990)
h. Sling
  • In Stroke Physical Therapy the use of the sling is controversial. No shoulder support will correct a glenohumeral joint subluxation. However, it may prevent the flaccid arm from hanging against the body during functional activities, thus decreasing shoulder joint pain. They also help to relieve downward traction on the shoulder capsule caused by the weight of the arm (Hurd, Farrell, and Waylonis, 1974; Donatelli,1991).

3. Limb physiotherapy

  • Limb physiotherapy/Stroke Physical Therapy includes passive, assisted-active, and active range-of-motion exercise for the hemiplegic limbs. This can be effective management for the prevention of limb contractures and spasticity and is recommended within AHCPR (1995). Self-assisted limb exercise is effective for reducing spasticity and shoulder protection (Davis, 1991). Adams and coworkers (1994) recommended passive full-range-of-motion exercise for a paralyzed limb for potential reduction of complication for stroke patients

4. Chest physiotherapy

  • In Stroke Physical Therapy, evidence shows that both a cough and forced expiratory technique (FET) can eliminate induced radio aerosol particles in the lung field. Directed coughing and FET can be used as a technique for bronchial hygiene clearance in a stroke patient.

5. Positioning

  •  In Stroke, Physical Therapy consistent “reflex-inhibitory” patterns of posture in resting is encouraged to discourage physical complication of stroke and to improve recovery (Bobath, 1990).
  • Meanwhile, therapeutic positioning is a widely advocated strategy to discourage the development of abnormal tone, contractures, pain, and respiratory complications. It is an important element in maximizing the patient’s functional gains and quality of life.

6. Tone management

  • A goal of Stroke Physical Therapy interventions has been to “normalize tone to normalize movement.” Therapy modalities for reducing tone include stretching, prolonged stretching, passive manipulation by therapists, weight bearing, ice, contraction of muscles antagonistic to spastic muscles, splinting, and casting.
  • Research on tone-reducing techniques has been hampered by the inadequacies of methods to measure spasticity (Knutsson and Martensson, 1980) and the uncertainty about the relationship between spasticity and volitional motor control (Knutsson and Martensson, 1980; Sahrmann and Norton, 1977).
  • The manual stretch of finger muscles, pressure splints, and dantrolene sodium do not produce apparent long-term improvement in motor control (Carey, 1990; Katrak, Cole, Poulus, and McCauley, 1992; Poole, Whitney, Hangeland, and Baker, 1990). Dorsal resting hand splints reduced spasticity more than volar splints, but the effect on motor control is uncertain (Charait, 1968) while TENS stimulation showed improvement for chronic spasticity of lower extremities (Hui-Chan and Levin, 1992).

7. Sensory re-education

  • Bobath and other therapy approaches recommend the use of sensory stimulation to promote sensory recovery of stroke patients.

8. Balance retraining

  • Re-establishment of balance function in patients following stroke has been advocated as an essential component in the practice of stroke physical therapy (Nichols, 1997). Some studies of patients with hemiparesis revealed that these patients have greater amount of postural sway, asymmetry with greater weight on the non-paretic leg, and a decreased ability to move within a weight-bearing posture (Dickstein, Nissan, Pillar, and Scheer, 1984; Horak, Esselman, Anderson, and Lynch, 1984). Meanwhile, research has demonstrated moderate relationships between balance function and parameters such as gait speed, independence, wheelchair mobility, reaching, as well as dressing (Dickstein et al., 1984; Horak et al., 1984; Bohannon, 1987; Fishman, Nichols, Colby, and Sachs, 1996; Liston and Brouwer, 1996; Nichols, Miller, Colby and Pease, 1996). Some tenable support on the effectiveness of treatment of disturbed balance can be found in studies comparing effects of balance retraining plus physiotherapy treatment and physiotherapy treatment alone.

9. Fall prevention

  • In Stroke Physical Therapy, falls are one of the most frequent complications( Dromerick and Reading, 1994), and the consequences of which are likely to have a negative effect on the rehabilitation process and its outcome. According to the systematic review of the Cochrane Library (1999), which evaluated the effectiveness of several fall prevention interventions in the elderly, there was significant protection against falling from interventions which targeted multiple, identified, risk factors in individual patients. The same is true for interventions which focused on behavioral interventions targeting environmental hazards plus other risk factors

10. Gait re-education

  • Recovery of independent mobility is an important goal for the immobile patient, and much therapy is devoted to gait-reeducation. Bobath assumes abnormal postural reflex activity is caused of dysfunction so gait training involved tone normalization and preparatory activity for gait activity.
  • In contrast Carr and Shepherd advocate task-related training with methods to increase strength, coordination and flexible MS system to develop skill in walking while Treadmill training combined with use of suspension tube. Some patient’s body weight can effective in regaining walking ability when used as an adjunct to convention therapy 3 months after active training (Visintin et al., 1998; Wall and Tunbal 1987; Richards et al., 1993).

11. Functional Mobility Training

  • To handle through the functional limitations of stroke patients, functional tasks are taught to them based on movement analysis principles. In Stroke Physical Therapy these tasks include bridging, rolling to sit to stand and vice versa, transfer skills, walking and staring etc (Mak et al., 2000).
  • Published studies report that many patients improve during rehabilitation. The strongest evidence of benefit is from studies that have enrolled patients with chronic deficits or have included a no-treatment control group (Wade et al., 1992; Smith and Ashburn et al., 1981).
  • Meanwhile, early mobilization helps prevent compilations e.g. DVT, skin breakdown contracture and pneumonia. Evidence have shown better orthostatic tolerance (Asberg, 1989) and earlier ambulation (Hayes and Carroll, 1986).

12. Upper limb training

  • By 3 months poststroke, approximately 37% of the individuals continue to have decreased upper extremities (UE) function. Recovery of UE function lags behind that of the lower extremities because of the more complex motor skill required of the UE in daily life tasks. That means many individuals who have a stroke are at risk for lowered quality of life.
  • Many approaches to the physical rehabilitation of adults post-stroke exist that attempt to maximize motor skill recovery. However, the literature does not support the efficacy of any single approach. The followings are the current approaches to motor rehabilitation of the UE.
a. Facilitation models
  • They are the most common methods of intervention for the deficits in UE motor skills including Bobath, proprioceptive neuromuscular facilitation, Brunnstrom’s movement therapy, and Rood’s sensorimotor approach. There is some evidence that practice based on the facilitation models can result in improved motor control of UE ( Dickstein et al,1986, Grade A; Wagenaar et al, 1990 ). However, an intervention based on the facilitation models has not been effective in restoring the fine hand coordination required for the performance of actions ( Kraft, Fitts & Hammond, 1992; Butefisch et al, 1995 ).
b. Functional electric stimulation
  • In Stroke Physical Therapy, Functional electric stimulation (FES) can be effective in increasing the electric activity of muscles or increased active range of motion in individuals with stroke ( Dimitrijevic et al., 1996; Fields, 1987; Faghri et al., 1994,Kraft, Fitts and Hammond, 1992 ). Some evidence showed that FES may be more effective than facilitation approaches ( Bowman, Baker and Waters, 1979; Hummelsheim, Maier-Loth, and Eickhof, 1997 ).
c. Electromyographic biofeedback
  • In Stroke Physical Therapy, biofeedback can contribute to improvements in motor control at the neuromuscular and movement levels ( Kraft, Fitts and Hammond, 1992; Moreland and Thomson, 1994; Wissel et al., 1989; Wolf and Binder-MacLoed, 1983; Wolf, LeCraw and Barton,1989; Wolf et al., 1994 ). Some studies have shown improvement in the ability to perform actions during post-testing after biofeedback training ( Wissel et al.,1989; Wolf and Binder-MacLoed, 1983; Moreland and Thomson, 1994). However, the ability to generalize these skills and incorporate them into daily life is not measured.
d. Constraint-induced therapy
  • Constraint-Induced (CI) therapy was designed to overcome the learned nonuse of the affected UE. In the most extreme form of CI therapy, individual post-stroke are prevented from using the less affected UE by keeping it in a splint and sling for at least 90% of their waking hours. Studies have found that the most extreme of CI therapy can effect rapid improvement in UE motor skill ( Nudo et al., 1996; Taub and Wolf, 1997; Taub et al., 1993; Wolf et al., 1989 ) and that is retained for at least as long as 2 years ( Taub and Wolf, 1997 ). However, CI therapy, currently are effective only in those with distal voluntary movement ( Taub and Wolf, 1997 ).

13. Mobility appliances and equipment

  • Small changes in an individual’s local ‘environment’ can greatly increase independence, use of a wheelchair or walking stick. However, little research has been done for these ‘treatments’. It is acknowledged that walking aids and mobility appliances may benefit selected patients.
  • Tyson and Ashburn (1994) showed that walking aids had an effect in poor walkers – a beneficial effect on gait (Level of evidence = III, Recommendation = Grade B). Lu and coworkers (1997) concluded that the wrist crease stick is better than stick measured to the greater trochanter. (Level of evidence = IIb, Recommendation = Grade A

14. Acupuncture

  • The World Health Organisation (WHO) has listed acupuncture as a possible treatment for paresis after stroke. Studies had sown its beneficial effects in stroke rehabilitation.
  • Chen et al. (1990) had performed a controlled clinical trial of acupuncture in 108 stroke patients. They stated that the total effective rate of increasing average muscle power by at least one grade was 83.3% in the acupuncture group compared with the controlled group which was 63.4% (p<0.05).
  • Hua et al. (1993) had reported a significant difference in changes of the neurological score between the acupuncture group and the control group after 4 weeks of treatment in an RCT and no adverse effects were observed in patients treated with acupuncture.

15. Vasomotor training

  • Early stimulation of the muscle pump can reduce the venous stasis and enhance the general circulation of the body. It then hastens the recovery process.

16. Edema management

  • Use of intermittent pneumatic pump, elastic stocking or bandages and massage can facilitate the venous return of the oedematous limbs. Therefore, the elasticity and flexibility of the musculoskeletal system can be maintained and enhance recovery process and prevent complications like pressure ulcer.

17.Acupuncture

  • Acupuncture is an alternative therapy which people have been making use of over centuries. Although it is rarely utilized by stroke patients in the US, it is an accepted practice on stroke sufferers in some countries, including China. This therapy is considered to be able to boost the blood flow to the parts which do not have feature.
  • This is the reason why it is often utilized in cases of paralysis, where the blood flow increases, helping to bring the muscles with function. Acupuncture is widely used in cases of language issues and balance troubles. Although some researchers have actually stated that acupuncture is very useful and effective, often these studies are skewed or small.

18. Talk Therapy

  • Some people have problems coping with their new disabilities after a stroke. It is common for people to have emotional reactions after a stroke.
  • A psychologist or other mental health professional can help people adjust to their new challenges and situations. These professionals use talk therapy and other methods to help people with reactions such as depression, fear, worries, grief, and anger.

MANAGING STROKE COMPLICATIONS

Ataxia, Gait Disturbance, and/or Falls
  • Mobilize patients within 24 hours, provided that they are alert and hemodynamically stable. Rehabilitation includes lower limb strength training to increase walking distance after stroke. Gait and/or standing post-stroke are improved with gait retraining (including task-specific), balance training, electromyography (EMG)-biofeedback training, and functional electrical stimulation.
Deterixcity
  • Consider referral of patients with upper limb weakness or decreased coordination for physical and occupational therapy. Mental practice is associated with improved motor performance and activities of daily living performance.
Cognitive Dysfunction
  • Compensatory strategies (e.g., reminders, day planners) improve memory outcomes. Consider referral of patients with cognitive deficits either for neuropsychological assessment or to an OT trained in the cognitive evaluation. Also, consider referral to driving simulation training or assessment programs.

Neglect: Visual scanning techniques and limb activation therapies improve neglect. Consider referral of patients with hemisensory neglect for perceptual retraining by an OT and/or neuropsychologist.

Dysarthria and Dysphasia
  • Consider referral of patients with impaired speech for assessment and training. Intensive speech and language therapy in the acute phase, especially with severely aphasic patients, showed significant improvement in language outcomes.
Hemianopsia
  • Consider ophthalmologist referral regarding optical prisms for patients with homonymous hemianopsia as this improves visual perception scores.
Community Re-Integration
  • Referral to the community – based support services is associated with increased social activity. Education and information also have a positive benefit.
  • Maintain Adequate Delivery – of oxygen is very important to maintain oxygen levels. In some cases, airway ventilation may be required. Supplemental oxygen may also be necessary for patients when tests suggest low blood levels of oxygen.
  • Manage Fever – Fever should be monitored and aggressively treated with medication since its presence predicts a poorer outlook.
  • Evaluate Swallowing – Patients should have their swallowing function evaluated before they are given any food, fluid, or medication by mouth. If patients cannot adequately swallow they are at risk of choking. Patients who cannot swallow on their own may require nutrition and fluids delivered intravenously or through a tube placed in the nose.
  • Maintain Electrolytes – Maintaining a healthy electrolyte balance (the ratio of sodium, calcium, and potassium in the body”s fluids) is critical.
  • Control Blood Pressure – Managing blood pressure is essential and complicated. Blood pressure often declines spontaneously in the first 24 hours after stroke. Patients whose blood pressure remains elevated should be treated with antihypertensive medications.
  • Monitor Increased Brain Pressure – Hospital staff should watch carefully for evidence of increased pressure on the brain (cerebral edema), which is a frequent complication of hemorrhagic strokes. It can also occur a few days after ischemic strokes. Early symptoms of increased brain pressure are drowsiness, confusion, lethargy, weakness, and headache. Medications such as mannitol may be given during a stroke to reduce pressure or the risk for it. Keeping the top of the body higher than the lower part, such as by elevating the head of the bed, can reduce pressure in the brain and is standard practice for patients with ischemic stroke. However, this practice also lowers blood pressure in general, which may be dangerous for patients with massive stroke.
  • Monitor the Heart – Patients must be monitored using electrocardiographic tracings to check for atrial fibrillation and other heart rhythm problems. Patients are at high risk for heart attack following stroke.
  • Control Blood Sugar (Glucose) Levels – Elevated blood sugar (glucose) levels can occur with severe stroke and may be a marker of serious trouble. Patients with high blood glucose levels may require insulin therapy.
  • Monitor Blood Coagulation – Regular tests for blood coagulation are important to make sure that the blood is not so thick that it will clot nor so thin that it causes bleeding.
  • Check for Deep Venous Thrombosis – Deep venous thrombosis is a blood clot in the veins of the lower leg or thigh. It can be a serious post-stroke complication because there is a risk of the clot breaking off and traveling to the brain or heart. Deep venous thrombosis can also cause a pulmonary embolism if the blood clot travels to the lungs. If necessary, an anticoagulant drug such as heparin may be given, but this increases the risk of hemorrhage. Patients who have had a stroke are also at risk for pulmonary embolisms
  • Prevent Infection – Patients who have had a stroke are at increased risk for pneumonia, urinary tract infections, and other widespread infections.
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Home Treatments of Stroke

Changing Your Diet

This is the very first one out on the list of the most effective tips on how to treat stroke naturally at home within a short time period that we would like to introduce in the article and everyone should make use as soon as possible.

Eating Ginkgo Biloba

Ginkgo biloba is used to treat stroke. It aids to prevent the blood clots from growing and increases the bloodstream to the brain. The herb has been proven to inhibit the free-radical formation.

This herb is used widely in Europe in order to treat complications of stroke containing balance and memory problems, vertigo as well as disturbed thought processes

Eating Turmeric

Turmeric is one of the home remedies on how to treat stroke that you and my other readers should know and make use of it for good. Many studies say that the compound curcumin containing in turmeric can reduce the formation of blood clots. Turmeric is a key ingredient in cooking and may be found in most of the curry spice blends. You should consider eating more curry dishes to reduce and even treat your stroke.

Eating Ginger

Ginger is a cardiac tonic because it can treat stroke, decrease cholesterol levels, aid poor circulation, and prevent blood clots excessively. Take 2 tsp of ginger daily for about 7 days can neutralize the blood clotting effects of 100 mg of butter. You can take advantage of ginger in your cooking or you can take ginger tea by using 1-2 tsp of freshly grated ginger root per cup of hot water. Steep it until cool. Besides, you can also add ginger in salads. Continue reading this entire article to discover other home remedies for stroke that you can follow easily at home. In brief, this is also one of the most useful tips on how to treat stroke naturally and fast at home that people should not look down yet try making use right from today to be free from this stubborn and serious health issue!

Eating Carrot

In a study, the consumption of carrots can reduce the risks of stroke. Women who eat 5 servings of carrots per week suffer 68% fewer stroke risk than those who eat carrots less than 2 times a month. Carrots are high in beta-carotene and other essential carotenoids. So, eat more carrots to see how to treat stroke naturally. They are great as snacks, especially the baby carrots. Add them to vegetable soups or make carrot juice. In case you want to do better, add some pieces of garlic and ginger in order to provide them with zest.

Using Pigweed

Some experts think that pigweed can prevent stroke as it can reduce the risk of a heart attack while there are biological similarities between heart attack and ischemic strokes. Pigweed is a great plant source of calcium. Use young leaves in salads or steam more mature leaves.

 Using Apple Cider Vinegar

It is helpful to stroke problems in a lot of ways. It is a natural purifier and detoxifier, so its functions are to cleanse the blood of any toxins that can contribute to the stroke problem. This vinegar also helps thin the blood, making it easier to flow throughout the body.

Taking Vitamin C

It is a natural antioxidant. This vitamin can eliminate free radicals that contribute to the condition. Besides, the vitamin also aids the immune function and replenishment of tissues. As you know that stroke can be risky, but it is a condition that is able to be treated. With the proper nutritional supplements as well as treatment considerations, people can experience a nearly full recovery from this condition.

Using Coconut Oil

Coconut oil is high in medium fatty acids. These fats function to boost nutrient absorption, which contributes to improving recovery. The unique composition of this oil also boosts the neutral passageways to boost brain functioning as well as recovery. This is also a great natural ingredient and the use of it is also among the best tips on how to treat stroke naturally at home without requiring any type of drugs, pills, or medical interventions so that people should try making use of it as soon as possible to achieve the best result as desired!

Taking Vitamin B6

Vitamin B6 is a water-soluble vitamin that can be a useful plus to stroke victims fighting against related illnesses. Vitamin B6 is best taken sublingually as oral administration is less efficient in allowing it to enter the bloodstream quickly. It is inexpensive and available at most health food stores and pharmacies. More importantly, it has no toxicity; in other words, it is difficult to overdose on B6, so you can use it without any worry.

Taking Vitamin B12

B12 is also a water-soluble vitamin that allows the function of physical, emotional, and mental abilities. It involves the metabolic function of each body cell, which makes it essential to those who have the body’s systems weakened by a stroke. Besides, B12 also plays an important role in aiding the body to absorb fatty acids. This is important as omega-3 fats are responsible for maintaining the health of the brain as well as nerve tissue.

 Using Fish Oil

Fish oil is also a great and nutritious natural ingredient that can help when it comes to tips and home remedies on how to treat stroke naturally at home! Omega-3 fatty acids have been proven to offer positive benefits, including treating stroke. Fish oil, especially from fatty fish like salmon, are very high in healthy fatty acids and has an ideal ratio of DHA, EPA, and ALA. An alternative for vegetarian people is hempseed oil, although it is more expensive.

 Using Taurine

A component of many drinks, taurine is a natural organic acid. It has been used to regulate hypoglycemia, hypertension, and diabetes which may be risk factors among patients who are finding ways how to treat stroke. It helps stroke treatment by increasing oxygen uptake to the brain, and by stabilizing the cellular membranes’ health. Besides, it also prevents free-radical damage to the body.

 Using Chinese Motherwort

Some practitioners in traditional Chinese medicine take aerial parts in order to treat stroke. This herb works on the liver, heart, and kidney meridians, and relieves blood stagnation. A study found that the extract could reduce the area affected by a stroke, improve neurological damage caused by a stroke, and have a protective effect on cells of the brain. This study also supports the traditional use of this herb for boosting recovery after a stroke. Never combine this remedy with other blood-thinning or stroke medicines.

Using Baikal Skullcap

It is one of the fundamental herbs in Chinese medicine and it is used to treat stroke. The root has 4 potent flavonoids: norwogono side, baicalin, oroxyloside as well as wogonoside. Skullcap extract may help stroke recovery by treating paralysis and cerebral thrombosis resulting from stroke.  This study also shows that the skullcap extract in treating stroke-related brain damage and helping stroke recovery. Consult your doctor before taking this herb or combining it with other blood thinners.

Using Ginseng

Ginseng is an herb used to encourage your body’s defenses against stress and disease. A study tested ginseng extract containing ginsenoside Rb1 with induced stroke. This study also found that the extract boosted the recovery of neural behavior and simultaneously stimulated the formation of new brain neurons. Consult your doctor before taking it in case you suffer from heart or blood pressure problems.

Drinking Raw Fresh Juices

A patient suffering from a stroke needs to add raw fresh juices to the daily diet as this will help to relieve the severity of the stroke. Besides, taking raw fresh juices will also help to relieve the side effects and then allow this person to get back to normality effectively and slowly.

Taking A Bath In Epsom Salt

Taking a bath in Epsom salt several times a week has been shown to be a good home remedy how to treat stroke. This aids to relax the muscles and rejuvenate them as well. This method is suggested to help lessen a person who has suffered from a stroke to get back to normality a lot faster.

Reducing Stress

Stress contributes to the cardiovascular problem and if severe, it can lead to a heart attack or stroke. There are a lot of options that help you reduce stress levels such as adequate sleep, regular exercise, laughing, or volunteering. Watching television does not relieve, but may aggravate tress. Besides, try to avoid situations that make you angry or anxious.

Herbal Remedies of Stroke 

Many natural remedies are based on the standard Chinese medication to cure the impairments causing by an ischemic stroke. Most of the natural supplements are designed to help to increase the blood flow to the brain regions that were damaged during the cerebral mishap. Some supplements are known for their neuroprotective effects. That means they can protect the brain cells from further harm.

Massage

Massage is a special kind of touch therapy that has been shown and well-known to lesser blood pressure, assistance improve depression, and advertise leisure. Some researchers have actually revealed that it is very useful for stroke survivors since it can help to decrease the quantity of depression and anxiety they feel over the restrictions. Massage can also enhance the blood flow to the muscles that are either spastic or paralyzed.

 Drinking Soy Milk

This is actually an interesting tip on how to treat stroke and prevent this disease naturally without meeting any difficulty (excepting the case that you are a soy hater!). Soy milk is an ideal drink for people with high blood pressure as it has effects on preventing atherosclerosis, adjusting blood lipid disorders, and lowering blood pressure. Every day, for good, people should consume about 500ml soy milk mixed with 50g white sugar for times throughout the day.

Eating Grape

Grapes, including fresh grapes and raisins, are good for people with high blood pressure because the composition of the grape contains a high level of potassium salt which has the antihypertensive, diuretic effects, and it can enrich the amount of potassium lost by the use of Western medicine.

Eating Apple

Apple is always good for health. Some people even believe that if they eat an apple every day, they will not have risks of any disease. Apple contains a high level of potassium, combine with and push the extra sodium out of the body. This will help the body manage and maintain a normal level of blood pressure. For good, you should eat 3 apples or drink the apple juice three times (about 50ml/time) per day. This is actually one of the best tips on how to treat stroke naturally people should not miss!

 Eating Grapefruit

Grapefruit contains a high level of naringenin – an antioxidant that can help the liver to burn excess fat effectively. Grapefruit also helps to improve the control of blood sugar, lower blood sugar levels, and it is very good for people with cardiovascular disease or obesity.

Eating Garlic

Garlic has effects on lowering hyperlipidemia and hypertensive. Every day, if you eat 2 cloves of raw garlic, pickled garlic, or drink 5ml of vinegar with pickled garlic, it can help to maintain stable blood pressure levels. In addition, the diet with garlic can help to reduce the risk of colon cancer, prevent esophageal cancer, and inhibit breast cancer. Eating one or two cloves of garlic every day will help to reduce 13-25% of the triglycerides level, lower the risk of blood pressure, cholesterol, and blood clotting.

 Eating Tomato

This is one of the best tips on how to treat stroke at home that I would like to show my readers in this article. In fact, the tomato is very rich in vitamin C and P, and if people eat raw tomato regularly every 1-2 days, they will be able to prevent high blood pressure effectively, especially when there are bleeding complications of the eye. In addition, Vitamin A, C, and lycopene contained in tomatoes can help to prevent prostate, lung, and stomach cancer. Tomatoes also have effects on lowering blood pressure, preventing atherosclerosis – one of the dangerous factors which lead to coronary artery disease in the heart and stroke.

 Eating Water Spinach

Water spinach is very good for health. It contains a high level of calcium so that it is very useful for maintaining the osmotic pressure of the circuits and blood pressure at normal levels. Water spinach is a special veggie which is perfect for people with high blood pressure with the sign of a headache – the main cause of stroke. This is the last tip on how to treat stroke naturally which people should try!

Homeopathic Treatment

There are following remedies which are helpful in the treatment of  stroke:

  • Aconite Nap –the remarkable remedy for cerebral stroke, it is the first remedy to be employed in a sudden and violent attack
  • Baryta carb – it is a very useful remedy in this case where bleeding is associated with one-sided paralysis
  • Kali Brom – this remedy is indicated when there is a sudden rupture of blood vessels in the brain with paralysis and comma
  • Opium – excellent medicine for apoplexy; comma and obstructed respiration; patient lies down; loss of consciousness with eyes half-open after the brain hemorrhage.
  • Pituitrinum – well-known medicine for cerebral stroke; checks the cerebral hemorrhage; helps in the absorption of blood clots; apoplexy due to hypertension.
  • Zincum met – acts well in the cases of cerebral stroke; brain-fag; paralysis of the brain
  • Hyoscyamus – brain hemorrhage with involuntary stools and urination; patient falls down and screams; with a red face
  • Glonoinum – threatened apoplexy due to sunstroke
  • Nux Vomica – threatened brain hemorrhage with giddiness; pain and fullness of head; apoplexy in alcoholics
  • Strontium carb – threatened cerebral hemorrhage from shock after high blood pressure and as a sequence of chronic hemorrhage
  • Asterias rub – threatened cerebrovascular bleeding; a sudden rush of blood to the head.

LifeStyle

  • Smoking – has been associated with a two to a four-time increased risk of ischemic stroke and intracranial bleeds. It is one of the leading preventable risk factors for stroke. It takes two to four years after smoking cessation for the excess risk to go down.  Smoking cessation options such as counseling, nicotine replacement therapy, or agents such as bupropion should be offered to all appropriate patients. Passive tobacco smoking should be avoided.
  • Regular exercise – (burning 2000 to 3000 calories per week) has been shown to reduce stroke risk by half.
  • Obesity– The risk of ischemic stroke is increased by 22% for overweight individuals and by 64% in obese individuals as compared to normal-weight individuals.
  • Diet– American heart association recommends a diet that has increased intake of fruits, vegetables, and whole grains and limited intake of sugar, saturated fat, trans-fat and red meat. Most Mediterranean diets advocate increased consumption of vegetables, whole grains, fruits, nuts, and olive oil. Moderate amounts of fish, poultry, and dairy products are allowed, whereas red meat is to be avoided. It is uncertain whether the health benefits are due to the consumption of the before mentioned food items, or an under-consumption of red meats (and subsequently decreased intake of saturated fats). Absolute risk reduction is approximately three cardiovascular events per 1000 person-years treated (PREDIMED study).
  • Alcohol– Chronic alcoholism and heavy drinking are risk factors for stroke. J shaped association between alcohol and ischemic stroke risk has been suggested by most studies. There is a protective effect from light to moderate consumption (likely due to an increase in HDL and a decrease in platelet aggregation) and increased risk of stroke with heavy alcohol consumption (due to a hypercoagulable state, alcohol-induced hypertension, cardiomyopathy, and Afib). Stopping or reducing alcohol consumption is recommended for patients with ischemic stroke or TIA.
  • Lower socioeconomic status – including low income, lower education level is associated with an increased risk of stroke recurrence.

References

What is the best treatment for stroke

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