eMedicine Specialties > Emergency Medicine > Neurology

Stroke, Ischemic: Follow-up

Author: Joseph U Becker, MD, Fellow, Global Health and International Emergency Medicine, Stanford University
Coauthor(s): Charles R Wira, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale School of Medicine; Jeffrey L Arnold, MD, FACEP, Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center
Contributor Information and Disclosures

Updated: Jun 19, 2009

Follow-up

Further Inpatient Care

Referral to a physician with special interest in stroke is ideal. Stroke care units exist and are said to show improved outcomes with specially trained personnel. See the discussion on Stroke Centers in Special Concerns. Comorbid medical problems need to be addressed. Assessments of swallow function, prior to the reinstitution of oral feeding is recommended.11 Patients should receive deep venous thrombosis prophylaxis, although the timing of institution of this therapy is unknown. Serial monitoring and interventions when necessary early in the clinical course and eventual stroke rehabilitation and physical and occupational therapy are the ideals.

Milionis et al showed a 10-year risk reduction for recurrent stroke when statin therapy was added after a first stroke. Statin use also reduced the risk of mortality, even after adjustment for potential confounders, such as blood pressure control, reported investigators. The study was a retrospective observational analysis of 794 patients hospitalized for a first-time ischemic stroke that linked hospitalization and death records from the Athenian Stroke Registry. The analysis included a period, from January 1997 onward, during which poststroke statin therapy was not common practice.74

Complications

The most common and important complications of ischemic stroke include cerebral edema, hemorrhagic transformation, and seizures.

  • Significant cerebral edema after ischemic stroke is though to be somewhat rare (10-20%).11
  • Early indicators of ischemia on presentation and on noncontrast CT scan are independent indicators of potential swelling and deterioration. Mannitol and other therapies to reduce intracranial pressure may be utilized in emergency situations, although their usefulness in swelling secondary to ischemic stroke are unknown.11 Some patients furthermore experience hemorrhagic transformation of their infarct. This is estimated to occur in 5% of uncomplicated ischemic strokes, in the absence of thrombolytics. Hemorrhagic transformation is not always associated with neurologic decline and ranges from small petechial hemorrhages to hematomas requiring evacuation. 
  • The incidence of seizures ranges from 2-23% in the immediate post-stroke recovery period. Post-ischemia strokes are usually focal but may be generalized. A fraction of patients who have experienced stroke develop chronic seizure disorders. Seizures secondary to ischemic stroke should be managed in the same manner as other seizure disorders that arise as a result of neurologic injury.11

Patient Education

For excellent patient education resources, visit eMedicine's Stroke Center and Dementia Center. Also, see eMedicine's patient education articles Stroke, Transient Ischemic Attack (Mini-stroke), and Stroke-Related Dementia.

Miscellaneous

Medicolegal Pitfalls

  • Informed consent
    • If a treatment option is available, the patient, or their proxy, should be allowed to decide whether to accept or reject it.
    • Since t-PA can harm some patients, patients or their medical decision makers must clearly understand the risks and benefits and give their informed, written, consent before t-PA is administered.
  • Diagnostic recommendations
    • The clinical diagnosis of stroke must be as accurate as possible, and special care must be taken to avoid the misdiagnosis of stroke mimics.
    • Hospital protocols must be in place to ensure that patients with undifferentiated stroke have prioritized access CT imaging within 10 minutes of arrival.
  • Therapeutic recommendations
    • The benefit of early aspirin administration is modest.
    • Systemic anticoagulation is not recommended.
    • If the administration of t-PA is considered, care must be given to follow the current inclusion and exclusion criteria guidelines derived from the NINDS study. Protocol violations have been demonstrated to result in higher rates of cerebral hemorrhage and decreased efficacy of thrombolytic treatment.

Special Concerns

  • With the advent of t-PA for use in selected patients with acute ischemic stroke, many medical professionals now consider undifferentiated stroke with symptom duration less than 3-4.5 hours to be a medical emergency.
  • Specialized stroke care (stroke systems)
    • Given the multitude of factors that comprise the care of the patient with acute stroke, the concept of the specialized stroke center has evolved. Current systems utilize two separate center designations: Primary Stroke Centers (PSCs) and Comprehensive Stroke Centers (CSCs).11
    • The Primary Stroke Center is designed to maximize the timely provision of stroke-specific therapy including rt-PA and is also capable of providing care to patients with uncomplicated stroke. The Comprehensive Stroke Center shares the commitment to acute delivery of rt-PA of the PSC and also provides care to patients with hemorrhagic stroke and intracranial hemorrhage and all patients with stroke requiring ICU level of care.11
    • The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has certified greater than 200 PSCs since 2004. Accreditation processes for CSCs are underway.11
    • Once patients have been identified as potential stroke patients, their emergency department evaluation must be fast-tracked to allow for the completion of required laboratory tests and requisite noncontrast head CT scanning as well as the notification and involvement of neurologic consultation. These requirements have led to the development of "stroke codes" or "stroke activations" in which EMS crews have been trained to identify possible stroke patients and arrange for their speedy preferential transport to PSCs or CSCs.
    • Additionally, Stroke Centers should have personnel versed at monitoring "stroke vital signs" such as blood pressure, glucose levels, temperature, oxygenation, and change in neurologic status. Hospitals with specialized stroke teams have demonstrated significantly increased rates of thrombolytic administration and decreased mortality. Cumulatively, the center should identify performance measures and include mechanisms for evaluating the effectiveness of the system as well as its component parts. The acute care of the stroke patient is more than anything a systems-based team approach requiring the cooperation of emergency department, radiology, pharmacy, neurology, and ICU staff.
    • A stroke system should ensure effective interaction and collaboration among the agencies, services, and people involved in providing prevention and the timely identification, transport, treatment, and rehabilitation of individual stroke patients in a locality or region.
  • Palliative care is an important component of comprehensive stroke care. Some stroke patients will simply not recover, and others will be in a state of debilitation such that the most humane and appropriate therapeutic concern is the comfort of the patient. Some patients have advanced directives providing instructions for medical providers in the event of severe medical illness or injury.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous editor, Charles V Pollack Jr, MD, to the development and writing of this article.



More on Stroke, Ischemic

Overview: Stroke, Ischemic
Differential Diagnoses & Workup: Stroke, Ischemic
Treatment & Medication: Stroke, Ischemic
Follow-up: Stroke, Ischemic
References
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Further Reading

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Keywords

ischemic stroke, acute stroke, acute ischemic stroke, CVA, loss of neurologic function, cerebrovascular accident, stroke syndrome, thrombosis, embolism, hemorrhage, hemorrhagic stroke, cerebrovascular disease, neurologic complications, antithrombotic therapy, thrombolytic therapy, recombinant tissue-type plasminogen activator, rt-PA, t-PA, extracranial embolism, intracranial thrombosis, death of neurons, cerebral infarction, paradoxical emboli, cardiogenic emboli, valvular thrombi, mitral stenosis, endocarditis, prosthetic valves, mural thrombi, lipohyalinosis, pure motor strokes, pure sensory strokes, ataxic hemiparetic strokes, thrombotic occlusion, arterial stenosis, atherosclerosis, platelet adherence, polycythemia, sickle cell anemia, protein C deficiency, fibromuscular dysplasia of the cerebral arteries, prolonged vasoconstriction, thoracic aortic dissection, arteritis, acute neurologic deficit, altered level of consciousness, hemiparesis, monoparesis, quadriparesis, monocular visual loss, binocular visual loss

visual field deficits, diplopia, dysarthria, ataxia, vertigo, aphasia, carotid bruits, hypesthesia, hemianopsia, homonymous hemianopsia, agnosia, visual agnosia, receptive aphasia, expressive aphasia, cortical blindness, altered mental status, impaired memory, vertebrobasilar artery occlusions, nystagmus, dysphagia, facial hypesthesia, syncope, loss of pain sensation, loss of temperature sensation, smoking, heart disease, coronary artery disease, left ventricular hypertrophy, chronic atrial fibrillation, hypercholesterolemia, transient ischemic attacks, TIAs

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Contributor Information and Disclosures

Author

Joseph U Becker, MD, Fellow, Global Health and International Emergency Medicine, Stanford University
Joseph U Becker, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Charles R Wira, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale School of Medicine
Charles R Wira, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Jeffrey L Arnold, MD, FACEP, Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center
Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians
Disclosure: Nothing to disclose.

Medical Editor

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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