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The diagnosis and management of stroke
Unlike many illnesses, there is no simple test to confirm
that a person has had a stroke. Hence the first diagnosis
will be made on the basis of the history of the attack (e.g.
how rapidly it came on and what the individual experienced),
the person’s background (e.g. age, blood pressure history,
other illnesses) and the nature and location of the symptoms.
Unfortunately, there are still significant regional variations
in the medical services available for the management of stroke
victims after diagnosis. In a study a few years ago, the King’s
Fund in London commented that ‘....(stroke) services were
often haphazard and poorly tailored to the patient’s needs...’.
Though there has been some improvement, the ideal situation
described below is not yet generally available.
As a general rule, someone suspected of having had a stroke
should receive different levels and types of attention at
different times – some of which will overlap:
- assessment
- immediate management
- investigation
- long-term management
At the moment, many people are not admitted to hospital following
a stroke. With the development of new medicines, it will be
necessary for more people to stay in hospital to reap the
benefits that the new treatments will bring.
During assessment, the doctor or hospital specialist
will determine the risk factors present and question the relatives
and/or patient about their state of health before the attack
and any previous history (e.g. previous mini-strokes, dizzy
turns, headaches, falls, and so on). There will also be a
detailed examination (called a neurological assessment) to
determine the extent of the problems the person has since
the stroke. This will bring together the ‘specialist’ team
who will assess the degree of nursing required, the extent
of any disabilities, and whether the person can swallow and
eat adequately.
After assessment, the individual who has had a stroke will
require immediate management. This will include the
measurement of temperature, blood pressure, heart rhythm,
fluid balance, and urinary output. Their emotional and psychological
state will also be monitored, because shock and depression
may develop. Immediate management may also involve some immediate
treatment. For example, if it is clear that there has been
an ischaemic event, then selected people may be given aspirin
or one of the newer ‘clot-busting’ medicines, but this has
to be done as soon as possible after the stroke. This is still
not universal practice, however, and may vary in different
parts of the country and in different hospitals.
In the investigation stage, the hospital will organise
a series of clinical procedures. These will help to rule out
any other possible causes of the stroke, assess the location
and extent of the damage, and find out how well other bodily
functions are performing. Everyone suspected of having had
a stroke is likely to be given tests which examine their urine
and blood, to have their heart function checked using an ECG
(electrocardiogram), and to have a chest X-ray.
Depending on how well or ill the person is and their medical
history, the hospital may also organise a series of more specialised
tests. These will include computed tomography (CT) scans of
the brain to look for the exact site of damage – though this
should be done at the assessment stage if at all possible.
If this suggests that more detailed information is needed,
a magnetic resonance imaging scan (MRI) may also be performed.
If any heart malfunction is suspected, then the heart may
be examined using an ultrasound device in a procedure called
an echocardiogram. Finally, if there may be a partial
blockage in the arteries in the neck, a special sound doppler
test may be carried out. All these tests are non-invasive
and painless. Once all this information has been assessed
– which may take from one to two weeks – it should be clear
whether the person has had an ischaemic or a haemorrhagic
stroke, how extensive it is, or whether there is some other
cause for the symptoms.
All the above measures can be classed as the acute phase
of management and diagnosis. As the patient stabilises, decisions
about long-term management have to be made and treatment
commenced. This will depend on the type of stroke experienced
and on a host of factors special to the individual, but could
include medicines that help prevent blood clotting, or surgical
procedures to free up partially blocked arteries.
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