As soon as you notice the signs of a stroke in yourself or someone else—being off-balance, struggling to see or speak, or experiencing droop, weakness or numbness on one side of the body (typically the face or limbs)—you need to call 911.
“We have this phrase, ‘time is brain,’ and that’s because the brain has only a certain period of time when it can withstand the loss of blood that happens during a stroke,” says UNC Health neurointensivist David Y. Hwang, MD. “We have a certain window to provide the therapies that restore blood flow to the brain and stop the symptoms, so they aren’t permanent.”
The window for these treatments is only a few hours long in some cases, and sooner is always better. You won’t have time to wait to see if symptoms resolve or to get a ride to the hospital rather than taking an ambulance.
“When we say ‘time is brain,’ we’re talking about seconds,” Dr. Hwang says. “Calling 911 is critical because the time it takes you to get to the hospital is an important factor. The ambulance alerts the hospital about your symptoms so that the emergency department can prepare therapies before you show up.”
Here’s what happens when that ambulance arrives at the hospital.
Treatment Options for Stroke
At the hospital, you’ll have a quick physical exam where your doctor will check your symptoms. It’s important to note when symptoms started so they can determine which treatments you’re eligible for.
You’ll have a head CT scan as soon as possible after arriving. There are two types of strokes; ischemic, where blood flow to the brain is blocked by a clot, and hemorrhagic, where a blood vessel bursts and causes bleeding in the brain. Both types cause similar symptoms, but the treatments are different.
“The CT scan is to make sure there’s no bleeding in the brain from a burst vessel,” Dr. Hwang says. “If you’re having an ischemic stroke, the CT doesn’t always show the clot, but if there’s no bleeding in the brain and your symptoms are consistent with stroke, we’d consider the therapies that could reopen blood flow to the brain.”
Your doctor will first consider the thrombolytics alteplase (tPA) or tenecteplase (TNK). These medications, administered via an IV, are sometimes called “clot-busters” because they activate an enzyme in your blood that breaks down the protein that makes your blood clot, which is helpful when you have a skin wound but dangerous when it blocks blood flow to your brain.
“These typically need to be administered less than three to four and a half hours after symptoms started,” Dr. Hwang says. “Again, this doesn’t mean you have four and a half hours to get to the hospital. The sooner you can get these medications, the more likely you are to do well.”
For several decades, the window to receive thrombolytics was only three hours; in 2008, a large study supported extending that window an additional 90 minutes for certain patients. Research is continuing about ways to extend the time further. Some people with clotting disorders or taking certain blood thinners may not be able to take thrombolytics.
If you’re within a six-hour window of your symptoms starting and CT imaging shows a large blood clot in the brain, your doctor also may consider a thrombectomy, or surgical removal of the clot. You might have both thrombolytic therapy and a thrombectomy, or just one or the other. During a thrombectomy, your doctor inserts a catheter into the femoral artery in your groin, maneuvers to the brain and extracts the clot.
When you’re past that six-hour window but have a large clot, your doctor may order additional imaging to see if there’s still salvageable brain tissue; if there is, you might be able to receive this procedure up to 24 hours after symptoms start.
If you’re having a hemorrhagic stroke, your treatment will depend on what type of blood vessel burst. You may need emergency surgery to repair the vessel or to clear the blood from the brain.
What Happens in the Days After a Stroke
Progress after treatment is different for everyone.
“For some people, their symptoms get better in the 24 to 48 hours after a thrombolytic medication,” Dr. Hwang says. “Others might have a slow response in those first 48 hours, but improvement happens over time. Overall, people who get the thrombolytics tend to have more symptom improvement over a period of months than similar patients who do not receive medication.”
That means your doctor may not be able to tell you an exact long-term prognosis while you’re in the hospital. They’ll focus on making sure you’re stable and don’t suffer any adverse reactions from the treatments, such as bleeding complications or spikes in blood pressure.
Stroke rehabilitation starts as soon as you’re stable after treatment.
“We have physical therapists, occupational therapists and speech language pathologists who start working with you in the hospital so that you’re on a pathway to getting active again and regaining any function lost in the stroke,” Dr. Hwang says.
These professionals will start making a plan for long-term rehabilitation.
“People can be surprised how quickly we start talking about transferring you to a rehabilitation hospital or having physical therapy at home,” Dr. Hwang says. “Recovery will continue over weeks, months and years when you start these therapies early. That’s important for the best possible outcome.”
About 1 in 4 people who have one stroke will have another, so your doctor will perform additional tests to try to figure out why your first stroke happened. They may recommend lifestyle changes, including diet, exercise and sleep. You may have an underlying medical condition that needs to be better controlled, such as high blood pressure or diabetes.
“We want to try to understand what happened and if there’s anything we can do to prevent another stroke,” Dr. Hwang says. “Secondary stroke prevention starts right away.”
Talk to your doctor about what you can do to prevent a stroke. If you need a doctor, find one near you.