The New Jersey Comprehensive Stroke Center at University Hospital
The hours and days following treatment of acute stroke are critical to a patient’s survival and prognosis for recovery without disability. In fact, a patient’s condition may remain life-threatening for weeks, depending on the type and severity of the stroke. Emergency intervention – fixing the immediate problem causing the acute stroke (such as removing the blockage or repairing the burst aneurysm) — accounts for just 30 percent of a patient’s chances for survival.
The main goals during the critical care and recovery period are to keep unaffected portions of the brain from becoming damaged and to prevent complications — any of which could prove life threatening. This phase of treatment requires the specialized skills of neuro-intensivists — doctors, nurses and other staff specially trained in managing the unique stabilization needs of brain trauma patients and the host of complications that can develop.
Neurological Intensive Care
Intensive care units with staff with expertise in neurological care provide the best environment for stroke patients following an acute attack. Management of blood pressure, oxygenation, body temperature, nutrition and fluids are critical. Brain swelling is a common problem and the pressure it causes on normal tissue can lead to further cell damage. To get stroke victims safely past the swelling, medication can lower metabolism and oxygen requirements. Early studies suggest that reducing brain temperature (hypothermia) can also help.
Infection control is also a major consideration at this juncture. For example, patients who must be on a ventilator are at particular risk for “aspiration pneumonia,” inflammation of the lungs due to invasion of bacteria. Patients requiring urinary catheterization are at risk for urinary tract infection.
Patients in the ICU are closely monitored around the clock and receive appropriate preventive or interventional therapies — including drug treatment and endovascular/surgical procedures. The time factor remains critical here. All action is taken promptly and accurately.
Identifying Cause and Risk Factors
Part of the critical care and recovery process includes a comprehensive stroke evaluation to determine the factors that contributed to the patient’s stroke. This will allow for a treatment plan to eliminate or modify those factors.
For example, if the patient suffered an ischemic stroke, the team will want to determine the source of the clot. Only 20 percent of ischemic strokes are caused by a blockage originating in the brain; the remaining 80 percent are attributable to a cardiac embolism. Brain scans taken during the acute treatment phase will not reveal this source. Consequently, additional tests will be required during critical care and recovery.
Some sort of rehabilitation generally starts within 24 hours of the patient’s admission. The extent of the therapy depends on the severity of the patient’s condition. At its simplest and earliest, rehab is useful in preventing some of the complications that may develop while the patient is in critical care. For example, patients with limited or no movement may develop muscle contracture, arthritis, frozen joints and other problems of immobility.
For patients who are farther along, physical, occupational and/or speech therapy may be initiated as well.
Stroke Step-Down Care
Some comprehensive stroke centers may have a special stroke “step down” unit for patients who have been stabilized, can breathe on their own, and no longer require the intensive level of care provided in the neuro-ICU. The level of care provided in such units, however, still exceeds that provided in a traditional inpatient setting, and the staff have the specialized training and experience in neuro-intensive care.
The focus in step-down is on round-the-clock monitoring to ensure that the patient remains stable and can eventually be moved to the most appropriate destination for recovery and rehabilitation. A specialized step-down unit can detect even the smallest changes in a stroke patient’s condition and the patient can quickly be returned to the ICU if necessary.