In the event of an ischemic stroke, the first goal is to get blood flowing to the affected area of the brain quickly to prevent brain cells from dying. This is why calling 911 at the first sign of symptoms is especially important for possible treatment with alteplace (tPA). This medication dissolves clots that block arteries within the brain. The quicker tPA is given, the more effective it is [2]. Studies have shown that patients that receive tPA often have a better recovery compared to those that did not receive treatment with tPA. However, tPA does not come without risk. There is a 6 % chance of bleeding into the area of stroke associated with this treatment [2]. The important thing to remember is that patients receiving tPA have the same risk of dying compared to those that did not receive tPA. Thus, despite the bleeding risk, receiving tPA does not increase your risk of dying when compared to not receiving tPA. Another treatment option is an endovascular procedure. This is when doctors with advanced training try removing the blood clot directly from the blood vessel using special devices. Researchers are still trying to determine the best situations for this procedure [3]. Once initial treatment is completed, the medical team will continue to closely monitor the person. In the first few days after a large stroke, there is a risk of swelling in the brain due to the injury caused by the stroke. The person can become sick enough to need a breathing tube and breathing machine because they become too sleepy to breathe properly. Should swelling occur, the medical team can use medicines to try to decrease the amount of swelling. In severe cases, when the patient meets strict criteria, an operation called a hemicraniectomy can be done. When this is done, a neurosurgeon takes part of the person’s skull off giving the brain more space to swell outwards. The piece of skull is saved and will be put back in place several months later. In the mean time, the person’s head is protected by a special helmet until the skull can be put back on [6].

Immediately after the stroke, the stroke patient will not be allowed to eat or drink until their swallowing is tested. A stroke often affects the swallowing muscles which could result in food going into the lungs and causing pneumonia which would prolong recovery or in some cases could result in death [3]. Stroke patients with swallowing problems will work with Speech Therapists to learn to swallow safely.

The stroke patient’s blood pressure will be left high for several days after the stroke to maximize blood flow to the affected area of the brain. This prevents death of brain cells around the area of the stroke [3]. Their heart will be checked for an irregular heart rhythm called atrial fibrillation. This heart rhythm poses significant risk of stroke and the patient may need to be on lifelong blood thinners if found to have this rhythm. There will be other scans and blood tests ordered depending on medical and family history.

In a hemorrhagic stroke, a blood vessel in the head breaks and blood leaks out into the brain and sometimes the spinal fluid. There is very little room in a person’s head for anything extra such as blood which is no longer contained in a blood vessel so this kind of stroke often makes a person very ill immediately and they have to go to an Intensive Care Unit [4]. With this kind of stroke people may immediately become unconscious and require a breathing tube and ventilator (breathing machine) while being treated. The blood which has leaked out can cause the pressure inside the person’s head to become very high causing brain damage and even death. Special monitors are often used to monitor the pressure inside the brain. Specific medicines can be used to try to control the high pressure. Sometimes the person has to be sedated(made very sleepy) or kept very cold to allow the brain time to heal from the effects of the high pressure [4, 5]. The blood from bleeding into the brain is mixed in with brain tissue so surgery to try to remove the clot is usually not helpful. Just like with ischemic strokes, sometimes an operation called a hemicraniectomy might be done to relieve the high pressure by giving the brain room to swell outwards and have time to heal [7]. Sometimes people may have seizures from the blood irritating the brain. They will get medicine to treat the seizures and prevent future seizures. Seizures can affect recovery from the initial stroke and change how someone functions in their day to day activities. The person needs to be extra careful about activities in which they or people around them could be seriously hurt if they were to have a seizure. In the United States as a safety measure, after a person has a seizure, he or she is not allowed to drive until a certain amount of time has passed in which they do not have seizures. This time frame varies from state to state [4]. Sometimes, the bleeding that happens is very small and while someone becomes sick enough to come to the hospital, they do not become sick enough to go to the ICU. They still have to stay in the hospital while their medical team finds out why the bleeding occurred. Often it is because a person’s blood pressure is too high and needs to be controlled better. If the person was taking any kind of blood thinner, this will be stopped to give the brain time to heal. When they leave the hospital, they will usually be asked not to take any over-the-counter pain medication besides acetaminophen. Other widely available pain medicines can increase the risk of bleeding. When the person is seen in clinic for follow up by a neurologist, they may need to get follow up brain scans. Sometimes bleeding in the brain is caused by a tumor or a malformed vessel that was not seen initially because the blood in the brain made it hard to see. It takes several weeks for the blood to resolve and allow anything that might be there to be seen properly [5].

Stroke recovery and rehabilitation often starts as soon as the survivor is treated for the stroke. Depending on the location and amount of brain tissue affected by the stroke, the ability of a person to recover and benefit from rehabilitation varies. After the acute phase of either kind of stroke, the brain and body may be able to recover some, if not all, of the function that was lost. This time period of recovery may last days, months, and even years. Generally, the process of recovery is most rapid in the first few weeks and this often sets the rate for further improvement. Rehabilitation is begun as soon as possible, often while the patient is still in the hospital. Rehabilitation focuses both on maintaining the person’s current abilities as well as the regaining of functions affected by the stroke. Stroke rehabilitation involves the patient, family, caregivers, and a variety of healthcare specialists. As every patient and stroke is different, the healthcare specialists needed to assist in the patient’s rehabilitation may vary as outlined in Table 11.1. The number of specialties involved in the process may be overwhelming to both patients and their families. It is important to understand their roles as they will be working with the patient and families through recovery and rehabilitation. In some cases, the patient can be discharged to their home with outpatient therapy, done through a community center or hospital. For patients with debilities that make travel difficult, home therapy may be available. In other cases, a patient may leave the hospital to go to an inpatient rehabilitation facility for several weeks before they are able to return home. It is important to remember that some patients are too sick or disabled after a stroke to be able to participate in rehabilitative therapies. In these cases, therapy may be deferred. Occasionally, when a person’s disabilities require a large amount of nursing care, the best option for the patient and their family is discharge from the hospital to a skilled nursing facility or nursing home.