Notice:
- Immediately make an emergency call! (Call number 112)
- The occurrence of disorders of consciousness is a mandatory emergency physician indication.
- Transport with advance notification at the destination hospital. The hospital should be a stroke competent hospital – preferably with stroke unit.
General measures
- In cerebral infarction, the best possible blood flow must be maintained around the damaged area. Therefore, elevated blood pressure should not be lowered except in cases of malignant hypertension!Note: In the acute phase of an ischemic infarction, pressure lowering should be avoided as long as it is below 210/110 mmHg.
- Furthermore, attention must be paid to the general risks of a bedridden patient – e.g. pneumonia (pneumonia), deep vein thrombosis (TBVT).
- Cerebral edema (brain swelling) which occurs in between five and ten percent of patients, must also be observed and treated if necessary.
- Nicotine restriction (refrain from tobacco use) including passive smoking.
- Limited alcohol consumption (men: max. 25 g alcohol per day; women: max. 12 g alcohol per day).
- Aim for normal weight! Determination of BMI (body mass index, body mass index) or body composition by means of electrical impedance analysis and, if necessary, participation in a medically supervised weight loss program.
- BMI ≥ 25 → participation in a medically supervised weight loss program.
- Review of permanent medication due topossible impact on the existing disease.
Stroke Unit
After an apoplexy, the patient should be observed on a so-called stroke unit (stroke unit).There, the following values are monitored:
- Respiration
- Blood pressure
- Heart rate
- Glucose (blood sugar)
- Electrolytes
- Blood clotting
- Body temperature
Early phase after apoplexy
Prevention and, if necessary, therapy of:
- Respiratory regulation disorders
- Dysphagia (swallowing disorder)
- Aspiration pneumonia (pneumonia caused by, among other things, vomited stomach contents entering the lungs).
- Urinary tract infections
- Electrolyte and blood sugar imbalances
- Cardiac arrhythmias
- Thrombi (blood clots that can cause blockages in blood vessels).
- Re-insults (recurrence of a stroke).
Note: Do not mobilize and stimulate too early. This could increase cell death in the infarct border zone, as a metastable zone forms around the infarct area.
Phase after patient discharge
- Regarding fitness to drive: if there is any doubt about fitness to drive, a driving test with a neuropsychologist is useful and advised.
Notes on fitness to drive after a cerebral infarction.
| Group 1 | Group 2 | |
| For intracranial stenosis and occlusion of large cerebral arteries. | Yes | No |
| Grace period | 6 month | N/A |
| For high-grade carotid stenosis after successful desobliteration (invasive reopening of a segment of blood vessel obstructed by an obstacle to passage (e.g., a thrombus)) | Yes | Yes |
| Grace period | 1 month | 3 months |
| For high-grade carotid stenosis, treated conservatively | Yes | Yes |
| Grace period | 3 months | 6 months |
| In the case of dissection of the large brain-supplying arteries | Yes | Yes |
| Grace period | 3 months | 6 months |
| Cardioembolic-related – CHA2DS2-VASC to 5, anticoagulated (inhibition of blood clotting). | Yes | Yes |
| Grace period | 1 month | 3 months |
| Cardioembolic-related – CHA2DS2-VASC to 5, not anticoagulated. | Yes | No |
| Grace period | 1 month | N/A |
| Cardioembolic-related – CHA2DS2-VASC > 5, anticoagulated. | Yes | Yes |
| Grace period | 1 month | 3 months |
| Cardioembolic-related – CHA2DS2-VASC > 5, not anticoagulated. | No | No |
| Grace period | N/A | N/A |
| Microangiopathic condition | Yes | Yes |
| Grace period | 1 month | 3 months |
| For unclear genesis/low risk profile. | Yes | Yes |
| Grace period | 1 month | 3 months |
| For unclear genesis/high risk profile. | Yes | Yes |
| Grace period | 3 months | 6 months |
Legend
- Group 1: passenger cars, trucks up to 3.5 t, passenger cars plus trucks up to 3.5 t.
- Group 2: buses, trucks > 3.5 t, buses + trucks > 3.5 t
Conventional non-surgical therapy methods
- Transcranial magnetic stimulation (TMS; transcranial: “through the skull“)-technology that uses strong magnetic fields to both stimulate and inhibit areas of the brain; one protocol of brain stimulation is theta-burst stimulation (magnetic stimulation over the cerebellum that enhances neuronal connections in strength; stimulation consists of multiple short bursts (from 50-100 Hz for 100-1. 000 ms) separated in time by a longer interval (seconds)).Indication: patients with apoplexy in the area of the contralateral cerebral artery (middle cerebral artery) with hemiparesis (hemiplegia) (patients often continue to suffer from balance and gait problems for a long time)In a phase II study, the method was better at strengthening balance than sham stimulation.
Vaccinations
The following vaccinations are advised:
- Flu vaccination
- Pneumococcal vaccination
Nutritional medicine
- Nutritional counseling based on nutritional analysis
- Nutritional recommendations according to a mixed diet taking into account the disease at hand. This means, among other things:
- A total of 5 servings of fresh vegetables and fruit daily (≥ 400 g; 3 servings of vegetables and 2 servings of fruit).
- Fresh sea fish once or twice a week, i.e. fatty sea fish (omega-3 fatty acids) such as anchovies, herring, salmon, mackerel, sardines, tuna – Regular consumption of fish may reduce the risk of apoplexy (stroke).
- High-fiber diet (whole grains, vegetables).
- Observance of the following special dietary recommendations:
- Diet rich in:
- Vitamins (vitamin B2, B6, B12, D).
- Omega-3 fatty acids (sea fish)
- Diet rich in:
- Selection of appropriate food based on the nutritional analysis
- Patients with overweight or obesity (obesity) are less likely to die after apoplexy and carry less disability than ideal weight patients (Obesity Paradox).In contrast, compared with people of supposedly ideal weight, the risk of dying from apoplexy is reduced by 14 percent in overweight people. In obese (obese) patients, the risk of death decreases by 24 to 45 percent.
- See also under “Therapy with micronutrients (vital substances)” – if necessary, taking a suitable dietary supplement.
- Detailed information on nutritional medicine you will receive from us.
Sports Medicine
- Light endurance training (cardio training) and strength training (muscle training) for prevention / after rehabilitation (effective; but only small effects).
- After a transitory ischemic attack (TIA; sudden circulatory disturbance of the brain leading to neurological disorders that regress within 24 hours) or a stenosis-related apoplexy (stroke), myocardial infarction (heart attack), apoplexy (stroke), or vascular-related death occur 5.4 times more frequently in inactive patients than in moderately physically active patients; for ischemic apoplexy, as much as 7-fold increased rate for recurrence of apoplexy in the physically inactive participants.
- Cochrane Stroke Group: “We found that cardiorespiratory fitness training, particularly involving walking, can improve fitness, balance, and walking after stroke”; strength training may play a role in improving balance.
- Establishing a fitness or training plan with appropriate sports disciplines based on a medical check (health check or athlete check).
- Detailed information on sports medicine you will receive from us.
Psychotherapy
- Psychotherapy, if necessary
- Detailed information on psychosomatics (including stress management) can be obtained from us.
Rehabilitation
Following the stay in the stroke unit, rehabilitation must take place. About two-thirds of apoplexy patients initially also have impaired mobility. Rehabilitation methods can help improve walking ability, walking distance, walking speed, and gait and stance stability.These include different therapeutic methods such as, depending on the extent of the stroke and the affected brain region:
- Physiotherapy
- Physical therapy:
- Transcutaneous electrical nerve stimulation (TENS) for the treatment of urinary incontinence (bladder weakness):
- Mean number of incontinence episodes within 24 hours (MD -4.76, 95% CI -8.10- -1.41).
- Functional abilities were improved with moderate strength of evidence (MD 8.97, 95% CI 1.27-16.68)
- Transcutaneous electrical nerve stimulation (TENS) for the treatment of urinary incontinence (bladder weakness):
- Physiotherapy
- Endurance training
- Intensive gait training (assisted by equipment if possible); improvement of:
- Walking speed (= progressive gait training).
- Walking distance (endurance training)
- Treadmill training, moderate; 40 minutes three times a day, aiming for an intensity of the load of 60 to 70 percent of the heart rate reserve; this leads, among other things, to improved glucose tolerance (oGTT)Heart rate reserve (according to Karvonen) = (Maximum heart rate – resting heart rate) x intensity of the load + heart rate at rest Maximum heart rate (MHF, HFmax) = 220 – age.
- Intensive gait training (assisted by equipment if possible); improvement of:
- Measures to improve balance (for this purpose better combined mobility training than isolated balance training).
- Occupational therapy
- Neuropsychology
- Speech therapy – Intensive speech therapy helps patients with chronic aphasia after strokeNote: After only six months, the symptoms of aphasia are solidified.
Furthermore, skills lost due to the infarction, such as speaking or walking, are trained again, because many function can be taken over by other areas of the brain.
