The first signs of both strokes and TIAs are acute neurological deficits consistent with the part of the brain affected. They are often preceded by a severe headache. In subarachnoid hemorrhages, the headache is not only sudden but also explosive, very severe, and without other neurological manifestations (Graykowski, 2008).

Some of the clinical signs and symptoms are suggestive of either ischemia or hemorrhage (Box 20-2). Persons with hemorrhage have more specific neurological changes, including seizures and more depressed level of consciousness than those with an ischemic stroke. If a person is deeply unresponsive following a stroke he or she is unlikely to survive (Boss, 2010a). Nausea and vomiting are suggestive of increased cerebral edema in response to an event of either type. Neurological changes may include alterations in motor, sensory, and visual function; coordination; cognition; and language and depend on the area of damage.

Diagnosis includes the determination and correction of possible extra-cerebral causes, if any (e.g., infection or hypoglycemia), confirmation of the type of stroke and identifying exactly where in the brain the damage has occurred. This is done through the use of a computed tomography (CT) scan or magnetic resonance imaging (MRI).

After a TIA resolves, there should be no residual effect other than an increased chance of recurrence and the possible increased risk for stroke as noted earlier. Early complications of a simple stroke include extension of the amount of damage and recurrence. Brain edema is always a problem, and could result in obstructive hydrocephalus (Graykowski, 2008).

The potential long-term effects of a stroke may be minimal but also may include paralysis and hemiparesis limiting movement, and dysarthrias, dysphagias, and aphasias limiting speech. Post-stroke depression has been found to negatively affect rehabilitation. Whenever paralysis or hemiparesis occurs, the development of spasticity or unusually tight muscles in the affected limb(s) is a risk. Spasticity can lead to contractures if it is not managed well and even sometimes when it is. Pain in the affected side is not uncommon and may be treated with muscle relaxants or medications specific for neuropathic pain (see Chapter 8). The medications, added to the potential limitations of the stroke, significantly increase the risk for falls. Other complications include blood clots (deep vein thrombosis [DVT]) in the affected limb, pressure ulcers, aspiration pneumonia, and urinary tract infections (Llinas, 2010).

All actual or potential cerebrovascular events are considered emergencies and should be treated as such. However, because TIAs are highly transient they often resolve on their own before the person is even seen by a health care provider. Instead, the person reports “I think I had a small stroke last week” or they do not seek care at all. If the deficits and symptoms were fleeting, the diagnosis is made through the clinical interview. Management is considered preventive—to prevent recurrences and to decrease any possible risk factors for strokes (see the Healthy People box). The person and family are also instructed in the appropriate emergency response to the return of any signs or symptoms of a stroke or another TIA (see Box 20-1). Anticoagulant therapy has been proven to prevent recurrent cardioembolic strokes and TIAs. Aspirin, 81 to 325 mg/day, is the mainstay of therapy for elders with TIAs. However, for those who are aspirin sensitive, clopidogrel (Plavix) may be used (Llinas, 2010). Warfarin therapy or one of the newer related medications is usually used in persons to prevent another stroke and in those with atrial fibrillation to prevent the occurrence of the first stroke (Graykowski, 2008).

Acute management is accomplished in emergency departments and intensive care units. The acute management of the stroke requires careful attention to the accuracy of the diagnosis. For ischemic strokes caused by an embolism, the compromised circulation to the brain must be restored rapidly. This is done in emergency rooms and is called reperfusion therapy using recombinant tissue plasminogen activator (rt-PA) if the facility is equipped to do so (see the Healthy People box).

If the person has had a hemorrhagic stroke and it is misdiagnosed, the bleeding will be rapidly accelerated by the rt-PA, and the person will die. The initial response to the hemorrhagic stroke is to find a means to stop the bleeding if possible.