Most stroke patients are initially treated in the emergency room of a hospital, often after having been transported there by ambulance. The patient's present condition will be assessed, which includes, in addition to many other investigations, a blood pressure check and a determination of whether or not the patient is able to communicate, and if so, if the patient is experiencing any paralysis or numbness.

Emergency room neurologists will ascertain if the drug "tissue plasminogen activator" (tPA), a clot-busting drug, would be appropriate treatment. tPA is generally indicated if the stroke is caused by a blood clot. tPA is contraindicated if the stroke is caused by an intracranial or subarachnoid hemorrhage, or if the patient had recent intracranial surgery, or a recent head injury. Whether or not a hemorrhage is present is often determined through a CT scan. Because tPA significantly thins blood, in order to dissolve a clot, use of tPA is not appropriate, and indeed harmful, if a stroke is caused by internal bleeding, rather than a clot.

If tPA is appropriate, it must be administered within the first three hours of a stroke to be effective. If administered within the three-hour timeframe, tPA can often have a dramatic effect in halting the damage caused by a stroke, and aiding the stroke patient's recovery. Given that timing is so important in the administration of tPA, most hospitals record the time the patient arrived at the emergency room, and the precise time tPA was administered.

Because tPA is such a powerful blood thinner, patients to whom it is administered will generally develop large, dark bruises. These bruises will go away, although it may take days or weeks.

Once the patient is stabilized, he or she will be brought to the critical care or intensive care section of the hospital, where they will be monitored to make certain their condition remains stable. During the patient's stay in CCU or ICU, if the stroke was caused by a clot, additional tests may be performed in an attempt to determine where the clot originated. Most clots originate in the heart area, in the neck, or in the brain itself. In many cases, the origin of the clot is never discovered.

During this time also, the patient will typically be visited by speech and physical therapists, generally on a daily basis, who will perform assessments of the patient's current condition, and will help the patient begin recovering damaged speech and/or physical functions. During one of these visits, a therapist will test the patient's ability to swallow liquids and foods (some stroke patients acquire difficulty swallowing). If the patient is able to swallow properly, the I.V. feeding tube is removed, and the patient is transitioned back to solid food.

As the patient continues to improve, he or she will be transferred out of the CCU or ICU section, usually to either the neurological wing or therapeutic wing of the hospital. Physical and speech therapy will continue on a daily basis.

It is not unusual for a severe stroke patient, particularly a left-brain stroke patient, to have complete paralysis on one side of their body initially, but then have function return to that paralyzed side of their body (although numbness may remain), so that in a relatively brief period of time, sometimes within a week, depending upon the severity and location of the stroke, they are able once again, with the help of physical therapy, to walk.

It is also not unusual for left-brain stroke patients who have had their speech centers damaged by a stroke to initially believe they are speaking normally, even though, in fact, their speech does not make any sense. This confusion can obviously cause a great deal of frustration for the stroke patient, who may believe the people he or she is "communicating" with are ignoring his or her requests.

Patients are discharged from the hospital once it is felt the immediate danger of a stroke is past, and the patient is being discharged to an environment where they will receive adequate care as they continue their recovery. Discharge is usually to the patient's home. If the effects of the stroke are still severe, there is generally the option, if the patient's insurance will cover it, of discharge to a residential rehabilitation clinic, if that is the stroke patient's and caregiver's decision. Stroke patients who still have severe physical disabilities are generally held longer in the hospital than patients with severe speech disabilities. Most hospital discharges occur on Fridays and Saturdays.

When a patient is sent to a hospital following a stroke, staff will normally perform a number of tests to gain more information regarding the stroke. These tests can assist the patient's doctor in determining the possible cause of the stroke, and help assess the patient's current state of health.

The most common diagnostic tests performed at the hospital are:

Blood Pressure - High blood pressure can be a contributing cause of a stroke.

Blood Tests - Used to check for clots, to determine cholesterol and sugar levels in the blood, and gain information on the patient's general health.

Electrocardiogram (ECG) - Checks to see if the patient has an irregular heartbeat, which can be another cause of a stroke.

CT or CAT Scan - An x-ray of the brain to determine if there are any blocked arteries or other injuries to the brain, and to discover the extent of damage caused to the brain by a stroke.

MRI Scan - A scan that uses waves to produce a detailed image of the brain, to assess its current state.

Transthoracic Echocardiogram (TTE) - A noninvasive method of examining a heart's condition by sliding a transducer, a small microphone-like instrument, around the chest or abdominal wall. The transducer sends sound waves into the chest, the echoes of which reflect off the different sections of the heart.

Transesophageal Echocardiography (TEE) - A type of echocardiography that uses sound waves to obtain high resolution moving images of the heart and the heart's blood vessels, including the size and shape of the heart, and how well the heart chambers and valves are performing. Often used to locate heart muscle that isn't contracting properly, blood clots located inside the heart, and dysfunctions of the aorta (the principle artery used to transfer blood from the heart to the rest of the body).

Carotid Ultrasound - Another test that uses a transducer and echo to produce images from inside the body, in this case the two carotid arteries, one on each side of the neck. The carotid artery carries blood from the heart to the brain. A carotid ultrasound provides detailed information on the degree to which these arteries are functioning properly, as well as information on the blood flowing through them.

Medication after discharge falls into three categories:

• Medication to prevent another stroke

• Medication to help the patient cope with their changed circumstances

• In the case of intellectual disability, such as loss of the speech function, medication to help repair the cognitive and communication functions of the brain

Medication to prevent another stroke focuses on controlling those physical conditions a patient has which are known to contribute to stroke incidence. If a patient has, for example, high blood pressure, or high cholesterol, he or she will be prescribed medicine to help moderate those conditions. If the cause of a stroke was a blood clot, the patient may also be asked to take a blood thinner. Depending on the nature of the patient's stroke, the blood thinner may be over-the-counter aspirin, taken daily, or may be coumadin, or one of its many variants. Coumadin is a prescription blood-thinner that is taken daily. Because of its powerful effect, patients taking coumadin usually have to have a blood test performed on a regular basis, generally once a month, once the coumadin level in their blood has stabilized, to make sure the coumadin level within their blood is at an acceptable level. The acceptable level for coumadin is between 2.0 and 3.0. Lower than 2.0, clots are more likely to form. Higher than 3.0, excessive bleeding is possible. A blood test may be the drawing of a sample of blood with a syringe, or a "blood stick" test, in which a fingertip is pricked, and a small sample of blood removed. Coumadin levels are adversely affected by foods which contain high levels of vitamin K, such as spinach and other dark green, leafy vegetables. Patients who have had a clot-based stroke should generally avoid large doses of vitamin K, such as are found in some one-a-day vitamins.

After a stroke, it is quite common for the patient to feel depressed, because of the touch of mortality a stroke, much like a heart attack, brings, and also because of the patient's reduced intellectual and/or physical capabilities. It is not unusual for a stroke patient to be prescribed an anti-depressant to help cope with their depression.

There has been much research done on drugs which might help the brain to repair itself following a stroke, particularly speech and other cognitive functions, and several studies suggest anti-depressants might aid the brain's recovery from a stroke, in the sense of helping the re-routing of impaired brain functions to new, unaffected areas of the brain. Ritalin, taken in small doses for a period of several months, has also been looked at as an aid in brain repair of speech and cognitive functions. All such possibilities should be discussed with the patient's physician.

Someone who has suffered a stroke must, obviously, avoid those activities which have been shown to cause strokes.

Stroke patients must:

• Control their high blood pressure

• Stop smoking

• Drink moderately

• Control their cholesterol level

• Exercise regularly

• Take medication to regulate their coumadin level, if applicable

• Avoid stress

Disabilities such as paralysis or aphasia caused by a stroke exist because an area of the brain in charge of that function has been damaged.

The brain does repair itself, to the extent it can.

As mentioned above, some anti-depressants, as well as low doses of Ritalin, may help the brain to knit together again.

The greatest aid to the brain's recovery of damaged functions, however, is therapy.

Physical therapy can help the paralyzed patient learn to use their limbs again.

Speech therapy can help the patient regain the speech function. The key to speech recovery is to have the patient attempt to speak as much as possible. Depending on the severity of a stroke, this may begin by helping the patient to recite the alphabet, the days of the week, or the months of the year. Although this can be a difficult task for some stroke patients, the effort itself, trying to recall, for example, the days of the week, helps the brain repair itself, since the brain is being actively used to attempt to perform a task. The more the brain must try to produce a correct answer to a question, the more the brain finds new routes towards recovery. In other words, especially during the early stages of speech therapy, it really does not matter if the patient is able to answer a question correctly. What is more important is that the patient uses his or her thought processes to try to produce a correct answer, since the attempt itself, whether successful or not, aids cognitive repair.

Therapy, physical, speech, or otherwise, should begin as soon as possible, while the patient is still hospitalized. Once the patient has been discharged, therapy should continue almost immediately after discharge, and certainly within the first week of discharge. Studies have shown that the early months following a stroke are the optimum time for a patient to make tremendous gains in recovering physical or speech functions. The further away from a stroke, the more difficult it is for the patient to recover functions, although recovery continues, at a diminishing rate, for years.

Most stroke patients experience an improvement from their initial condition following a stroke. Those who have been paralyzed regain at least some function in the affected limbs; those who have lost the ability to understand speech recover some of that facility.

The degree to which a patient recovers functions lost because of a stroke depends on a number of factors, including whether or not the patient received tPA, if applicable, within three hours of their stroke, the severity of the stroke, the age of the patient, and the amount of therapy the patient receives following the stroke.

Stroke specialists generally regard the first three months following a stroke as the optimum period for the stroke patient to recover lost functions, followed by six months after the stroke, one year, and two years. The further in time from the stroke, the more difficult it may be to reacquire physical or speech functions, although improvement does continue, but at a slower pace. Initially, it was believed stroke patients do not generally improve after two years, that they plateau, but extensive anecdotal evidence suggests improvement does, in fact, continue indefinitely.

Because the greatest recovery of lost functions is realized in the first three months, it is vitally important that stroke patients receive as much physical and/or speech therapy as possible during this period. Depending upon the severity of the stroke, patients may require therapy, at a diminishing frequency, for one or two years following their stroke. At least initially, therapy may be required five days a week.

Studies suggest a stroke patient who has been administered tPA, if applicable, within the first three hours of a stroke, and who receives adequate therapy afterwards, may recover up to ninety percent of their affected functions. For most stroke patients, full, one hundred percent recovery does not occur. Although this statement may appear disheartening, it must be remembered that many stroke patients die during their stroke, and that any patient who survives a stroke, and recovers nearly all their functions, has much for which to be grateful.