Ischemic strokes

In the case of ischemic strokes, the purpose of treatment is to undo or remove, in the shortest possible time, the clot that is cutting off the natural blood circulation in the brain. There are two ways to do this:

• Intravenous thrombolysis. This treatment is used to break down clots that close the intracranial artery. It has a time limit on when it can be administered, and is effective in 40% of cases. When the drug has dissolved the clot and the closed artery has been uncovered, the artery is said to have been recanalised.
• Thrombectomy (neurovascular intervention). This is performed in cases where the drug has not been effective or cannot be administered. In this case, the clot is removed by an invasive intraarterial procedure through the femur.

Haemorrhagic strokes

In haemorrhagic strokes, the treatment aims to stop the bleeding that has been caused by the rupture of a vessel and prevent the increase in size of the haemorrhage. Therefore, regular monitoring of the patient is performed to gauge the level of consciousness and any neurological deficits. This is maintained for at least the first 72 hours after suffering a stroke. We also perform intensive monitoring of blood pressure, blood sugar levels and temperature to foresee possible complications.

Brain bleeding can cause inflammation of the surrounding brain tissue (known as oedema). If this happens, it is necessary to administer medication intravenously to reduce it.  In people who are being treated with oral anticoagulants or who have alterations in haemostasis (a process that the body performs to slow down bleeding), it should be corrected as soon as possible.

In more severe cases, specialists may recommend surgery to drain the bleeding. The decision on surgical treatment is made based on factors such as the location and size of the haemorrhage, age, and the patient’s medical history. This is a difficult decision as it is not always possible to access it without causing damage to other areas of the brain. 

Rehabilitation

The purpose of neurorehabilitation is to regain lost or diminished neurological functions as a result of a stroke. However, there are phases of recovery:

• The first three months is when we see the greatest degree of neurological recovery.
• In the first six months, functional recovery takes place.
• After approximately a year, there is adaptation to disability and reintegration into the community.
• Up to two years after the attack, language and balance can continue to improve.

The interdisciplinary team involved throughout the different stages works so that the patient has the maximum independence and adaptation to their environment.  To meet these goals, it is advisable to start recovery as soon as possible and, from the initial stages, foster the participation of patient and caregivers. 

It should be mentioned that there is “Spontaneous recovery”: this is when the brain has the ability to recover from the damage it has suffered on its own. This recovery, however, may not be enough to reduce the sequelae. That is why it is advisable to always follow the instructions of specialists.

Interdisciplinary team

An interdisciplinary team deals with the recovery of a patient who has suffered a stroke. Each of the professionals acts according to the evolution of the condition and the needs that arise at any given time:

• The neuropsychology  staff are involved when behavioural changes occur as a result of damage to the brain. There may also be impairment of memory, language (comprehension and expression), attention and concentration, the speed with which the brain processes information, visual recognition, programming of motor functions, mood changes, etc.
• Physiotherapy will be involved for people who, after suffering a stroke, have motor deficits such as walking, balance, loss of strength and muscle tone, among others.
• In the case of a patient with a disability, occupational therapy aims to help the patient carry out their daily tasks independently (dressing, eating, handling money, among others) and supports adaptation to the environment, which sometimes involves adapting the home and providing utensils appropriate for daily activities without assistance from others, or with as little assistance as possible.
• Cases where problems with language and communication skills are detected will involve speech therapy. These obstacles may manifest as an inability to convey or understand what the person is saying, presenting incoherent language (aphasia), difficulty in articulating words (dysarthria), or an inability to speak at all. It also deals with problems related to dysphagia (inability to swallow), which can lead to changes in diet, incorporating safe eating techniques (to prevent malnutrition, dehydration and food passing into the lungs) or, in more severe cases, having to use a feeding tube.
• The social care team aims to achieve the maximum social integration of the patient, guiding and providing professional support in the social and family aspects of the people affected. They provide information on benefits, access and use of existing health and social resources, and how to manage them. 

Other professionals such as doctors, nurses and orthopaedic technicians are also involved in the rehabilitation process.

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The aim of this treatment is to regenerate a haematopoiesis (the process by which the different types of blood cells form, mature, and circulate from stem cells), which has been eliminated by administering drugs or ionizing radiation, followed by the implantation of the donor's immune system, which is able to recognise and attack the malignant cells in the patient. 

In this way, the bone marrow stem cells (factory of the defences) are changed for those of a healthy person (the donor). To undergo this process the patient is admitted to hospital for between one and three months. 

1st step: 

• Find a compatible donor (one that the body of the receiver will accept). 
• This donor can be from anywhere in the world.

2nd step: 

• Conditioning process to make room for the new cells.

• Admittance to hospital in isolation for approximately three weeks. 
• Required medication; chemotherapy, which is usually not as strong as traditional chemotherapy. Sometimes radiotherapy. 

3rd step: 

• Transfuse (the process of passing blood from one person to another, by means of a transfusion) the cells to the receiver. 
• Wait for engraftment, whereby the new cells attach to the receiver's bone marrow (implantation). 

What complications may arise?

• Infections: while the cells of the donor are not yet working. 
• Rejection: the receiver's defence cells attack the donor’s cells. 
• Graft-versus-host disease (GvHD): The donor's cells attack the receiver's body. 
• Partial recovery of defences.
• Need for a blood or a platelet transfusion. 

What do I have to do after the transplant?

• Regular check-ups during the first year. 
• Frequent medication recommended by the experts. 
• A slow return to normal life and complete recovery. 

Treatment

There are three different levels of treatment:

a) medical, with the use of medication or hormones to substitute the alterations mentioned. A diet that creates little urea or that contains low levels of potassium, drugs to control excess or lack of sodium, potassium, calcium, phosphorus, magnesium or acidity. And medication to treat anaemia.

b) extrarenal purification methods: haemodialysis (passing the blood through an external circuit to purify it and filter out toxic substances using a suitable filter), and peritoneal dialysis, during which a solution is circulated inside the patient's peritoneal cavity and is then extracted, taking the toxic substances usually expelled through urine with it.

c) kidney transplant from a living or deceased donor. In this instance, the new kidney takes over the functions of the diseased kidney. How long a kidney graft lasts varies and relies on controlling episodes of organ rejection that may occur after transplant. A young patient with kidney insufficiency may require more than one kidney transplant over their lifetime, although the useful life of these grafts is increasing day by day thanks to new immunosuppressant drugs.

Treatment

To treat herpes we use so-called antiviral drugs, such as acyclovir, famcyclovir and valacyclovir, which are the most effective in treating people affected by HSV-1.

Although the intensity and frequency of the symptoms will be reduced, they do not cure the infection.

Who may need a lung transplant?

Currently, 4,000 lung transplants are carried out every year around the world, including children and adults, especially in Europe, the United States, Canada and Australia. In the case of Catalonia, nine lung transplants are carried out per million inhabitants, a figure that puts us at the top of the tables. Our experience ranges from month-old babies to 70-year-olds.

What is the survival rate for lung transplants?

Normally, it is a pneumologist with a patient with chronic respiratory insufficiency who contacts the Lung Transplant Unit for both adults and children at the Vall d'Hebron Hospital. From that first point of contact, the patient will be assessed by a multidisciplinary team in order to offer the best option, which might involve a transplant or simply medical treatment. It is important to remember that people who undergo lung transplants need to be strong enough to both wait for the operation and recover from it. This is a fundamental, complex requirement that must be met if the transplant is to provide benefits for the patient.

The survival rates for lung transplants are very positive. More than half of all patients are still alive after five years of the operation, and one in three patients after ten years. However, the goal of specialists is to continue researching to improve these results and prevent chronic rejection, and all the factors that lead to this complication.

What treatment should a lung transplant patient receive?

Patients undergoing lung transplants must take an immunosuppressive therapy and prophylactics for an extended period of time. Most of these treatments are oral and in some cases may be inhaled.

What lifestyle should patients follow after a lung transplant?

In order to prevent complications, the medical advice given by your doctor should be followed precisely, avoid stress or over-exertion and make sure you follow the medication plan exactly. Aside from that, you can expect to lead a normal life.

What is it for?

The purpose of the transplant is to implant a heart from another person (usually from a donor in a state of brain death) to take over the functions of the heart of the sick person. Sometimes, heart disease causes lung problems or vice versa: pulmonary disease can cause heart disease. In these cases, the heart and the lungs must be transplanted, which is called a "cardiopulmonary transplant". Depending on the type of illness, one or both organs will be transplanted, whatever offers the maximum benefit at the lowest risk.

Before the intervention, a team of professionals must study the patient following a clinical and surgical protocol in order to guarantee success.

The operation

The operation is performed under general anaesthesia. During the process of heart transplant, the sick heart is removed and in its place a new one is implanted. Sometimes, it is also necessary to transplant the lungs.  

In order to perform these operations, a multidisciplinary team of highly specialised and experienced professionals is required, as well as advanced technology and appropriate facilities.

Post-operative care

Post-operative care is handled by the Intensive Care Unit, where intensive doctors, cardiac surgeons, cardiologists and pulmonologists take care of the patient until they are stable, when they are then moved on to a conventional hospital ward.

During this process, the doctor indicates personalised immunosuppressive therapy programme and infection prevention to be followed by the patient, along with any appropriate modifications that might be needed during the post-operative period.

When is a transfusion required?

This treatment is indicated in patients who present a lack of essential blood components at any given time.

Transfusions carry a set of risks and the decision to undergo a transfusion should only be taken by a doctor after looking at the patient’s condition and taking an analysis and assessment of the situation. In this case, patients must always sign an authorisation document called an “informed consent” form.

How is a transfusion of blood and/or haemoderivatives done?

Blood and its components are obtained from volunteers and altruistic donors. Before making a blood donation, donors must fill out a questionnaire about their state of health and, in addition, they must undergo a medical examination. All the blood components obtained are then analysed to make sure there are no diseases that can be transmitted through the blood.

Before making the transfusion, we must verify the blood derivative is compatible with the patient's blood. The physician in charge must assess the risk and benefits of treatment for the patient.

All the components are administered through a vein with a venous catheter.

Risks

Although blood transfusions are now very safe, some undesired side effects may occur:

• Mild reactions, such as fever or chills. These are easily treatable.
• Severe reactions, such as the destruction of red blood cells, haemolysis, severe allergic reactions and pulmonary oedema, with a significant risk for patients. These are uncommon.  

The transmission of infectious diseases associated with blood is very unlikely nowadays. All donated blood is subject to prior analysis to find out about the blood group and prevent the transmission of infectious diseases such as syphilis, hepatitis B, hepatitis C, HIV, Chagas disease and infectious diseases

The transmission of infectious diseases associated with blood is very unlikely nowadays. All donated blood is subject to prior analysis to find out about the blood group and prevent the transmission of infectious diseases such as syphilis, hepatitis B, hepatitis C, HIV, Chagas disease and human T-lymphotrophic virus.

When is chemotherapy required?

Chemotherapy is administered in different ways and for various reasons:

• Before surgery or radiotherapy to reduce tumours.
• After surgery or radiotherapy to eliminate cancer cells.
• As a treatment, for instance in cancers of the blood or lymphatic system.
• As a treatment for recurrent cancer.
• To treat cancer that is spreading throughout the body, metastatic cancer.

How does chemotherapy work?

The human body is made up of different cells that each have a certain function. Cancer begins when a group of cells reproduces very quickly and uncontrollably. This affects the cells’ function and, therefore, stops the body functioning normally.

Chemotherapy acts on these cells, which may or may not be cancerous, that are rapidly reproducing. This causes side effects, which will depend on the medication, dose, duration and each individual person.

Chemotherapy can be intravenous or oral, meaning it can be administered by the vein or by the mouth. The first option is the most common.  

To administer this treatment, sometimes a catheter is left in place that is then connected to a disc below the skin. The medication is administered through this device. This catheter is called a port-a-cath, although there are more types of catheters. The way the vein is accessed depends on the characteristics of the person and the duration of the treatment.

Chemotherapy is applied at intervals and the duration depends on the type of programme, control and treatment.

Risks

Chemotherapy can produce the following side effects:

• Risk of infections, bruising easily, bleeding, feeling of weakness and fatigue, as it acts on the blood cells
• Hair loss, change of colour or consistency of hair, as it acts on the roots of hair.
• Loss of appetite, nausea, vomiting, diarrhoea, difficulty in eating and sores in the mouth and lips, as it acts on the cells of the digestive tract.