Invasive Stroke Treatments

Time is brain, so diagnosis and treatment must be spot on in order to restore blood flow to the affected part of the brain. The quicker the signs of stroke are recognized and emergency medical treatment is sought, the more opportunities open up for interventional therapies. Interventional therapies must be individualized and tailored to the patient’s diagnosis.

In particular, patients who experience ischemic strokes caused by blood clots, may be given clot-busting drugs, such as Alteplase (Activase) also known as tPA (tissue plasminogen activator) intravenously when they arrive at the hospital within three hours from the onset of stroke symptoms. However, this treatment option may not be available for everyone. Sometimes the clot in the brain artery is too large for the drug Alteplase to dissolve or the time frame of the patient’s hospital presentation is outside the 3 hour time frame. A group of neuro-interventional specialists that include a physician, nurses and techs are available to treat patients in the neuro-interventional radiology suite.

Interventional clot busting therapies helps extend the required treatment time for Alteplase (tPA) up to six hours. A catheter (a thin tube) is inserted under x-ray guidance, into the large artery (femoral artery) in the groin area and directed up to the site of the clot. These catheters are very long and can be as thin as spaghetti.  From there, the neuro-interventional physician injects the clot-busting agent into the catheter that is directed right to the clot. The medication in dripped in slowly and methodically to dissolve the clot. The patient undergoes the entire procedure under general anesthesia. The procedure can take up to several hours to complete.

Other means to break up or remove clots can be done by mechanically. The neuro-interventional physicians have at their disposal advanced clot-retrieving systems like MERCI and Penumbra as other treatment options.

The MERCI is a tiny corkscrew-shaped device, inserted into the catheter that allows the neuro-endovascular physician to snag the clot and then pull the clot back into the catheter. This procedure can be used up to eight hours after the onset of stroke symptoms.   http://www.concentric-medical.com/maintopic.php?id=3

Penumbra is a device that retrieves the clot by aspirating it back into the catheter. It can be used up to six to eight hours after onset of stroke symptoms. It is thought that the suction is effective in removing rigid clots. http://www.penumbrainc.com/hi-res

I am often asked by stroke patients I see if they could have been candidates for the “clot busting ” medication known as Tissue Plasminogen Activator (t-PA), a thrombolytic drug approved by the U.S. Food and Drug Administration for the urgent treatment of ischemic stroke—the type of stroke that impedes arterial blood flow in the brain due to a narrowing or clot (blood or cholesterol plaque).

When stroke symptoms are observed, (facial drooping, slurred speech or leg and/or arm weakness, to name a few for instance) a radiological study of the brain called  “CT scan” is quickly ordered to be sure the stroke is not due to a bleeding vessel. t-PA is never given for bleeding strokes..

t-PA is a weight based medication that is administered through an intravenous (IV) line. In order to qualify for this treatment doctors who treat stroke follow a very detailed list of inclusion/exclusion criteria. The physician has a detailed list of conditions or procedures that can exclude a patient from treatment due to the increased risk of bleeding. The single most important criteria for t-PA eligibility is presentation to the emergency department when stroke symptom onset--self reported or witnessed--occurred in less than 3 hours.

Why 3 hours?

A stroke causes the surrounding tissues where the initial insult has occurred to become oxygen starved. Lack of oxygen over minutes and certainly hours will cause this brain tissue to die or become “infarcted.” The infarcted tissues can then become irritated and swollen increasing the risk for bleeding in and around the area of damaged tissue.

That is why it is very important to know exactly when patients were last known to have stroke symptoms. It is unfortunate that all too often, stroke symptoms are dismissed. At times, it saddens me that I cannot console patients or family members who feel regret at not having made the call to 911. I urge them to tell others—family, friends and strangers—to make the 911 call at the first signs of stroke. Three hours can seem like a lot of time, but it may not compare with the burden of facing the remainder of one’s life with disability.

My name is Ana Tattersall Cocke. In my role as the director for the Baptist Health System stroke services and as an Advanced Practice Nurse I have a committed interest in caring and educating our patients on stroke. I hope you will find this stroke blog useful and informative. Feel free to send me a comment via this blog.

I often educate my patients on the following topics:

Blood Supply and Lack of Blood Supply to the Brain

© 2008 Nucleus Medical Art, Inc

The most common stroke symptoms include:

• Weakness or numbness on one side of the body
• Blurry, dimming, or no vision
• Difficulty swallowing, talking, or comprehending others
• Dizziness, falling, or loss of balance
• Severe or unusual headache

Call for emergency medical help immediately. Brain tissue dies quickly when deprived of oxygen, but there is a brief window of opportunity to reverse some of the damage.

Treatment of Ischemic (blocked artery) Stroke
When blood clots lodge in the brain arteries, doctors can use a medication called Tissue Plasminogen Activator (tPA) to dissolve them. It is important to note that intravenous tPA cannot be given to people who come into the emergency room more than three hours after the onset of stroke symptoms because it can increase the risk of bleeding inside the brain. As a result, Baptist Health System Emergency Department affliated doctors and neurologists follow a rigorous protocol to make sure stroke patients in San Antonio will have the best outcome when treated with tPA. 

Treatment of Hemorrhagic (bleeding) Stroke
Poorly controlled hypertension is the most common cause of bleeding strokes because hypertension injures the small artery walls in the brain. Other sources for bleeding in the brain can include trauma to the head, certain medications or cancer. Often times, these patient need surgery.

Transient Ischemic Attacks (TIAs) are temporary clots that block an artery in the brain or neck. The person presents with stroke symptoms but they resolve within minutes. This is “warning sign” of impending stroke that should not be ignored. TIA requires immediate medical attention. 

Ana Tattersall Cocke Clinical Nurse Specialist, APRN
Recognizing Stroke

 

 

Tommye Austin, RN, PhD(c), MSN, MBA, CNAA, BC
Stroke Program Implementation Development Director
Read Blog Disclaimer

In the summer of 1996, I woke up one summer morning to find my face frozen on the left side. I was unable to close my left eye. I thought that I was having a stroke, so I pulled out my nursing books and reviewed the symptoms for a stroke…needless to say the facial drooping was not the same as what was indicated in the text. I was experiencing Bell's Palsy, a form of temporary facial paralysis resulting from damage or trauma to one of the two facial nerves. Other symptoms that I experienced with Bell’s Palsy included drooping at the corner of my mouth, pain around the jaw and behind my left ear, impaired speech, hypersensitivity to sound in my left ear, and difficulty drinking from a cup.

Bell's Palsy: Facial Droop

© 2008 Nucleus Medical Art, Inc.

Diagnosing Bell’s Palsy is done by performing an electromyography (EMG) that can confirm the presence of nerve damage and determine the severity and the extent of nerve involvement. An x-ray of the skull can help rule out infection or tumor. A magnetic resonance imaging (MRI) or computed tomography (CT) scan can eliminate other causes of pressure on the facial nerve.

It is easy to confuse Bell’s palsy with a stroke if you don’t know the facts. Always remember that the American Stroke Association wants you to know the warning signs of stroke:

• Sudden confusion, trouble speaking or understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden, severe headache with no known cause
• Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body.
  
  Learn more about stroke care at Baptist Health System.

Stroke occurs in all age groups, in both sexes, and in all races in every country. It can even occur before birth, when the fetus is still in the womb. In African-Americans, stroke is more common and more deadly--even in young and middle-aged adults--than for any ethnic or other racial group in the United States. Scientists have found more and more severe risk factors in some minority groups and continue to look for patterns of stroke in these groups. So, regardless of who you are… know the signs:

• Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
• Sudden confusion, trouble speaking or understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden, severe headache with no known cause

Act FAST if you believe someone is experiencing stroke symptoms. If a person is having trouble with these basic commands, call 911 immediately.

For More Information
The Brain and Stroke Network at Baptist Health System 
Stroke Care at Baptist
American Stroke Association website

While high blood pressure is the most common cause for stroke, there are other less-well-known culprits that exist such as cigarette smoking, birth control pills, riding a roller coaster, pregnancy, getting a salon hair wash, and chiropractic neck adjustments.

Smoking almost doubles a person's risk for ischemic stroke. Nicotine in cigarettes raises blood pressure, and carbon monoxide reduces the amount of oxygen that blood can carry to the brain. Cigarette smoking also increases the risk of stroke by promoting thickening of the arteries and increasing the levels of blood clotting factors, such as fibrinogen.

The American Stroke Association states that birth control pills that contain estrogen can increase your risk of having blood clots, which can lead to a stroke if the clot forms in the brain. Birth control pills can also increase your blood pressure. Birth control pills are not recommended for women over 35 who smoke because there is an increased risk for cardiovascular disease. So if you smoke while on birth control, then you are placing yourself at a higher risk for stroke.