Treatments of Stroke
The most effective stroke treatments can only be given within the first few hours after a stroke has occurred. Once you are identified by ambulance or emergency personnel as someone who could be having a stroke, doctors will first need to know when your symptoms started. They will also need to make sure that your symptoms are not the result of bleeding inside your brain, as medical treatments for stroke can worsen bleeding. This information will help them determine what type of stroke you are having and what type of treatment you will need.
There are two main types of stroke treatment:
Treatment of Ischemic Stroke
The treatment of ischemic stroke aims to dissolve, remove, and break up a blood clot that is preventing blood from reaching an area of the brain. The most common treatments for ischemic stroke are the following:
Intravenous TPA
This is the first line of treatment against ischemic stroke. Tissue plasminogen activator or TPA is injected into the bloodstream through an intravenous line. TPA travels in the blood until it reaches the clot that is causing the stroke. Once there it begins to break up the clot until blood can flow past it toward the affected areas. (This can be done at a primary or comprehensive stroke center)
What is TPA?
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 their symptoms for two important reasons: First, three hours after the onset of symptoms TPA is no longer as effective; second: Three hours after the onset of symptoms TPA can increase the risk of bleeding inside the brain. This is one of the most important reasons why you should call 911 immediately after you feel stroke-like symptoms.
Intra-Arterial Thrombolysis
This treatment, which depending on the location of the stroke in the brain can be given for up to 6 hours after the onset of symptoms, consists of the injection of TPA, or a similar agent, directly into the blood clot that is causing the stroke. To do this, a special small catheter is inserted into one of the major blood vessels in the leg, and is strategically advanced towards the brain using fluoroscopic guidance. Once the blood clot is found, the small catheter is passed into its center where the injection is delivered. After sometime, the TPA, or similar agent, begins to dissolve the blood clot until blood can flow past the clot towards the area of the stroke. Unfortunately, because this treatment requires special equipment and technical expertise, it is only performed at a Comprehensive stroke center.
The MERCI Retriever
The Mechanical Embolus Retrieval in Cerebral Ischemia, or MERCI retriever, is used to remove or break up blood clots that have wandered into a small blood vessel causing it to become occluded. This is done by carefully passing a special device that’s look like a “cork screw” from a blood vessel in the leg all the way into the blood vessel in the brain where the blood clot is trapped. The retriever captures the clot and pulls it out of the body, thus returning blood flow to the affected area.
Penumbra System
The penumbra system utilizes a suction catheter that is directed into the area of occlusion and utilizes suction to remove the clot restoring blood flow within the artery.
Treatment of Hemorrhagic Stroke
The treatment of hemorrhagic stroke aims to stop bleeding, and to remove blood which might lead to swelling and increased pressure inside the brain.
Below are the two most common causes of hemorrhagic strokes and their treatments
Ruptured Aneurysm: Aneurysms are weak portions along the wall of a blood vessel which balloon out until they rupture. Aneurysms usually rupture because of high blood pressure. Ruptured aneurysms require brain surgery to repair the damaged blood vessel.
Abnormal Brain Blood Vessels: Examples of these include arterio-venous malformations or AVMs, and cavernous malformations. Typically these are blood vessels that are connected to one another in an abnormal way that causes them to bleed into the brain. When these abnormal vessels bleed into the brain, surgery is often needed to remove the abnormal blood vessels.
Endovascular Coiling
Endovascular therapy is a minimally invasive procedure that accesses the treatment area from within the blood vessel. In the case of aneurysms, this treatment is called coil embolization, or "coiling". In contrast to surgery, endovascular coiling does not require open surgery. Instead, physicians use real-time X-ray technology, called fluoroscopic imaging, to visualize the patient's vascular system and treat the disease from inside the blood vessel.
Endovascular treatment of brain aneurysms involves insertion of a catheter (small plastic tube) into the femoral artery in the patient's leg and navigating it through the vascular system, into the head and into the aneurysm. Tiny platinum coils are threaded through the catheter and deployed into the aneurysm, blocking blood flow into the aneurysm and preventing rupture. The coils are made of platinum so that they can be visible via X-ray and be flexible enough to conform to the aneurysm shape. This endovascular coiling, or filling, of the aneurysm is called Embolization. ANS performs more endovascular cases than any other group in New Jersey.
Clipping
Clipping is a surgical procedure performed to treat a balloon-like bulge of an artery wall known as an aneurysm. As an aneurysm grows it becomes thinner and weaker. It can become so thin that it leaks or ruptures, releasing blood into the spaces around the brain - called a subarachnoid hemorrhage (SAH). A neurosurgeon places a tiny clip across the neck of the aneurysm to stop or prevent an aneurysm from bleeding.
What is aneurysm clipping?
The goal of surgical clipping is to isolate an aneurysm from the normal circulation without blocking off any small perforating arteries nearby. Under general anesthesia, an opening is made in the skull, called a craniotomy. The brain is gently retracted to locate the aneurysm. A small clip is placed across the base, or neck, of the aneurysm to block the normal blood flow from entering. The clip works like a tiny coil-spring clothespin, in which the blades of the clip remain tightly closed until pressure is applied to open the blades. Clips are made of titanium and remain on the artery permanently.
Aneurysms vary in their size and shape. Saccular aneurysms have a neck at their origin on the main artery and a dome that can expand and grow like a balloon These are the easiest to place a clip across. Some aneurysms have a wide neck or are fusiform in shape having no definable neck. These are more difficult to place a clip across. Since aneurysms have various neck configurations, clips are made in a variety of shapes, sizes, and lengths.