Stroke treatment
Diagnosis phase: After calling 911 and before operation
If 911 was not called, there is a very good chance that the person who had a stroke will have extensive and permanent brain damage or will die. After calling 911, make sure to continue observing the person closely before the paramedics arrive. The paramedics will come and take the person to the nearest hospital or to one that has the necessary resources to treat a stroke. As soon as the paramedics arrive at the hospital, they will take the person to a metal table in order to prepare them for a computerized tomography (CT) scan of the head.This is a machine that takes X-rays of the head to allow doctors to see what happens inside the head without needing to cut it open. These scans can determine whether or not the stroke is ischemic (due to a blood clot) or hemorrhagic (due to the rupture of a blood vessel). The medical staff may also insert a small, plastic tube called a catheter into the bladder and move all the way up to the brain. They will then insert a dye known as contrast to get a better image of blood vessels on the CT scan. This is better known as computerized tomography angiogram(CTA).
For more minor strokes that cannot be found on a CT scan, they are more likely to order a magnetic resonance imaging (MRI) scan. They do this to get a three-dimensional image of the brain, which makes it easier to see small clots in smaller blood vessels. It is possible they insert a catheter to conduct a magnetic resonance angiogram (MRA) to get a better picture of blood vessels with the injection of contrast into a catheter. However, a CT scan is more time-efficient, costs half as much as an MRI scan, and is still able to correctly identify the source of the stroke. Therefore, it is much more widely utilized.
Whether or not they use order a CT or an MRI, once they determine the type of stroke it is, they most likely will conduct the corresponding procedures:
Ischemic stroke
Since an ischemic stroke involves a blood clot that stops oxygen and other essential nutrients from getting to the brain, the goal of the procedure is to remove or dissolve the blood clot itself. Consequently, doctors will want to administer drugs that break up the clot. If the clot is found in a small blood vessel, the most common drug is known as tissue plasminogen activator (tPA) [1]. It can only be given to the patient within 4 and a half hours after symptoms first begin, which is why calling 9-1-1 as soon as possible is absolutely crucial [2]. After the 4 and a half hour window, there is a high risk that tPA use will cause bleeding in the affected area. TPA is administered through a catheter that is usually inserted into the bladder and moved all the way up to the brain. Once it reaches the clot, it releases tPA to dissolve it.
If the clot is found in a large blood vessel, the most common treatment is known as intra-arterial thrombolysis [1]. This removes the clot within a time window of 6 hours after the presentation of symptoms. This may also be given if the 4 and a half hour time window has passed, even if the clot is found within a small blood vessel. It is administered to the patient with a catheter, or a flexible tube that is inserted into the body to send drugs or fluids to a specific organ or location, that sends the inta-arterial thrombolysis drug to the affected blood vessel(s). This is slightly different from tPA because it uses different drugs to break up the clot, even though it is administered in the same way.
Based on the location of the clot, surgical intervention may be necessary. If the clot is found in an artery in the neck called the carotid artery or in one in the brain called the middle cerebral artery within 6 hours of the onset of symptoms, the doctor will perform a procedure known as a mechanical thrombectomy. All this means is that the doctor will remove a clot and place a plastic or metal tube that physically keeps the blood vessel from clotting, also known as a stent. This can also be done when tPA or intra-arterial thrombolysis cannot be given
Another procedure that might be seen for a clot in the carotid artery is a carotid endarterectomy. Instead of placing a stent, this procedure removes the plaque made up of deposits of fat that caused the clot [3].
Transient Ischemic Attack (TIA)
For a transient ischemic attack, no procedure will be done, but the doctor will more likely run more tests to determine where the clot might be. In addition to the CT and MRI scans and angiograms, 3 other diagnostic tools may be utilized by the healthcare team:
- Carotid ultrasonography: a wand-like device sends high energy sound waves that go through your tissue and bounce back. The doctor can then interpret the results to see if the carotid artery is more narrow than it should be or is completely blocked. This is usually done as a noninvasive way to check the health of the carotid artery.
- Echocardiogram/Echocardiography: a device called a transducer sends sound waves into the chest cavity that bounce back and create an image. This is usually done as a noninvasive way to check the health of the heart.
- Transesophageal echocardiogram (TEE): a transducer is placed into the esophagus (the tube that connects the mouth to the stomach). The esophagus is located directly behind the heart so it creates a clearer picture of the heart and blood vessels than a traditional echocardiogram.
After one or more of these tests, it is likely that the healthcare team will be able to locate the clot. This might come after some physical tests as well such as testing reflexes, vision, strength, muscle movements, and language capabilities. (For spanish version, have some phrases/tips that can be used) [4]
Hemorrhagic stroke
- If it is an aneurysm (diagnosis, etc.):
tPA should never be given for a hemorrhagic stroke because it would increase the loss of blood and pressure within the brain. If the aneurysm has ruptured and only produces a small bleed, surgical intervention is most likely not necessary. The treatment plan would include close monitoring of the patient, administration of intravenous (IV) fluids, and supportive care until the body heals from the bleeding. If the ruptured aneurysm leads to extensive bleeding, surgical intervention is most likely necessary. The doctors will conduct surgery to reduce the bleeding and the swelling of the brain. They do this by tying off the ruptured blood vessel and draining out the blood that has already left the blood vessel. This procedure would require another angiogram (specific imaging of blood vessels) a couple of months later to ensure that the blood vessel is still properly functioning. If there is a highly trained neuroendovascular surgeon, or a surgeon who specializes in operating on blood vessels within the brain, another option is to place platinum micro-coils into the aneurysm to seal it off from the rest of the blood vessel [5]. This would require a check up six months later to make sure that the aneurysm is still sealed off from the rest of the blood vessel.
- If it is an AVM (much rarer form):
Since AVMs are congenital, the doctors will most likely be able to identify it quickly through the imaging techniques discussed at the beginning of this page (CT or MRI scans). Depending on the location of the AVM, doctors will attempt to remove it. If they cannot remove it, they will try to repair the ruptured blood vessel and decrease the bleeding and swelling within the brain [6].
Cryptogenic stroke
Unfortunately, since these strokes do not have a known cause, there is no specific treatment dedicated to cryptogenic stroke cases. If no known cause is determined with either CT or MRI scans, then a general treatment of antiplatelet therapy and education about potential stroke risk factors are the main course of treatment. Platelets are small molecules found in the blood that help create clots so by directing molecules that stop blood from clotting, it might help break the clot and end the stroke. Since almost 90 percent of all strokes come from blood clots, there is a better chance than not that the stroke was caused by a blood clot and not by the bursting of a blood vessel [7]. Antiplatelet drugs are also known as blood thinners and include drugs such as aspirin, clopidogrel (also known by the generic name Plavix), and dipyridamole (also known by the generic name Aggrenox. Please follow the instructions given by your doctor, as they are professionally trained and will tailor the treatment to each individual case. These drugs have been listed only as a small list of potential antiplatelet drugs that might be given.
Brain stem stroke
For a brain stem stroke, the same procedures are depending on the type of stroke it is. If the stroke is ischemic, tPA or intra-arterial thrombolysis would be used if deemed appropriate. Surgical intervention is much less common for brain stem stroke because any error on the surgeon's part could result in fatal consequences. If the stroke is hemorrhagic, depending on how bad the bleed is, there are new techniques that are being developed under the field of microsurgery. Microsurgery uses extremely small instruments to minimize the risk of surgical error and allow for surgical intervention when the bleeding is extensive. Surgical intervention is normally done to decrease the buildup of pressure within the brain. However, this is still not extremely common because there are still no standardized guidelines on how to approach brain stem hemorrhage in the United States [8].
References
[1] https://www.healthline.com/health/thrombotic-stroke
[2] https://www.ahajournals.org/doi/10.1161/STR.0000000000000074
[3] https://www.tgh.org/embolic-stroke-treatment
[6] https://www.healthline.com/health/hemorrhagic-stroke#recovery