Treatment Guide: Stroke

The latest lines of attack for dealing with a stroke

Stroke kills more than 150,000 people a year, making it the third leading cause of death in our country. Those who survive are often left with severe, long-term disabilities like paralysis and speech and cognitive impairment. Strokes are often called “brain attacks” because they resemble heart attacks. Over 85 percent are ischemic strokes, which occur when a clot clogs a vessel in the brain and cuts off delivery of life-giving oxygen carried by the blood. Far less common are hemorrhagic strokes, in which a weakened vessel in the brain ruptures, flooding the area with blood and damaging the surrounding tissue. Strokes are not preventable except by controlling the risk factors of high cholesterol and blood pressure. But they are treatable within a very small window of time.

[sidebar]“Time equals brain destruction,” says Dr. Patrick Waters, director of the Stroke Program at Nazareth Hospital. “You must get the patient to the hospital within three hours of the attack. After that your options are much more limited. Don’t wait for a driver; call 911 immediately if you have any symptoms.”

Symptoms: Symptoms come on suddenly, unaccompanied by pain. They are: numbness on one side of the body; confusion or trouble speaking, blurred vision, dizziness or loss of balance and a searing headache. “All the technology in the world is no good if patients don’t get to the hospital in time to use it,” says Dr, Michael Rubin, director of neurosciences at Virtual Hospital.

Drug treatments: The front-line attack, effective only within that three-hour window of symptom onset, is called IV tPA. Doctors intravenously inject a high-dose clot-busting drug into the circulatory system to rapidly dissolve the blockage and restore blood flow. This ground-breaking advance in stroke treatment was approved by the FDA in 1996 and remains the standard primary early response except for patients already taking blood-thinners or those have had surgery within the previous two weeks.

Interventional treatments: Once the three-hour timeframe for clot-busting drugs has passed, there are a few high-tech catheter-based techniques, available only at university hospital stroke centers like Penn and Jeff, that have a longer six-to eight hour window when they can be used. The first to gain FDA approval three years ago was the Mercy Device. In this procedure a micro catheter with a corkscrew-like attachment is threaded through an artery from the groin to the brain, where it snares the clot and pulls it out.

A newer version called Penumbra works on the same principle. A thin wire inside the catheter breaks the clot into pieces, which are suctioned out by a vacuum at the other end. The Wingspan Stent System is both an emergency treatment and a potential stroke prevention measure for high-risk patients who have too much plaque in their brain arteries. Jefferson neurosurgeon Dr. Erol Veznedaroglu says, “It’s the first step in something really great.” Similar in concept to heart stenting, this system is threaded through the leg to a location in the brain where either a clot has already formed or there’s significant enough blockage to be life-threatening. At its destination, the stent expands and pushes the blockage against the artery wall. Then it remains in place to keep the passage open.     

Transient ischemic attacks: Known as TIAs or mini-strokes, these have the same symptoms as a stroke but they dissipate within minutes or an hour. But they shouldn’t be ignored. “These are warning signs that a big stroke is coming,” says Dr. Brian Cucchiara, assistant professor of neurology at Penn. “Even if they resolve, you should absolutely come to the ER because studies show that 10 percent of TIAs lead to a stroke within 48 hours.” The standard treatment for TIAs has been to put patients on a regimen of blood thinners; now it’s just as likely there will be a more aggressive intervention to map the blockages and open the narrowed arteries to prevent a stroke from occurring.