Stroke: Early Treatment Protocol
Guest: Dr. Angela Hays – Neurosciences
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Angela Hays, who is Assistant Professor of Neurosciences here at MUSC. Dr. Hays, in an earlier podcast, we talked about hemorrhagic stroke. Let’s turn now and think about what you do, as a neurologist, when somebody appears in the emergency room with symptoms suggestive that they might be having a stroke. What does a doctor do?
Dr. Angela Hays: Well, the main focus of care in the first couple of hours after somebody comes in with a stroke is determining, first of all, is it a hemorrhagic or an ischemic stroke, meaning, is it caused by bleeding or is it caused by lack of blood flow to a portion of the brain? And, secondly, determining if there’s anything that we can do to restore the blood flow and improve the patient’s symptoms. So, determining whether it’s a bleeding type of stroke or a clotting type of stroke is actually pretty easy.
A head CT that can be done without any contrast will show a hemorrhagic stroke just about 100 percent of the time. Now, an important thing to note is that a clotting type of stroke or an ischemic stroke will not show up on a CAT scan for several hours. So, if the initial CT scan is negative then what we do is give something called IV contrast, which is a medication that’s given through an IV that makes the blood vessels appear white on the imaging, and then do another set of images. It gives us a sense of whether or not all the blood vessels in the brain are filling with this contrasted blood.
In the event that we find a region of tissue that’s not getting enough blood, then that gives us a pretty good indication that what we’re dealing with is in fact a stroke and that, furthermore, it’s a stroke brought about by lack of blood flow to that specific region of the brain. So, if we can actually see a blockage in the vessel, then that gives us a whole lot of options. Patients that are having an ischemic stroke or a clotting type of stroke, even in the absence of a clot that we can see, are candidates for a medication called tPA, or tissue plasminogen activator, which can be given into the vein and can, in many cases, dissolve the clot and improve the patient’s symptoms. What studies show is that if tPA is given within three hours, it gives the patient a much better chance of recovering back to their self or close to their normal self if you follow them out for about three months, but it doesn’t necessarily work immediately.
The second option that we have, for instance, if a patient isn’t a good candidate for IV tPA, or if we’ve given IV tPA and it still seems like the blood vessel is blocked off is we can take a patient to the angio suite, also called the Cath Lab, and our neurointerventional radiologist can run a catheter up through a blood vessel in the leg, and actually run that catheter right up into the brain and, in some cases, deliver tPA directly to the clot or even, perhaps, remove the clot physically. And that can be done even if the patient comes to the emergency room after the symptoms have been present for three hours. That may still be an option, although it’s usually only effective within the first six to eight hours after the symptoms start. So, I think he key point is if a patient has symptoms that you think might have resulted from a stroke, you should get them to the nearest hospital as soon a possible.
Dr. Linda Austin: Now, I understand that there are some, technologically, very new ways of removing clots. Now, I suppose that doesn’t really pertain to hemorrhagic stroke.
Dr. Angela Hays. No. Unfortunately, the treatment for ischemic stroke, at this point, is progressing very rapidly. For hemorrhagic stroke, we still don’t have that
many options. There are a couple of studies underway looking at different ways to try to remove the clot material that occurs in a hemorrhagic stroke to try to relieve pressure on the surrounding brain. It remains to be seen whether that’s going to turn out to be actually beneficial to patients of not. That study is currently available at MUSC.
As far as ischemic strokes go, there are a number of catheter-based mechanisms to try to remove the clot. Probably the simplest, and the one that we have the most experience with, is delivering a drug that dissolves clot directly into the clot itself, and that’s been used with a couple of different agents. But, like I said, it usually needs to be done within six hours in order to be effective.
Other methods include something called the Merci Device, which is basically a cork screw that you an twist into the clot which allows the physician to pull the clot out of the blood vessel. And that’s approved for use within the first 10 hours. And then there’s a new device that we have recently started using at MUSC, called the Penumbra Device, which is a suction catheter with an inflatable balloon on the end that allows you to thread a wire through the clot then inflate the balloon and try to pull back into the suction catheter. That’s sort of a quick and dirty explanation. I’m sure, you know, that it’s probably a lot more complicated than that in the Cath Lab.
Other things that we’re looking at currently, as far as experimental methods to treat stroke, there’s a trial underway, at MUSC, using a device called the _____ (4:56) device, which is inserted into an artery in the leg and threaded up into the aorta, and used to increase perfusion to the brain during the setting of a stroke. And that’s something that might be available for people that aren’t candidates for any of the other interventions that we’ve talked about. And there’s also a trial that we’re hoping to start enrolling in soon for a clot busting drug that’s like tPA but a little bit more specific that we’re hoping to use for patients that come in after the three-hour window who aren’t eligible for tPA.
Dr. Linda Austin: If a patient has had a hemorrhagic stroke, and I’m sure the answer to this varies according to how severe it is, over what period of time do you see ongoing recovery? When do you sort of say to yourself, probably, this patient is about as recovered as they will get?
Dr. Angela Hays: The situation varies from patient to patient, of course. In general, most of the recovery for any kind of stroke is going to occur within the first three months, although people do continue to report some degree of recovery out to a year. Hemorrhagic strokes frequently are more devastating that ischemic strokes, and, unfortunately, depending on the portion of the brain that’s involved, it may be evident at an earlier point that the stroke is going to be very disabling, particularly if it involves a part of the brain called the brain stem, which is responsible for allowing a person to stay awake and controlling a lot of the functions that sustain life, including breathing and regulation of the heartbeat.
Dr. Linda Austin: Dr. Hays, thanks so much for talking with us today.
Dr. Angela Hays: Thank you for having me.
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