Section: Saint Barnabas Medical Center News

Master Strokes

08/12/2015

By the time you finish reading this article, someone in this country will have died from a stroke. That's what the statistics show: according to the U.S. Centers for Disease Control and Prevention, one American dies from stroke every four minutes. Sometimes referred to as a "brain attack," stroke is the fourth leading killer, taking almost 130,000 lives a year. Another 665,000 or so people suffer nonfatal strokes, but many of them are left disabled—some permanently.

Despite those grim numbers, progress is being made in the fight against this terrible disease, says Danielle Haskins, M.D., medical director of the Comprehensive Stroke Center at Saint Barnabas Medical Center. "Developments in prevention and early treatment are helping to limit the damage caused by strokes," she says.

For example, new guidelines call for expanded use of the blood clot-busting drug tPA (tissue plasminogen activator), the only FDA-approved medication to restore blood flow to blocked arteries in the brain, which cause ischemic stroke. (Strokes caused by bleeding into the brain are called hemorrhagic.) Until recently, tPA was thought to be useful only within a three-hour window after the onset of symptoms. "However, research from Europe has found that some patients experiencing an acute ischemic stroke still benefit from tPA up to four-and-a-half hours after onset," Dr. Haskins says. The American Heart Association and American Stroke Association now endorse extending the time for appropriate patients.

Further changes are also being looked into, she says. Researchers are investigating whether to broaden the population of patients eligible for tPA to include those suffering strokes that heretofore have been considered too minor to treat with the drug. "Up to one-third of those patients who didn't receive tPA were still disabled three months later, and that is not acceptable if we can reduce it," says the doctor. Also under investigation is whether the drug could be offered to those who suffer so-called "wake-up" strokes, in which they go to bed feeling well but wake up with stroke symptoms. "Currently they are not eligible for treatment because of the time limit," she says. "However, there is some indication that many of these strokes occur shortly before people wake up." When these studies are complete, guidelines may change to include these patients, she says.

Surgical options have advanced as well. In the past, when someone suffered an ischemic stroke due to a narrowed carotid artery, surgeons would wait four to six weeks before opening the artery surgically. "It was thought that the brain had to 'cool down' after a stroke, so we'd wait for the swelling to go down," says Dr. Haskins. But research has shown that in people who are not severely disabled by their initial stroke, it is both safe and effective to open the artery within the first two weeks. "The risk of having another stroke while waiting is higher than the risk of further injury operating earlier," she says. "That is important because most stroke recurrences happen in the first couple of weeks, so doing this earlier gives a better chance of preventing the next stroke."

The biggest change in surgical procedures, she says, is in the devices used to remove blood clots from blocked blood vessels. "Tools have evolved a lot in the last few years," she says. Previous devices would corkscrew into the clot to pull it out, but new ones deploy a stent like the ones used to open blocked heart arteries. "As the stent expands, it restores blood flow," Dr. Haskins says. "We let it sit in there for a few minutes, and then, when the stent is pulled out, the clot is removed with it." The new tool has resulted in much shorter procedure times and faster restoration of blood flow than is achieved with the older devices.

Speed is essential with stroke. "As we like to say, 'time is brain,'" says the doctor. "The earlier a patient comes to the hospital, the more options we have to limit the damage. People who are treated within one hour of the stroke do better than those who arrive two hours after symptoms. In fact, every five minutes improves outcomes. The earlier blood flow is restored, the more likely we'll see good results."

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