Advances in Treatment for Acute Stroke Dr. Syed Zaidi

Fast Assessment TIME IS BRAIN Recognize stroke symptoms: acute change in balance, visual symptoms, speech difficulty, facial asymmetry, extremity weakness Contact 911/ First Responders. Be transported to a local hospital equipped to handle acute stroke patients

Treatment for Stroke Patients TPA: tissue plasminogen activator- Clot Buster Approved by the FDA in 1996 Must be given within 3-4.5 hours of stroke symptom onset or Last Known Well The sooner this drug is given, the better the results Must be evaluated to be a candidate. There is certain criteria used to include or exclude a patient from being a TPA candidate

TPA: Clot Buster

Some Exclusion Criteria for TPA Unclear when symptoms started Anticoagulant Use- strong blood thinners like Coumadin, Pradaxa, Eliquis, Xarelto Recent major surgery or trauma The EC staff or stroke neurologist will review your history to determine if you are a candidate

WHAT TO DO NOW !!! There’s an absolute tPA contraindication Patient is outside the window for tPA tPA is not working WHAT TO DO NOW !!!

A New Standard of Care- the role of endovascular treatment Five recent medical studies closely looked at the role of endovascular treatment for acute stroke patients It was discovered that TPA may not be sufficient in patients that have larger clots in their main larger intracranial vessels and they may require an endovascular intervention to remove the clot There are certified stroke centers like Toledo Hospital that have specially trained neuro-interventional physicians who can perform this procedure emergently for stroke patients.

Endovascular Treatment Acute ischemic stroke patients are screened through clinical exam and sometimes imaging to see if they have a large vessel occlusion Screening includes a National Institute of Health Stroke Assessment (clinical exam) Radiology studies. Every stroke patient needs to have a noncontrast CT Brain Possible additional studies such as specialized CT or MRI scans may be performed

The Lab: Cerebral angiography This study is done in a specialized neuro suite where pictures are obtained hoping to identify an area of occlusion

53 yo with aphasia and right sided paralysis – Pre Thrombectomy Run

Mechanical Embolectomy

Final angiographic run

Hemorrhagic stroke

A Few Causes of Hemorrhagic stroke Aneurysm Rupture or other vessel abnormalities Uncontrolled High Blood Pressure (Hypertension) Amyloid Angiopathy- protein build up in the brain. Often associated with dementia Brain Tumors Substance Abuse (Cocaine)

Management of Hemorrhagic Stroke Subarachnoid Hemorrhages need to be evaluated by cerebral angiography to see if the bleed is related to an aneurysm (weakness of the blood vessel) that ruptured. Treatment can be endovascular or an open brain surgery Intraparenchymal bleeds can sometimes be managed without surgery. In some cases with larger bleeds though, surgical evacuation may be necessary.

Subarachnoid Hemorrhage Medical Emergency Often related to cerebral aneurysm rupture Requires a higher level of care with Neurosurgical and Neuro-interventional capabilities

Neurointerventional Suite Treatment of cerebral aneurysm with platinum coils

Intraparenchymal Bleed

Intraparenchymal Bleed Majority of the time can be managed without surgery Often required aggressive blood pressure control and monitoring in an ICU setting Neurosurgeon should be available if there is any change in case surgery is warranted.

Questions??