An ischemic stroke is a condition that affects 87% of all those diagnosed with strokes. Such a stroke is the result of the blockade of the blood vessels carrying a fresh supply of blood to the brain. This blockade is usually in the form of fatty deposits or plaque fragments. As a result of the blockade, the brain and its sensitive tissue are unable to receive oxygenated blood and give out carbon dioxide.
Within minutes, an ischemic stroke can lead to the destruction of sensitive brain cells and tissues. Since these tissues rely on a constant supply of oxygen, their function can stop immediately. Most patients who suffer from ischemic strokes face crippling consequences that are directly related to the part of the brain that suffers damage.
While there are a number of Ischemic Stroke Treatments, they depend on two factors namely;
1. The type of Ischemic Stroke
Embolic Stroke: An ischemic stroke caused by a fatty deposit (Embolus) that forms elsewhere in the body, other than the brain, is called embolic stroke. This pre-formed clot travels in the blood vessels leading to the brain and gets deposited in the smaller arteries that run deeper into the brain sections. 15% of emboli originate in the heart as a result of atrial fibrillation.
Thrombotic Stroke: An ischemic stroke caused by a fatty deposit that forms inside the arteries of the brain is called thrombotic stroke. A thrombus forms in patients who have been diagnosed with high cholesterol and atherosclerosis.
2. The Damage Caused By The Ischemic Stroke
As mentioned previously, the part of brain damaged during the stroke determines the repercussions a patient will face. For instance, if the motor controlling function of the cerebellum has been affected, a patient will find it difficult to move body parts or control these movements accordingly.
An ischemic stroke can cause lasting injury. Depending on the areas being affected, a patient may lose partial or complete control of body parts, the ability to see, talk or a combination of all. While many of these affects can be treated, others often leave the patient crippled and handicapped for life.
For this reason, ischemic stroke treatments are an essential topic that should be studied in detail by both; doctors as well as patients so they know what to expect. Timely and effective ischemic stroke treatment can be crucial in limiting the damage caused and the recovery that the body has to go through.
Using Tissue Plasminogen Activator (tPA) is a widely used ischemic stroke treatment option. It is a FDA approved clot busting drug that is part of the antiplatelet therapy for acute ischemic strokes. tPA should be administered soon after an ischemic stroke is reported. What really is tissue plasminogen activator (tPA) and how does it work in a stroke?
This clot buster is actually a protein that is produced inside the cells of blood vessel linings, and can also be produced in a laboratory. As an enzyme, it helps in the breakdown of clots that have formed in the arteries, which is why injecting more of this agent into the blood stream post-stroke proves to be an effective ischemic stroke treatment plan.
When injected via a catheter, this clot busting drug catalyzes the conversion of the enzyme Plasminogen into Plasmin- the most crucial agent required for the dissolution of a clot.
Patients treated with tissue plasminogen activator within three hours of a stroke have a high chance of being alive and well after the treatment is completed. A number of studies that have arrived at similar results prove that treatment with tissue plasminogen activator is time constraint, i.e. it should be performed within a few hours of symptom reporting.
According to the Canadian Stroke Network, “All patients with disabling acute ischemic stroke who can be treated within 4.5 hours of symptom onset should be evaluated without delay to determine their eligibility for treatment.” However, surveys reveal that a mere 3% of patients fall under this category because the rest do not report the onset of a stroke to health care personnel.
What makes tissue plasminogen activator so effective is its ability to alter the Fibrinolytic System that leads to blood clotting. The increased enzyme activity as a result of tPA causes Hyperfibrinolysis. This process initiates a cycle of bleeding that melts away clots. The same has also been proven effective in lacunar stroke treatments.
Despite its benefits, the use of tissue plasminogen does not come without its risks. Since it reduces the thickness of blood dissolving lumps, this clot busting drug can also lead to excessive bleeding. In some extreme cases, tPA increased the risks of hemorrhages.
Taking clot busting drugs is not a safe option for every ischemic stroke patient. Some who have a long medical history of complications, liver disease in particular, are often advised to stay clear of these drugs. In such cases, a different approach to ischemic stroke treatment is taken.
Stent procedure is part of a more comprehensive surgery called Mechanical Thrombectomy. Intra-arterial thrombolysis is then carried out by inserting a catheter that contains a stent retriever. A stent retriever is a small cylindrical cage that is designed with the sole purpose of catching the blockade and pulling it out. When the catheter is moved towards the artery that contains the occlusion, the stent is made to expand so that it can capture the entire blockade and return blood flow to its normal pattern. However, the stent procedure can only be performed in patients who have a blockade in one of the big arteries leading to the brain. It should ideally be done within 6 hours of an ischemic stroke or symptoms surfacing.
Across the United States, stent procedures are performed at every major stroke center. It is important to keep in mind that a special team of qualified surgeons is required to carry out this procedure successfully. Research by the American Heart Association reveals that if stent thrombectomy is performed in a time sensitive manner, a complete recovery for stroke patients can be possible.
Carotid endarterectomy is a valid ischemic stroke treatment option when the stroke is caused by a blockade in the carotid artery. Also called Carotid Artery Disease, this cause of stroke is one of the most common among stroke patients. Carotid arteries are located on either side of the neck. They are major blood carriers in the body that branch out into smaller carotid arteries to supply oxygen to the brain.
The formation of plaque or fatty deposits in the carotid arteries hinders the constant supply of blood to the cells inside the brain, hence increasing the chances of an ischemic stroke. After careful diagnosis and comprehensive tests, doctors are able to pinpoint the location of the clot in the arteries of an ischemic stroke patient. In this instance, the condition can be treated by removing the accumulated plaque, in other words by performing a Carotid endarterectomy.
A carotid endarterectomy is a surgical procedure performed under local or general anesthesia. A surgeon makes an incision on the patient’s neck at the location of occlusion. He then cuts the carotid artery along its length. Once revealed, the clot is extracted using surgical tools. The incision is then closed by stitching up the artery using an artificial graft.
Another variant of carotid endarterectomy is called eversion carotid endarterectomy. In this procedure, surgeons aim for the same results via a different surgical technique in which the carotid artery is turned inside out, the occlusion extracted and the artery stitched back in place.
In most cases, a carotid endarterectomy is performed on patients who have more than 60% blockade in this vessel, which is difficult to remove using medication. Since this procedure is invasive, patients are given strict instructions in the aftermath of the surgery to make sure the recovery process is smooth.
Also known as Carotid Angioplasty with Stent Placement, an Angioplasty surgery is another option for ischemic stroke treatment that is predominantly performed on those patients who are not fit enough for an endarterectomy. Once plaque or fatty deposits are detected in the carotid arteries, a patient’s doctor will be able to decide which procedure works best for him.
An angioplasty surgery is performed by making a small incision at the groin. A patient may be sedated and numbing medications applied at the site of the cut. Through this incision, a catheter is inserted that travels up to the neck and the carotid arteries. The movement of the tube is monitored by x-ray images that display the exact position of the arteries and the accumulated plaque.
Next, a smaller wire is moved through the catheter at the same location; which is now the carrier for a smaller catheter that has a balloon attached to one end. When the devices reach the blockade, the balloon is inflated. As a result, the artery walls stretch and open up, making room for the plaque to flow out and improve blood circulation in the artery.
At the same time that the balloon is inserted, a stent may also be passed along the wire. This stent will help keep the artery stretched after the inflated balloon is pulled out of the body.
Angioplasty surgery is a much preferred way of dealing with big artery blockades that can lead to ischemic strokes because it is minimally invasive. Unlike the endarterectomy, an angioplasty surgery doesn’t require a patient to be opened up with major blood vessels exposed. Some instances in which angioplasty makes for a better alternative are:
• The patient is too ill for an invasive procedure.
• The patient has previously undergone carotid endarterectomy.
• The narrowing in the carotid artery is at a location that makes surgery hard.
• The patient has undergone radiation on their neck.
One particular complication that can result from an angioplasty surgery is the collection of more plaque or fatty deposits inside the stent. If this situation arises, it can become hard for doctors to manage ischemic stroke treatment because the opened up artery gives more room for blockades to accumulate.
The angioplasty and stenting surgeries have a number of variants, endovascular procedure being one of them. Similar to the former, this process also involves making incisions along the hip line and inserting catheters and stents to treat arteries with severe blockades. A similar procedure called endovascular embolism follows the same protocol, with the option of either inserting a balloon or a coil or a piece of foam- whichever is deemed safer by medical experts.
With plenty of treatment options available, caregivers often ask for the best one to be performed on their loved ones. The answer to this request is not a simple one. None of the procedures mentioned above are the best for everyone; because each comes with a list of limitations and each has certain strengths over the others. What makes one treatment an ideal plan of action for a patient is the series of factors that doctors consider before making a decision. These factors span a number of different categories. From lifestyle choices and previous medical records to family history, ability to recover from the procedure and past surgeries performed- a plethora of considerations are part of this process.
However, even before these factors are considered, experts assert that doctors who diagnose patients in emergency rooms first need to ensure that the symptoms being reported are in fact a result of blockades in the brain. Many a times, an ischemic stroke patient may not be able to report very clear and distinct signs and symptoms. In such cases, doctors should take charge and find out whether the indications can be attributed to the condition under discussion or not. X-rays, CT scans, MRIs and other imaging technologies should be used to detect the site of blockade, its extent and possibly, its origin.