Q&A: Treatment options for stroke

A: Treatment for stroke and brain aneurysms has advanced dramatically in the last 10 years. Getting timely treatment is key to minimizing brain damage and, in some cases, saving lives.

In particular for ischemic strokes — an interruption in blood supply to the brain — there is usually a brief interval of time between onset of symptoms and permanent death of brain cells. Treatment to reverse the neurological deficits has to take place during this time. The faster a patient gets to the right hospital, the better the odds of treatment success.

The treatment goal for ischemic strokes is to reopen the blocked blood vessels to restore normal blood flow to the brain. Once the patient arrives at the hospital, we perform imaging tests to identify stroke and blockage locations. The patient might be a candidate for a thrombolytic therapy using medication, such as the clot-busting drug tissue plasminogen activator (tpA). But we can only consider thrombolytic therapy if the patient has gotten to the hospital within 4½ hours from onset of symptoms.

Another treatment is a mechanical thrombectomy, using a small catheter inserted into the artery in the groin and guided into the cerebral arteries until it reaches the blockage. A small stent is then placed within the clot to remove it and reopen the artery. This restores blood flow to the brain tissue.

Brain aneurysms usually don’t have symptoms. We usually detect them while doing imaging for other conditions. Once detected, we work to prevent the aneurysm from rupturing and bleeding. Depending on size and location, some unruptured aneurysms have a high risk of bleeding and require immediate treatment. Others require monitoring to ensure the aneurysm does not grow.

All aneurysms that have ruptured and caused a subarachnoid hemorrhage — bleeding between the brain and tissues that cover it — need immediate treatment to stop and/or prevent further bleeding.

There are two aneurysm treatments. Through open surgery — a craniotomy, removing part of the skull to expose the brain — we place a metal clip around the aneurysm opening to prevent bleeding. Through endovascular surgery, we insert a small catheter into the artery in the groin and guide it into the cerebral arteries until it reaches the aneurysm. To prevent the aneurysm from rupturing again, we may then fill the aneurysm with platinum coils to induce clotting, or place a stent at the base of the aneurysm, or do both.

The main treatment goal for hemorrhagic strokes — in which a small blood vessel inside the brain leaks blood — is to control elevated blood pressure. If the patient is taking anticoagulant medications (which can increase the risk of bleeding), we reverse their effect with a counteracting medication. Sometimes, if the size of the hemorrhage (or clot) inside the brain is large enough, we place a catheter inside the clot through a small opening in the skull and remove the clot through the catheter using a special suction device. This is a minimally invasive procedure. By controlling blood pressure, preventing further bleeding and sometimes removing the clot, we give the patient the best opportunity to recover from the initial injury.

The key to getting timely care for stroke and aneurysms is dialing 911 immediately to get to a comprehensive stroke center.

Jorge Eller, M.D., is a cerebrovascular and endovascular surgeon at AtlantiCare Neurosciences Institute, co-medical director of AtlantiCare Stroke Program, and clinical professor in the department of neurological surgery at Jefferson Neurosciences at AtlantiCare Regional Medical Center in Atlantic City.