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Exciting breakthroughs in treatment

Do you have high blood pressure? Or high cholesterol, diabetes, atrial fibrillation? Did you know these are all risk factors for stroke? Not to mention being obese, smoking, drug and alcohol abuse, or being physically inactive. 

Did you know that 10% of all strokes occur in people younger than 45? 

“Rarely, even children can suffer strokes,” says Janice Miller, M.D., Neurologist and Medical Director of the UCHealth/Memorial Joint Commission-certified Primary Stroke Center. “Stroke is NOT a disease of only older adults. While the risk of stroke doubles every decade after 55, the latest statistics show that 34% of strokes occur in individuals under 65. Women account for about 40% of stroke patients and men 60%. Ethnicity is a risk factor, with African American males having the highest risk.”

Scary stuff, the prospect of a stroke. Every year in the U.S., nearly 800,000 people will have a stroke. Those with uncontrolled high blood pressure are seven times more likely to have a stroke than those with normal blood pressure, says Dr. Miller. “Due to advances in stroke care, stroke has fallen from the third leading cause of death to the fifth in this country, but it remains a leading cause of long-term disability.”

We’ve known for some time about getting treatment in the critical first three hours of stroke. But that timeframe is changing, and so is the treatment approach. 

Scott Shay, M.D., neurointerventionalist with Penrose St. Francis, says, “We now have extended hours of acute treatment in the emergency department for intravenous (IV) tissue plasminogen activator [tPA, a clot-dissolving substance].”

Dr. Shay says tPA has been FDA-approved for acute treatments since the 1990s within the 3-hour window, but following a large and very successful trial completed in Europe that looked at an extended window of 4½ hours for a specific group of people, the 4½-hour treatment time has been approved in many countries. The FDA has not yet approved the treatment in the U.S., says Shay. “This holds us back a bit, however our approach with our patients in an emergency who meet this specific timeframe is that we discuss it with our team and the patient/family and we do treat within this 4½-hour window. This is being done nationwide.”

Terri Kiernan, a nurse practitioner with Penrose St. Francis who specializes in acute stroke care, says in addition to the 4½-hour window is a series of four trials completed last winter that considered the benefits of intravenous tPA and intra-arterial tPA with mechanical clot retrieval. “Not unlike how cardiology takes patients directly from the emergency room to the intervention suite to break up and pull out the clot, now we can do this for a clot in the brain.”

Kiernan says all four trials separately showed amazing results, “not just better outcomes, but decreased length of stay in the hospital and shorter rehabilitation times.” One trial, she says, showed that the median time spent at home in the first 90 days post-stroke with IV tPA alone was 15 days. In patients who received both intravenous and intra-arterial tPA, time spent at home was 73 days.

Stroke treatment varies, of course, depending on whether a person experiences an ischemic or hemorrhagic (bleeding in the brain) stroke. “Ischemic stroke is the term we use for a stroke caused by stoppage of blood flow to a part of the brain by a clot or closure inside a blood vessel,” explains Dr. Miller. “This causes brain cells to be cut off from their energy supply and die. A small percentage of strokes—about 12%—are caused by bleeding into the brain from a ruptured blood vessel.”

If a blood clot is identified with no bleeding in the brain, says Terri Kiernan, “the patient would receive IV tPA, then go to the interventional suite where we would make a small hole at the large artery by the groin and move a small catheter up to the brain to administer tPA at the clot site, and then possibly utilize a device to take out more clot if necessary.”

As Dr. Miller says, newer-generation clot-retrieval devices add to the success of the combination IV tPA and endovascular thrombectomy [snagging and removing the clot].

Time is of the essence when it comes to stroke treatment. “At the moment a stroke occurs,” says Dr. Miller, “a number of brain cells die. However, around that area of initial damage is a much larger area of brain that is at risk of dying. Studies have shown that 1.9 million brain cells die per minute if blood flow is not restored. I cannot emphasize enough the importance of recognizing a stroke and calling 911.”