What You Should Know About Treatments for Ischemic Stroke

Ask the Experts

Fiorella David Fiorella, MD, PhD
Neurointerventional Radiologist
Director, Stony Brook Cerebrovascular Center
Co-Director, Stony Brook Cerebrovascular and Stroke Center

A major new recommendation from the American Heart Association/American Stroke Association (AHA/ASA) is for selected acute ischemic stroke patients to receive mechanical thrombectomy, a procedure to remove clots that block large vessels, as the standard of care. 

What’s the difference between ischemic and hemorrhagic stroke?
Ischemic stroke, which is the most common type (80 percent of cases), occurs when a blood vessel that carries oxygen and nutrients to the brain is blocked by a clot. With a hemorrhagic stroke, there’s bleeding in and around the brain. When part of the brain cannot get the blood and oxygen it needs, brain cells die. 

With both types of strokes, the symptoms come on suddenly. You can even go to bed feeling fine and wake up with symptoms. These include an uneven smile or facial droop, arm or leg numbness or weakness, and slurred speech or difficulty speaking. Additional warning signs include sudden confusion, trouble seeing in one or both eyes, trouble walking, dizziness, loss of balance or coordination, and a severe headache with no known cause.

Why is getting to the hospital fast so important?
Stroke survivors have the best outcomes when they receive treatment fast. The sooner you get to the hospital, the sooner you can receive lifesaving treatment. Get immediate help by calling 9-1-1. Alert the operator that you or a loved one are having symptoms of a stroke and ask to be taken to a stroke center where advanced treatments are available. Check the time. Knowing when the first symptoms appeared is important information for your care team.

What is IV r-tPA? 
Tissue plasminogen activator (or Alteplase IV r-tPA) also known as the “clot buster,” is an FDA-approved medication for ischemic strokes. However, it’s only given within 4 1/2 hours from the last time you were without stroke symptoms. Given intravenously (IV) through the arm, it dissolves clots and can save lives. But the ability of IV r-tPA to open up blood vessels in patients with severe stroke due to a large artery blockage (also known as an occlusion) is effective only between approximately 5% to 20% of the time. The larger the clot, the harder it is to dissolve. It’s estimated that 20 to 30 percent of acute ischemic strokes are due to large vessel blockage.

How is mechanical thrombectomy different? 
With mechanical thrombectomy, a tool called a stent retriever is inserted through a tube (catheter) into the blocked artery. With the help of x-ray guided imaging, the stent expands to stretch the walls of the artery, so blood can flow and the clot can be removed. Based on evidence of safety and effectiveness from several landmark research studies, mechanical 
thrombectomy has shown a reduction in disability at 90 days post stroke. For this reason, the AHA/ASA now recommend it as the standard of care for large vessel clot removal. Patients with large vessel blockages do much better when treated with mechanical thrombectomy than with just IV r-tPA alone. 

In the 20 years that I’ve been performing mechanical thrombectomies, I’ve witnessed the remarkable recovery of many patients who arrived severely disabled and went home from the hospital independent and disability-free. Of course, as seen from the clinical trials, it’s critical to have an appropriately trained, experienced physician to achieve these results. I performed nearly 100 mechanical thrombectomy cases in 2017 alone.

How much of a factor is timing?
Timely restoration of blood flow to the brain is key. The patient must get to a hospital with the physician experts and technology to perform a mechanical thrombectomy early enough to get the most benefit from the treatment. In Suffolk County, there are a limited number of hospitals that have this expertise and resources to perform mechanical thrombectomy. 

Studies show that calling 9-1-1 and getting safe, quick transport to the hospital from emergency medical service (EMS) may improve outcomes from a stroke because it often means quicker treatment. I provide stroke lectures to EMS providers across Suffolk County to help them recognize individuals thought to be having a stroke with potential large vessel blockages. When EMS alerts us that a stroke patient is on the way, our emergency room will call a stroke alert and stroke team members meet the patient at the door. This allows rapid assessment and radiologic imaging, which are critical to identify whether the individual is eligible for a mechanical thrombectomy.

Why choose Stony Brook?
Our experienced, highly trained medical team at Stony Brook Cerebrovascular and Stroke Center performs all the latest procedures, 24/7. This includes mechanical thrombectomy. We use the latest diagnostic tools and offer access to major ongoing clinical trials. And our critical care registered nurses, technicians and specialized anesthesia team are focused on stroke care and available 24/7.

For more information about Stony Brook Cerebrovascular and Stroke Center, visit neuro.stonybrookmedicine.edu.

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