Treatment of an acute ischemic stroke: Time is brain
Timing is everything and will affect what treatments are used. Treatment choices can include medications to break up the blood clot or surgery to remove the blood clot.
Medication – Alteplase is a clot-busting drug that can be given to dissolve the clot, but this medication must be administered within 4.5 hours of the time last known to be well, when stroke signs start. Because the benefit of Alteplase is time dependent, it is critical to treat with this medication as quickly as possible.
Surgery – Mechanical thrombectomy is a procedure in which attempts are made to surgically remove a blockage. Thrombectomy is indicated for patients with acute ischemic stroke due to a large vessel occlusion, and guidelines support treatment in eligible patients up to 24 hours after the last known to be well time.
Treatments of hemorrhagic stroke
Cerebral angiogram – This test may be used to look for the cause of your bleed. In emergencies, a cerebral angiogram may reveal an abnormality in a vessel that needs to be treated to stop the bleeding and/or to prevent further bleeding. In this case, treatment may be performed at the same time or very shortly after. Procedures to treat abnormal blood vessels include embolization (endovascular treatment) and surgical intervention with craniotomy.
Craniotomy – This procedure is more invasive and involves opening, and sometimes removal (craniectomy), of a portion of the skull. This may be necessary when aneurysms or arteriovenous malformations (AVM) cannot be embolized effectively. A craniotomy may be performed for resection (removal) of an AVM or a surgical clipping of an aneurysm.
Arteriovenous malformation resection (removal of an AVM) – Sometimes an embolization is performed before this procedure to reduce the risk of bleeding.
Surgical clipping – This procedure is performed by doing a craniotomy and placing a clip on the aneurysm to eliminate blood flow into the aneurysm.
Embolization – This procedure is minimally invasive and does not require cutting into the skull. Using the same technique used for a cerebral angiogram, a catheter is guided to the target vessel and an attempt is made to minimize blood flow to the affected area. This is also called endovascular treatment. Embolization can be performed using multiple techniques: coiling, intrasaccular flow disruptor, stenting, flow diverter and onyx.
- Coiling – This treatment is performed to fill an aneurysm from inside of the vessel. The coils induce clotting within the aneurysm and prevent blood from flowing into it. This is the most common treatment for ruptured aneurysms and does not require blood-thinning medication. Sometimes, coils may compact over time, causing a recurrence of the aneurysm.
- Intrasaccular flow disruptor – With this treatment, a meshed device is placed within the aneurysm to prevent blood flow inside it. An example of this is a WEB embolization. Aspirin may be prescribed following this procedure.
- Stenting – Stents may be used alone or in combination with coils. Stents are placed across the vessel where the aneurysm is to redirect blood flow straight through the vessel instead of into the aneurysm. When used with coils, stents can help hold coils in place and serve as an additional “barrier” for blood flow into the aneurysm. Because blood can stick to the stent, antiplatelet medications will be prescribed following the procedure.
- Flow diversion – This treatment uses certain types of stents called flow diverters, which are made with smaller grid patterns. The tighter grid allows less blood to move across the stent wall, which redirects the blood flow through the main vessel and away from the aneurysm, helping the artery heal from inside. As with stenting procedures, flow diverters require the use of antiplatelet medications.
- Onyx – This glue-like substance is used to seal off a vessel. This is most commonly used to treat AVMs, either alone or before a resection.