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Non-surgical procedures
These procedures use a thin, narrow, flexible tube called a catheter, which
is inserted into the body, usually in the groin, and threaded through the
blood vessels to the carotid arteries in the neck.
Carotid Endarterectomy
Carotid endarterectomy, also called carotid artery surgery, is a procedure in which blood vessel
blockage (fatty plaque) is surgically removed from the carotid artery.
View a detailed illustration of carotid endarterectomy (opens in new window).
Angioplasty/Stents
Doctors sometimes use balloon angioplasty and implantable steel screens called stents to treat
cardiovascular disease and help open up the blocked blood vessel.
Surgery
When surgery is being considered after a stroke, your age, prior overall health, and
current condition are major factors in the decision.
the carotid arteries. The benefits and risks of this surgery must be carefully weighed,
because the surgery itself may cause a stroke.
Stroke Prevention: Should I Have a Carotid Artery Procedure?
Stroke
Stroke Statistics
Smoking: You can decrease your risk by quitting smoking. Your risk may be
increased further if you use some forms of oral contraceptives and are a smoker. There is
recent evidence that long-term secondhand smoke exposure may increase your risk of
stroke.
High blood pressure: Blood pressure of 140/90 mm Hg or higher is the most
important risk factor for stroke. It usually has no specific symptoms and no early
warning signs. Thats why it is important to have your blood pressure checked regularly.
Controlling your blood pressure is crucial to stroke prevention.
Carotid or other artery disease: The carotid arteries in your neck supply blood to
your brain. A carotid artery narrowed by fatty deposits from atherosclerosis (plaque
buildups in artery walls) may become blocked by a blood clot. Carotid arteries are
treated by neurosurgeons through carotid endarterectomy, a procedure in which an
incision is made in the neck and plaque is removed from the artery; or carotid artery
angioplasty and stenting, an endovascular procedure that requires no surgical incision in
the neck.
History of TIAs: About 30 percent of strokes are preceded by one or more TIAs
that can occur days, weeks or even months before a stroke.
Diabetes: It is crucial to control your blood sugar levels, blood pressure, and
cholesterol levels. Diabetes, especially when untreated, puts you at greater risk of stroke
and has many other serious health implications.
High blood cholesterol: A high level of total cholesterol in the blood (240 mg/dL
or higher) is a major risk factor for heart disease, which raises your risk of stroke.
Recent studies show that high levels of LDL (bad) cholesterol (greater than 100 mg/dL)
and triglycerides(blood fats, 150 mg/dL or higher) increase the risk of stroke in people
with previous coronary heart disease, ischemic stroke or TIAs. Low levels (less than 40
mg/dL) of HDL (good) cholesterol also may increase stroke risk. You can often improve
your cholesterol levels by decreasing the salt and saturated fat in your diet. However,
some people inherit genes associated with elevated levels of cholesterol. Although they
may eat well and exercise, they still may have high cholesterol, and must take
medication to control it.
Physical inactivity and obesity: Being inactive, obese or both can increase your
risk of high blood pressure, high blood cholesterol, diabetes, heart disease and stroke.
Getting 30 minutes of moderate exercise, five days a week can help reduce your risk of
stroke. Check with your doctor first before starting any exercise program if you have any
health problems or have been inactive.
Recent research shows evidence that people receiving hormone replacement
therapy (HRT) have an overall 29 percent increased risk of stroke, in particular ischemic
stroke.
Age: People of all ages, including children, have strokes. But the older you are,
the greater your risk of stroke.
Gender: Stroke is more common in men than in women. In most age groups,
more men than women will have a stroke in a given year. However, women account for
more than half of all stroke deaths. Women who are pregnant have a higher stroke risk.
Some research has indicated that women may experience and interpret stroke
symptoms differently than men, causing them to delay seeking medical care, and
contributing to their higher stroke mortality rates.
Heredity and race: You have a greater risk of stroke if a parent, grandparent,
sister or brother has had a stroke. African Americans have more than two times the risk
Stroke Symptoms
The range and severity of early stroke symptoms vary
considerably, but they share the common characteristic of
being sudden. Warning signs may include some or all of the
following symptoms:
Stroke Effects
The effects of a stroke depend primarily on the location of
the obstruction and the extent of brain tissue affected. One
side of the brain controls the opposite side of the body, so a
stroke affecting the right side will result in neurological
complications on the left side of the body. A stroke on the
right side may result in the following:
Stroke Treatment
Rehabilitation following a stroke may involve a number of
medical specialists; but the early diagnosis of a stroke, its
treatment or its prevention, can be undertaken by a
neurosurgeon. Rapid and accurate diagnosis of the kind of
stroke and the exact location of its damage is critical to
successful treatment. Such technical advances as digital
imaging, microcatheters and other neurointerventional
straight wire inside the small catheter pokes out beyond the
clot and automatically coils into a corkscrew shape. It is
pulled back into the clot, the corkscrew spinning and
grabbing the clot. A balloon inflates in the neck artery,
cutting off blood flow, so the device can pull the clot out of
the brain safely. The clot is removed through the catheter
with a syringe.
Penumbra is also a microcatheter-based system device,
which works by an aspiration principle. It was approved by
the FDA in 2008.
Stentriever devices are the newest generation of
embolectomy devices for stroke. They are still in an
investigative phase, but work by breaking up the occluding
clot, combined with aspiration or withdrawal.
Medical Prevention
Medications used to help prevent stroke in high-risk patients
(especially those who have experienced a previous TIA or
ischemic stroke) fall into two major categories;
anticoagulants and antiplatelet agents.
Anticoagulants thin the blood and prevent clotting. Heparin
acts quickly and is given intravenously (through a vein) or
subcutaneously (beneath the skin) while a patient is in the
hospital. Slower-acting warfarin can be given orally and is
used over a longer period. Because these drugs affect the
blood's ability to clot, they require close monitoring by a
physician.
Antiplatelet drugs prevent platelet aggregation. Platelets are
specialized cells in the blood that initiate a healing process.
Large numbers of platelets clump together to form a clot,
which can sometimes block an artery or break loose, travel
through the bloodstream, and block a smaller artery.
Antiplatelet drugs make platelets less sticky and less likely to
form clots, reducing the risk of ischemic stroke in patients
who have had TIA or prior ischemic stroke.
Preventive Surgical Procedures
Carotid Endarterectomy Surgery (Carotid
Endarterectomy, CEA)
Patients will be given either a general or local anesthetic
before surgery. In this procedure, the neurosurgeon makes
Physical therapy involves using exercise and other physical means (e.g.,
massage, heat) and may help patients regain the use of their arms and legs and prevent
muscle stiffness in patients with permanent paralysis.
Speech therapy may help patients regain the ability to speak.
Occupational therapy may help patients regain independent function and relearn
basic skills (e.g., getting dressed, preparing a meal, and bathing).
Conclusion
Modern treatments for ischemic and hemorrhagic stroke have
reached an advanced state of development in the modern era
of digital and device technology. Neurointerventional
treatments enable surgical procedures in the brain without
the need to open the skull surgically, and provide excellent
treatment alternatives for all forms of stroke and
cerebrovascular disease. These developments are timely,
occurring in an era when stroke incidence is on the rise as
the population ages.
This news release is featured in a news conference at 7 a.m., HT, Thursday, Feb. 7.
This news release contains updated numbers from the abstract.
Study Highlights:
A minimally invasive surgery appears safe and may reduce long-term disability after a bleeding stroke.
If the findings are confirmed in a larger study, the surgery would be a major advance for treating
hemorrhagic stroke.
HONOLULU, Feb. 7, 2013 A minimally invasive procedure to remove blood clots in brain tissue after
hemorrhagic stroke appears safe and may also reduce long-term disability, according to late-breaking research
presented at the American Stroke Associations International Stroke Conference 2013.
Of the hundreds of thousands of Americans who have intracerebral hemorrhages (ICH) each year, most are
severely debilitated, said Daniel Hanley, M.D., lead author and professor of neurology at Johns Hopkins School
of Medicine in Baltimore, Md.
ICH is the most common type of bleeding stroke. It occurs when a weakened blood vessel inside the brain
ruptures and leaks blood into surrounding brain tissue, causing neurological damage. There is not a specific
evidence-based targeted treatment recommended for ICH and there is no long-term randomized data on surgical
treatment.
In one-year results of the Phase II study, MISTIE (Minimally Invasive Surgery plus rtPA forIntracerebral
Hemorrhage Evacuation), researchers found that patients treated with surgery and a clot- busting drug had less
disability, spent less time in the hospital and were less likely to be in a long-term care facility than other ICH
patients.
There is now real hope we have a treatment for the last form of stroke that doesnt have a treatment brain
hemorrhage, said Hanley, who is also director of the Brain Injury Outcomes Division at Johns Hopkins.
The overall study involved 96 patients at 26 hospitals who had a bleeding stroke. The stage two arm of the trial
focused on 25 patients who had the surgical procedure and 31 who were given standard post-stroke medical
care, which is medical management only. Patients were average age 60 and 75 percent were men.
During the treatment, surgeons cut a hole the size of a dime in the patients skull. A catheter is passed into the
brain tissue, pushing it through the longest part of the clot, which has formed from blood that pooled during the
stroke. Next they apply the clot-busting drug recombinant tissue plasminogen activator (rtPA) to the clot via the
catheter every eight hours for about three days. As the clot liquefies, it is removed through the catheter.
The studys patients had blood clots with an average volume of 46 milliliters, about the size of a golf ball, Hanley
said. The procedure removed 57 percent of the clots on average, while clots naturally dissolved in only about 5
percent in the standard medical care group in the few days after stroke.
The normal healing processes may be occurring more rapidly when you remove the blood, Hanley said. We
believe were actually stopping brain injury and preserving brain tissue that would otherwise be lost.
Researchers found less fluid buildup (edema) in the brains of the surgical patients four days after the procedure,
compared with the usual care group.
In six-month results presented last year, researchers noted that the surgical group had 11 percent better
functional outcomes. The newest findings showed that a year after the stroke, the advantage in the surgery group
had increased to 14 percent.
Likewise, yearlong results among patients with mild disability also showed a 14 percent difference between the
treatment groups. Again, more patients from the surgical group improved during that time frame. And compared
with the usual care group, 14 percent fewer of the surgical patients were in long-term care a year later.
That 14 percent shift is occurring across the spectrum from long-term care to moderate disability to mild
disability, Hanley said.
For patients who underwent the surgical procedure, median time spent in any level of hospital or rehabilitation
care was 38 days shorter than for the usual care group. That difference could represent a cost savings per
patient of more than $44,000, the researchers estimated.
Researchers noted that no hemorrhage was too large or too deep in the brain to be helped by the procedure.
Patients who had surgery between 36 and 72 hours after their stroke fared as well as those treated sooner.
Women as well as men, blacks as well as whites, and people over and under age 65 appeared to benefit equally,
although a larger study is needed to validate the findings. The researchers hope next to conduct a 500-patient
Phase III study at more than 75 sites.
Hanley said the training for surgeons is simple and the equipment is readily available. If the MISTIE findings are
confirmed, then we have a practical treatment that can easily be done by all trained neurosurgeons, he said. It
could make a substantial difference in this disease.
The study was completed as a cooperative program with Mario Zuccarello University of Cincinnati as the surgical
leader and co-principle investigator. A full list of co-authors and author disclosures is available on the abstract.
The National Institute of Neurological Disorders and Stroke funded the research; Genentech provided the rt-PA
drug, Alteplase.
Follow news from ASA International Stroke Conference 2013 via Twitter @HeartNews; #ISC13.
Statements and conclusions of study authors that are presented at American Stroke Association scientific
meetings are solely those of the study authors and do not necessarily reflect association policy or position. The
association makes no representation or warranty as to their accuracy or reliability. The association receives
funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers
and other companies) also make donations and fund specific association programs and events. The association
has strict policies to prevent these relationships from influencing the science content. Revenues from
pharmaceutical and device corporations are available atwww.heart.org/corporatefunding.