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Acute Stroke Treatment Options

Online Health Chat with Dr. Gabor Toth

May 5, 2011


Introduction

Cleveland_Clinic_Host: Each year, more than half a million Americans suffer from strokes. A stroke, or "brain attack," occurs when the blood supply is cut off from part of the brain. When the brain is deprived of blood, with its supply of oxygen and nutrients, for even a few minutes, it begins to die.

There are two types of stroke -- ischemic and hemorrhagic. In ischemic strokes, brain arteries become blocked, which prevents blood from nourishing the brain. In hemorrhagic strokes, brain arteries rupture from damage caused by high blood pressure and other risk factors or an aneurysm (an abnormal out pouching of a blood vessel) and cause blood to flood the brain, creating pressure that leads to brain-cell death.

There are many risk factors that increase the risk of stroke. Some factors can be controlled, while others cannot. some risk factors include: having high blood pressure, high cholesterol, heart disease, and/or diabetes; being overweight; drinking heavily; smoking; and having a family history of stokes. Ways to reduce these risks include: not smoking, limiting alcohol intake, controlling your weight and blood pressure, and finding out if you have an irregular heartbeat or a diseased carotid artery.

Immediate treatment of a stroke may limit or prevent brain damage. A thrombolytic agent or "clot buster" medication may be given within the first 4.5 hours of the onset of stroke symptoms, and patients may also qualify for emergent endovascular therapy to try to open blocked blood vessels. It is critical to call 911 and get to the hospital quickly if you experience stroke symptoms. Read how an expert answered questions about techniques, medications, and treatment options after a stroke occurs. Gabor Toth, MD, is involved in both medical and endovascular treatment of acute stroke patients at Cleveland Clinic.

Gabor Toth, MD, staff physician in the Cerebrovascular Center, received his medical degree from University of Pecs, School of Medicine in Hungary, then went on to complete his residency at University of Chicago Hospitals. He completed a fellowship in Vascular Neurology at Stanford University Hospital in Stanford, CA, and an endovascular surgical neuroradiology fellowship at UT Southwestern in Dallas, TX. His specialty interests include cerebrovascular disease, and interventional and vascular neurology.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Gabor Toth. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


starr: Is a brain aneurysm a type of stroke?

Dr__Gabor_Toth: If an aneurysm ruptures ("bursts"), it causes bleeding in the brain, called subarachnoid hemorrhage. Subarachnoid hemorrhage is a type of stroke. An unruptured aneurysm by itself is not a stroke.

coburnm: How does diabetes affect one's risk factors for stroke?

Dr__Gabor_Toth: It is one of the main risk factors for stroke, next to high blood pressure and cholesterol. Uncontrolled diabetes damages the blood vessels in the brain which may lead to stroke.

jollyo: What causes stroke, either just before or during delivery? What are the long-term problems associated with this?

Dr__Gabor_Toth: Pregnancy is a state with a lot of changes in the bodily functions. Sometimes it can result in a condition that causes the blood to be more prone to clotting or it can result in elevated blood pressure. Although rare, these factors may contribute to a stroke. The long-term consequences depend on the location, size, severity of the stroke, and how the causative factors are managed.


Basics

try2: Do the warning signs for a pediatric stroke differ from the warning signs for an adult stroke?

Dr__Gabor_Toth: In general, pediatric strokes are more difficult to diagnose than adult strokes. Newborns and babies may present with seizures, lethargy, and a tendency to use one side of the body. Older children may have similar signs and symptoms as adults.

jackson: TIA – Is temporary loss of some memory a symptom of stroke?

Dr__Gabor_Toth: It may or may not be typical of a stroke, depending on the timing, recurrence, other associated symptoms, and existing risk factors. There are other conditions that may cause similar symptoms (e.g., transient global amnesia, seizures, metabolic derangements, etc.). Brain imaging with MRI or CT may help clarify whether a stroke has occurred.

islandgirl: How does injury bring on a stroke? My aunt was in a car accident, suffered only ‘minor’ injuries. About a month later, she had a stroke. This was reportedly due to injury from the accident.

Dr__Gabor_Toth: It is possible that the accident caused an injury to a blood vessel; for example, a tear or dissection that at first did not cause any symptoms. However, later this can progress and cause narrowing or blockage of the vessel, bleeding, or even blood clot formation, which may lead to a stroke.

callista: Obviously, calling 911 is the first step to take when you think someone is having a stroke. Are there any other things you can do to help the person?

Dr__Gabor_Toth: Do not let the person drive or walk. Make sure that nothing is blocking their airway (mouth, nose). Try to get the exact time when the symptoms started. Make sure you take the person’s medications with you to the ER.

jeeper: Can a stroke change the personality/behavior of a person?

Dr__Gabor_Toth: Yes. Especially having a stroke in the frontal lobe (front part of the brain) can definitely do that.

kitty: What makes a person susceptible to multiple strokes?

Dr__Gabor_Toth: It depends on age and associated vascular risk factors, such as, high blood pressure, cholesterol, diabetes, smoking, obesity, unhealthy diet, drug abuse, and heart disease, which can all increase the risk of recurrent strokes. There are other less common conditions (blood clotting problems, aneurysms, genetic conditions) that can also contribute.


Treatments

pdipanfilo: Is TPA the only option for acute therapy?

Dr__Gabor_Toth: TPA is not the only treatment option these days for acute ischemic stroke. There are more invasive neurointerventional procedures that large medical centers may offer to select patients with blockage of large vessels in the brain. These procedures include direct intra-arterial tPA or other agents that may break up the clot, and mechanical clot disruption or removal with special devices placed directly into the arteries.

tres_bien: Does the treatment for stroke differ based on age or only on the type of the stroke and the cause?

Dr__Gabor_Toth: It mostly depends on the time and cause, but occasionally age can make a difference in treatment options.

aslycy: Besides coiling to correct an aneurysm of 7mm, are you also using the ONYX® HD" to correct?

Dr__Gabor_Toth: Onyx® HD-500 may be an option in select larger aneurysms.

panda: I’ve read about using a LaTis laser to treat stroke patients. Is the usage of this laser beneficial?

Dr__Gabor_Toth: This device is no longer marketed. Preliminary results in the early 2000s showed less favorable results than currently available stroke treatments.

joker: Why is it important to treat a stroke right away?

Dr__Gabor_Toth: When a stroke occurs, tens of thousands of brain cells (neurons) die every second. The longer it takes to restore blood flow to the brain, the more cells the patient loses irreversibly.

brandonia: What are the best treatment options for a stroke?

Dr__Gabor_Toth: There are different ways to treat stroke, depending on the acuity and severity of symptoms, underlying cause, age of patient, type of stroke, and many other factors. In general, medical, surgical, and endovascular treatment options are considered for patients who are having a stroke.

croyden: How do medications treat a stroke?

Dr__Gabor_Toth: Ischemic strokes are treated by trying to remove or dissolve a blood clot from blocked vessels.

Hemorrhagic (bleeding) strokes are treated by fixing or stabilizing ruptured blood vessels. Controlling very high blood pressure and correcting the effect of a blood thinner medication in the blood (if the patient takes one) are also part of the treatment regimen for these patients.

cuddleton: Someone mentioned to me about NeuroAiD™ stroke treatment, which is supposed to be based on Chinese TCM. Do you know anything about this treatment? If so, what are your thoughts?

Dr__Gabor_Toth: To my knowledge, some studies are still ongoing, but currently available data showed no definitive evidence of benefit in aiding stroke recovery in rehabilitation thus far.


Personal Experience

witter123: In 2004 I had a TIA. It was found that I had a 100 percent occluded left vertebral artery. I am taking Coumadin (warfarin), 81 mg aspirin, and Aggrenox®. Am I at risk for the right vertebral artery to occlude? If so, what preventive measures can be done?

Dr__Gabor_Toth: It is difficult to tell. It depends on what caused the blockage in the other artery in the first place and what kind of work-up you had for that problem. Being on Coumadin, aspirin, and Aggrenox® (aspirin and extended-release dipyridamole), though, seems like a lot of blood thinning medications used together. It would be important to know what other stroke risk factors you may have. In summary, someone with stroke expertise should look at all your results and images to determine your stroke risk and optimal medical management. The Cerebrovascular Center at Cleveland Clinic is happy to assist you, if you wish.

clara: I am on Plavix® and two 81 mg aspirin. My concern is my mother at the age of 51 had a hemorrhagic stroke. I recently read that you should ask your doctor about using Plavix® and aspirin. My doctor is telling me now that it would be too big of risk to change medicines. I have had open heart surgery and one graft in 2009 and three grafts in 2010. The grafts were not put into the bypass grafts.

Dr__Gabor_Toth: Usually aspirin and Plavix® (clopidogrel) in combination are not used for stroke prevention measures; however, they are frequently prescribed for cardiac purposes with proven benefit. As both are blood thinners, they do carry an increased risk of bleeding. I am not sure what type of hemorrhagic stroke your mother had (e.g., aneurysm, blood clot, vessel rupture, blood pressure related, etc.), which may affect your risk of having a stroke.


Family

Marta: My father went to the ER with symptoms of a stroke and the tests came back negative (MRI). Could he still have had a stroke or was this something else?

Dr__Gabor_Toth: It depends on a lot of things. There is a very low percentage of "MRI- negative strokes" that may exist. If his symptoms were considered a "TIA," he should still have the workup to make sure possible underlying "stroke-causing medical problems" are ruled out.

btt: As a caregiver of my elderly father who has suffered from a stroke, I am concerned about his being adamant about still driving. What are some of the warning signs of unsafe driving after a stroke?

Dr__Gabor_Toth: There is a specific driving evaluation test administered by The Occupational Therapy Department that is available to assess a patient’s driving skills and safety after a stroke.


Recovery and Rehabilitation

petel: What would be the cause of regression in a stroke patient? My grandmother had a stroke about four months ago and was progressing well when released. After about two months, she started having more problems with her right hand and arm, including swelling and unsteadiness.

Dr__Gabor_Toth: There could be many reasons for this, neurologic and non-neurologic. New strokes may occur, but many times other underlying medical conditions, such as elevated or too low blood sugar, urinary tract infection, heart problems, and blood pressure changes can cause worsening of prior stroke symptoms. Nevertheless, if your grandmother continues to worsen, she should definitely be evaluated by her physician.

oc1dean: What amount of cognitive ability is needed after the stroke to get to complete recovery? Has anyone documented how you move from stage to stage in Brunnstrom’s stages of stroke recovery?

Dr__Gabor_Toth: Thank you for these questions. These are more directed toward chronic stroke care, recovery, and rehabilitation and most of them could be better answered by a physical medicine and rehabilitation physician who specializes in stroke recovery.

I think in the Brunnstrom recovery you just move up from stage to stage (from 1 to 6) as more recovery occurs.

I am not sure if anyone exactly knows or can quantify "how much" cognitive ability or sensation is needed for recovery.

oc1dean: 1. Can neurons in the brain handle two separate tasks? 2. If not, then how is it decided which parts of brain function are thrown away to neuroplastically recover the dead areas. Hopefully, the thrown-away parts are like toe control rather than cognitive areas, which could lead me to insanity. How much control can one neuron have? Can neurons multitask?

Dr__Gabor_Toth: Neurons do not functionally operate as individual units. They are part of a huge network of cells. As such, each neuron has multiple connections with other cells via axons and dendrites. They communicate with each other via synapses. Because of this complex, intertwined cell mesh, it would be difficult to separate out what individual neurons do on a functional level. Millions of neurons in a specific part of the brain are usually responsible for a certain type of function (e.g., sensation, motor function, speech, hearing, comprehension, vision, etc.), but even these areas are closely associated and interacting with each other on multiple levels. This makes it hard to fully understand neuroplasticity and predict what exactly is going to happen during recovery after stroke.

pcbarclay: Dr. Toth, is extreme itching a side effect of stroke? I suffered a basilar artery stroke in December of 2008 and became paralyzed on my left side. I have very little pain, but the deep itching of my legs is incredible. It is not surface itching (positional), more under the skin.

Dr__Gabor_Toth: I am not aware of stroke causing itching. Pain, loss of sensation, burning, tingling, and numbness may occur.

jacko: Is memory loss due to stroke permanent?

Dr__Gabor_Toth: As with all deficits due to stroke, some degree of improvement is expected after the event. However, the degree of recovery depends on many things, including the size and location of the stroke, age of patient, previous strokes, other associated medical conditions, etc.

123contact: My father has paralysis from his stoke on the right side of his body. He is currently not able to walk. With therapy, will he regain use of that side of his body? If not, how would you make a determination?

Dr__Gabor_Toth: As with all deficits due to stroke, some degree of improvement is expected after the event. However, the degree of recovery depends on many things, including the size and location of the stroke, age of patient, previous strokes, other associated medical conditions, rehabilitation efforts, etc. Most improvement occurs in the first 6 to 12 months after the stroke, but a smaller degree of recovery is possible even later.

oc1dean: Has the spasticity issue finally been resolved? Should spasticity be treated? From 2004 to 2005, there were a number of researchers stating we should not treat spasticity. It was a normal protection effect of the stroke.

Dr__Gabor_Toth: Spasticity usually requires treatment if it causes pain, contractures or skin breakdown, interferes with activities of living, or impairs mobility.


New Ideas

oc1dean: Which of the following is considered to be some of the best possibilities for acute therapy? And who is testing them in clinical trials? They are: antidepressants, turmeric, stopping glutamate cell death, niacin, potassium, Irish coffee injection (caffeinol), xenon gas, Sigma-1 receptors, fish oil, marijuana, sensation stimulation, etanercept (Enbrel®), caffeine, sleep, nicotine, alcohol, hypothermia, inosines and NEP1-40, SB623, tocotrienols, cardiac glycosides, SK3 channels and N-WASP (?), snake venom, and bat saliva

Dr__Gabor_Toth: Many of the above agents have been tried in cell cultures, animal models, or less frequently humans. Results were many times controversial (antidepressants), potentially beneficial (potassium), indeterminate (caffeinol, desmoteplase - bat saliva), or no clear benefit was seen (ancrod - snake venom). Some agents/drugs have shown promising results in the lab, but no human trials have been conducted or completed yet (turmeric, niacin, xenon, NEP1-40).

One big problem is that many times the benefit seen in animals or cells does not translate into real benefit in humans later.

Clinical trials are usually conducted by large medical centers and hospitals, such as Cleveland Clinic. Due to the diversity, requirements, inclusion-exclusion criteria and large number of these trials, not all hospitals are involved in every study and not all trials are conducted in every hospital.

oc1dean: Could liposomes become the transport of choice to get past the blood-brain barrier?

Dr__Gabor_Toth: Although liposomes and basic science research are not my areas of expertise, I have heard of animal studies using liposomes for potential stroke therapy. It usually takes time from animal models to go to clinical trials. If the animal data are promising and the method/drug appears safe, human trials can be initiated in the future.


General Questions

fotismia: What is a good way to advocate stroke and brain aneurysm awareness? I lost my mother on Easter due to a hemorrhagic stroke (even though the wonderful medical team at Cleveland Clinic did everything in their power to save her), and I would like to become an advocate for awareness.

Dr__Gabor_Toth: If you call the Cleveland Clinic Cerebrovascular Center at 216-445-9897 and ask for Sue Jaeger, NP, she may be able to help you. You may have to leave a voice message and she will call you back.

flowersall: Instead of sugar, I use a lot of artificial sweeteners. Is there any link between using artificial sweeteners and having a stroke?

Dr__Gabor_Toth: A recent study found a possible association between diet soda and heart disease/stroke. Diet soda has been previously reported to potentially contribute to diabetes, migraines, and metabolic disease. These findings have not been confirmed in further studies yet. Artificial sweeteners have been linked to many diseases over the past decades, including obesity, fibromyalgia, cancer, and brain tumors, without conclusive results.

missouri: Can a severe migraine mimic stroke symptoms i.e., blinding headache, slurred speech, and weakness on one side? I ask because this happened to a friend in college.

Dr__Gabor_Toth: That is correct. It is called hemiplegic migraine or complicated migraine. It sometimes runs in families.

nommy: For osteoporosis patients, calcium intake is high. Will this condition increase the risk of carotid breakage?

Dr__Gabor_Toth: There have been studies suggesting that high calcium intake may increase risk of heart disease and stroke. Nobody knows how much is really "too much." You should talk to your doctor and take only the necessary amount of calcium daily.

oc1dean: What is considered the timeframes for subacute, acute, and chronic? Is it based on time or recovery?

Dr__Gabor_Toth: These time frames are arbitrary and change from one institution/physician/book/article to another. Usually, acute means within 24 hours, subacute is 24 hours to two to four weeks, and chronic is beyond that. As I said, these time frames are for estimation purposes only.

gotmilk: Is stress a factor with strokes, as it is with a heart attack? If yes, how?

Dr__Gabor_Toth: Stress is not a proven direct risk factor. However, it can increase blood pressure, change hormonal status of the body, and other metabolic derangements, which are certainly not beneficial in the long term.

just_asking: Is heat stroke really a form of stroke?

Dr__Gabor_Toth: Heat stroke is basically elevated body temperature due to heat and dehydration. It can cause severe problems, but it is not a stroke in the classical sense.


Closing

Cleveland_Clinic_Host: I’m sorry to say that our time with Dr. Gabor Toth is now over. Thank you again Dr. Toth for taking the time to answer our questions about acute stroke treatment options.

Dr__Gabor_Toth: Thank you very much for your questions. Have a good day.


More Information

To make an appointment with Gabor Toth, MD, or any of the specialists in the Neurological Institute at Cleveland Clinic, please call 216.636.5860, or call toll-free at 866.588.2264. You can also visit us online at clevelandclinic.org/Cerebrovascular.

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