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Treatment Options in Acute Ischemic Stroke

Online Health Chat with Dr. M. Shazam Hussain

May 11, 2012

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 this happens, the blood-deprived brain loses its supply of oxygen and nutrients. When the brain is deprived of blood 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 and prevent 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 of these factors include: high blood pressure, high cholesterol, heart disease, diabetes, heavy drinking, smoking, being overweight, and 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.

The Cerebrovascular Center at Cleveland Clinic’s Neurological Institute integrates a multidisciplinary team of neurologists, neurosurgeons, neuroradiologists, neurointensivists and rehabilitation specialists who provide expert diagnosis and medical, endovascular, and surgical management of all cerebrovascular conditions. Cleveland Clinic is a designated Primary Stroke Center.

A Primary Stroke Center is usually housed in a hospital where a group of medical professionals who specialize in stroke work together to diagnose, treat, and provide early rehabilitation to stroke patients. The Joint Commission’s Certificate of Distinction for Primary Stroke Centers recognizes centers that make exceptional efforts to foster better outcomes for stroke care. The Cleveland Clinic Primary Stroke Center provides services that have critical elements to achieve long-term success in improving outcomes. We provide quality care and effectively manage the unique and specialized needs of stroke patients.

M. Shazam Hussain, M.D, is the designated stroke center director and staff physician in the Cerebrovascular Center at Cleveland Clinic. He received his medical degree from University of Saskatchewan College of Medicine in Canada and then went on to complete a residency and fellowship at University of Alberta Hospital Canada in neurology and vascular neurology. Dr. Hussain joined Cleveland Clinic for his final fellowship in endovascular surgical neuroradiology. His specialty interests include acute stroke therapy, cerebrovascular diseases, and neuroimaging.

To make an appointment with Dr. Hussain or any other of the specialists in our 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.

 

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. M Shazam Hussain. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Aspirin

all_the_time: What is the best daily dose of aspirin?
Dr__Hussain: It will depend on the clinical situation, but the American Heart Association/American Stroke Association (AHA/ASA) guidelines would suggest aspirin 81mg or aspirin 325mg are effective for stroke prevention.

all_the_time: Following up then - if I take a low dose aspirin daily - is that just one thing I would need to do to prevent a stroke? Is there a certain age that I should start and can I do this on my own or should I work with my physician? What questions should I ask?
Dr__Hussain: It is also very important to control risk factor for stroke. We recommend people keep their blood pressure controlled (< 140/90 minimum), have their cholesterol checked and treated as needed, be screened for diabetes and to quit smoking if they currently smoke. Diet and exercise are also extremely important - walking at a decent pace for a minimum of 30 minutes a day is recommend.

my_friends: What about giving them an aspirin like they show on TV? Should you do that too or are there other factors that should be considered first?
Dr__Hussain: Due to concerns about putting anything into the mouth (which could get aspirated into the lungs), we generally do not recommend taking aspirin. Best thing to do is to call 911 and get to a hospital as soon as possible.

remember_me: If you think you are having a stroke, does it help to take an aspirin immediately?
Dr__Hussain: The data would suggest that we should give aspirin in the first 48 hours, and there is no definitive evidence that giving aspirin immediately helps the situation. That coupled with concerns of aspirating fluid or the medication into the lungs and potential bleeding lead us to not to recommend taking aspirin right away. Best thing is to call 911 and get assessed immediately.


Emergency Response

my_friends: If you think someone is having a stroke, what should you do besides calling 911?
Dr__Hussain: Calling 911 is the most important element to allow someone to get to medical attention as soon as possible. While waiting for EMS to arrive, having the person lie flat can be helpful. One should never place food or water into someone's mouth during a suspected stroke.

mama_mia: I know that getting treatment within the first three hours is critical with stroke victims. However, how can you guarantee that a patient will be evaluated for stroke upon going to the ER if you do not know that that is what the person has had? I have read some stories about delayed treatment in the ER.
Dr__Hussain: You are correct that it is extremely important to be assessed as soon as possible when stroke symptoms arise. If possible, a person or their family should ask to be directed to the nearest primary stroke center, which are designated by the national joint commission to meet standards for the assessment and treatment of stroke patients. Within the Cleveland Clinic Health system, Main Campus, Ashtabula County Medical Center, Euclid Hospital, Fairview Hospital, Hillcrest Hospital, Lakewood Hospital, Marymount Hospital, Medina Hospital, and Southpointe Hospital are all primary stroke center certified.

smooth_sailing: If we have no confidence in the hospital nearest the 911 call, is it good to take the patient to the Cleveland Clinic Emergency Room by automobile, so long as we can get there in 1 to 3 hours? I just did this recently, and my family was upset.
Dr__Hussain: As people with stroke can be critically ill and change quickly, we would recommend going to the nearest primary stroke center. Often from these centers, patients will be quickly transferred by helicopter (weather permitting) or by ambulance to the Cleveland Clinic. Often at these Centers, we can also give advice by telephone to the physicians there while the transfer is being arranged.

on_and_on: I know this is always asked, but what are the signs that a person is having a stroke? If you suspect someone is having a stroke, do you tell that when you call emergency?
Dr__Hussain: We recommend the acronym FAST

  • F - look for weakness, droopiness in the face
  • A - Arm or leg weakness on one side or the other.
  • S - Speech difficult (slurring or unable to get words out).
  • T - Time - if you see any of these symptoms, call 911 immediately.

Other symptoms include severe headache (worst of life), severe dizziness (vertigo), double vision or sudden severe confusion.

It is helpful to say you are suspecting stroke symptoms as it will allow the EMS team and the team receiving in the emergency room to be prepared for the rapid stroke response.


Carotid Artery

oldies: What are “specific symptoms” of carotid plaques?
Dr__Hussain: Unfortunately, most carotid plaques are silent until they cause stroke. Thus, people with carotid plaque should know the stroke warning symptoms, especially sudden onset of weakness on one side of the body and sudden speech difficulty (slurring speech or unable to speak). If someone has been found to have carotid plaque, it is important to be on appropriate medical therapy and monitor this closely with their physician. In certain selected cases, carotid surgery or stenting may be an option.

get_lucky: Other than surgery, what can be done for carotid arteries?
Dr__Hussain: The other primary option would be carotid artery stenting. Of course, one cannot overlook the importance of good medical management and controlling risk factors like high blood pressure, cholesterol, and diabetes, as well as quitting smoking.

this_is_it: Is surgery for carotid artery stenosis safer for persons over 80 than putting in a stent? What percentage of carotid blockage demands surgery in a person 80 years old?  
Dr__Hussain: Over age 80, surgery and stenting both carry significant risk, but may be warranted in certain situations. As a first line, medical therapy including blood thinners, good control of blood pressure, being on cholesterol lowering medications and controlling other risk factors is most important. In very select situations (depending on degree of stenosis > 60%, recent symptoms of stroke/TIA, progressive narrowing despite medical therapy), carotid artery surgery/stenting may be considered, but only so after taking into account all of the possible treatments and risk associated.


Stroke Risk Factors

to_the_bone: What is the relationship between diabetes and stroke? Does having diabetes make it harder to treat a stroke?
Dr__Hussain: Diabetes is considered a major risk factor for stroke. As such, it is very important to control it as much as possible to prevent stroke from occurring. High blood sugar while having a stroke can worsen a stroke, so while in hospital, protocols are set up to control blood sugar as much as possible.

hanibelle: Do strokes run in families? Am I more prone to a stroke if my parents had them?
Dr__Hussain: Certain stroke types can run in families, as can stroke risk factors. If your parents had strokes, especially at a young age (< 65), it would be worthwhile to see a stroke neurologist for assessment.

The other situation to mention is that of brain aneurysm. If 2 or more family members have had a brain aneurysm, we do recommend the other family member be screened.

got_milk: If a person has already had a stroke, or has had one or more TIAs, are they more prone to having another stroke? If so, how best can it be prevented?
Dr__Hussain: Someone with a stroke or TIA is more at risk to have another, especially soon after the first event. It is very important to get these checked out by a neurologist as soon as possible, since the risk can be reduced by looking for the underlying cause and starting the appropriate treatments (i.e. blood thinners, controlling risk factors, carotid artery surgery/stenting when indicated).

and_so_it_goes: If you recently had a DVT (deep vein thrombosis) - PE (pulmonary embolism) series within the last year and are having surgery soon, what precaution should you take and ask your doctor before surgery? Should a CT scan be done to check the lung for the old clot?
Dr__Hussain: It would be very important to have this optimized as soon as possible before surgery. I would definitely speak with your doctors and a good plan for around the time of surgery would be important.

maryb: In late February, I injured my outer thigh, resulting in a hematoma. I can't help but believe that the leg injury caused my stroke. Is this possible? I am a 37-year-old otherwise healthy (at least I thought I was) female.
Dr__Hussain: In any young person with a stroke, it is very important to be assessed by a stroke neurologist to look for the underlying cause.

corn_girl: Can plaque form on stents? If these break off will they cause a stroke?
Dr__Hussain: It is unusual to have plaque form on stents but it can happen. Fortunately these are usually very stable and it unusual to see recurrent stokes. That being said, it is important to have continued follow-up and monitoring for this.

Martens: What are some of the best ways to prevent a stroke?
Dr__Hussain: The best way is to maintain a good, healthy lifestyle - eating well, regular exercise and making sure one's risk factors are under good control.

Paige: Why do younger people, even young children, have strokes?
Dr__Hussain: Unfortunately, we are seeing younger and younger people having strokes (even children). Often the cause of the stroke is different then the usual causes. Some causes include tears of the inner lining of the artery (dissections), heart conditions or underlying clotting problems of the blood. I especially advocate that young patients be seen by a neurologist (ideally a stroke neurologist) to be assessed for these conditions.

Paige: In response to your answer regarding young people/children and stroke, do you think all children should be assessed for stroke risk factors, only say athletes or those with specific histories?
Dr__Hussain: In general, children in the United States are becoming more obese and risk factors like high blood pressure are being seen at much early ages (even in childhood). As such, children fulfilling this profile should be assessed and treated.

Georgia_bound: What is the relationship between PFO (patent foramen ovale) and stroke risk?
Dr__Hussain: This is a very controversial question as PFO is very common in the population, and the studies are very inconclusive. If it is linked to stroke, it certainly does not seem to be a high risk cause for recurrent events and many times is probably incidental.


After Stroke

ChuckSr: What can be done for vision partial loss due to stroke?
Dr__Hussain: Vision loss, like other stroke symptoms, may improve over especially the first 3 months after a stroke. To retrain the brain, it may be useful to try to use the eyes as much as possible - attempt to read and write. Assessment from a physical or occupational therapist may be helpful.

Bobby: Does improvement or recovery from a stroke only occur the first few months after a stroke? Can there be improvement later?
Dr__Hussain: Typically improvements happen in the first 3 months, but we have also seen improvement after that time frame.

OK: Can a person who has trouble finding the words when speaking be okay when writing them down instead, or does the same difficulty exist?
Dr__Hussain: Often the problem affects all forms of expression, but these can improve at different rates, especially in the recovery phase. Some people can get to the point where they can write more effectively than they can speak.

Martens: What are some suggestions for communicating with a person who suffered a stroke and now has aphasia (language difficulties)?
Dr__Hussain: Aphasia can be very frustrating both for the person who is experiencing from aphasia and those trying to communicate with them. Often, other forms of expression may be less affected - you may want to try writing as opposed to speaking. Music therapy is often helpful when trying to recover from aphasia, especially listening to a lot of music with singing. Patients will also sometimes notice that if they try to sing the words, they may come out better!

doggie_days: I have been lead to believe that within minutes or hours after someone is given tissue plasminogen activator (tPA), there should be instant improvement in their condition/symptoms. Is this accurate?
Dr__Hussain: Looking at the studies for tPA, the outcome at 3 months was assessed. Although we do sometimes see rapid improvement (~10% of cases), the real judgment of tPA’s effectiveness should occur at a later time.

William: Since the stroke 6 months ago, my 79-year-old father really seems out-of-it and confused. The physician said something about vascular dementia. What is that? Does it always happen with strokes?
Dr__Hussain: Dementia and strokes are intimately linked. Strokes in the right locations (i.e., in the thalamus, an important cognitive structure in the brain) or accumulating many strokes may lead to dementia occurring. Even in Alzheimer's dementia, it has been shown that stroke risk factors like high blood pressure and high cholesterol increase one's risk, leading physicians to speculate about a vascular role in this type of dementia as well.

myfav: My father had a mild stroke about 2 months ago. He is at about 90 to 95% completely back to normal. However, a few days ago, he had what I called a minor setback, where he had some memory difficulties for about 5 to 10 minutes (no other symptoms, just the memory difficulty). It only happened once that I know of. Is it common to have a few setbacks so late in the recovery process, or could something else be going on that we should have checked out?
Dr__Hussain: It would be important to have this assessed. Many possibilities can lead to these short episodes of worsening (infections, seizure), which may require other types of treatment.

Gregory: Can you talk about the meds used to prevent clotting? Many of my friends are on warfarin, but I hear that some newer ones do not require a weekly blood test like warfarin does.
Dr__Hussain: Recently, many new alternatives (such as dabigatran) to warfarin have been approved. These medications appear to be as effective as warfarin with similar or lower bleeding risks. They also do not require the same close monitoring for patients, which makes them attractive.


Miscellaneous

misbehaving: What exactly is a lacunar stroke? My brother-in-law has been told that he has had a few of them. Can you please tell me what they are, how serious they are, and what can be done to stop them?
Dr__Hussain: Lacunar strokes are strokes of the small penetrating blood vessels of the brain. These are typically related to high blood pressure or diabetes, so it is critically important to control these risk factors.

quiet: Is there anything that can be done to treat the fatigue that comes from having a stroke?
Dr__Hussain: Fatigue is extremely common after stroke/TIA (almost universal). The most important thing is to maintain ones activity, eat a good diet, and get regular exercise. There are medications which can be used, but they do have side effects and should only be used as a last resort.

MollieT: I know for heart attacks they say that women may have different symptoms than men. Is this also true with stroke?
Dr__Hussain: Unlike heart attack, stroke symptoms seem to be the same for women and men.

heavenly: Are routine preliminary tests done to determine if a stroke is the blockage or hemorrhage type?
Dr__Hussain: This is usually determined very quickly in the rapid stroke response in the emergency department, which is important as the treatments are quite different. A CT scan should be done ASAP (goal is as quickly as possible, within 25 minutes of arrival) which is a great test to assess for the presence of blood (i.e. hemorrhagic stroke).

high_handed: In your opinion, which type of stroke is worse, ischemic or hemorrhagic? Which has better recovery prospects?
Dr__Hussain: Depends on the size and location of the ischemic/hemorrhagic stroke, but all things being equal, hemorrhagic stroke tends to be worse. That being said, with good acute care and rehabilitation, a person with either type of stroke can make great recoveries.

charlie: I have a pacemaker and therefore cannot have an MRI; are there other good diagnostic tests for stroke?
Dr__Hussain: There are many good diagnostic tests for assessment of stroke. Often important information can be gained from CT scans, ultrasound testing, cardiac testing, and angiography, which can allow us to make a good assessment and treatment plan, even when MRI is not an option.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Dr. M Shazam Hussain is now over. Thank you, Dr. Hussain, for taking the time to answer our questions today about treatment options in acute ischemic stroke.

Dr__Hussain: It was my pleasure to speak with you all today. Stroke is a very important health problem - the leading cause of disability in the United States, in fact - so it is critically important for all of us to raise awareness about this condition and especially for everyone to know about the stroke warning signs so they can seek medical attention immediately. TIME IS BRAIN!

Once again, thanks again for the opportunity to speak with all of you.


More Information

To make an appointment with Dr. M Shazam Hussain or any other of the specialists in our 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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