When a person suffers a stroke, the swiftness of treatment can mean the difference between life and death or being able to function independently and suffering extensive disability.
As experts emphasize, time lost is brain lost. But for many who have a stroke, the life-changing event actually occurs when they’re asleep. That can mean precious hours are lost.
Treatment of ischemic stroke — the most common type of stroke, involving blockage of a blood vessel supplying blood to the brain — using clot-busting medicine, when appropriate, is now advised within the first four and a half hours after stroke onset. For patients who are candidates to have the clot mechanically or surgically removed, the procedure is generally recommended within the first six hours.
“So knowing that time frame is still very important, and it can help expedite treatment,” says Dr. Victor Urrutia, an associate professor of neurology and director of the Johns Hopkins Hospital Comprehensive Stroke Center in Baltimore. “The sooner you give the treatment, the better,” says Dr. Raul Nogueira, a professor of neurology, radiology and neurosurgery at Emory University School of Medicine and director of the neuroendovascular service at Grady Memorial Hospital in Atlanta. After the treatment windows pass, research has found these interventions don’t tend to benefit patients — who remain exposed to risks, like excess bleeding that can, like the stroke itself, be life-threatening
That makes it critical to call 911 and get emergency medical attention immediately when a person first notices common deficits, such as face drooping, arm weakness or speech difficulty, among other stroke signs highlighted by the American Heart Association and American Stroke Association. And it’s important to let clinicians know when those deficits first became apparent to help guide effective treatment. When a person has a stroke, they experience a sudden deficit, or difficulties doing certain things, explains Dr. Robert Brown, chair of the division of stroke and cerebrovascular disease and professor of neurology at Mayo Clinic in Rochester, Minnesota. And, of course, these symptoms vary. “At the onset of a stroke, people will have the abrupt onset of weakness in the face, arm or leg — oftentimes in combination — difficulty speaking, difficulty understanding others, difficulty with vision, difficulty with gait, difficulty with sensation, [or] numbness,” Brown says.
[See: 10 Ways to Lower Your Risk of Stroke.]
But even as clinicians continue to stress the absolute imperative of seeking treatment right away, new research is offering hope for a subset of patients who wake up to a stroke, or who otherwise aren’t able to get medical treatment within the first six hours.
“Think of a stroke as a forest fire,” Nogueira says. It starts small but expands over time. “What these therapies do is by dissolving or mechanically removing the blood clot, we put the fire out. So you can’t really regain the areas of the forest that has been burned, but you prevent larger areas of the forest from being burned,” he adds. Taking the analogy further, Nogueira notes how individual fires and circumstances vary: Some spread very quickly — rapidly causing extensive damage — while other fires spread more slowly. Similarly, he says, though research-based stroke treatment protocols appropriately focus on the clock, individual patient and stroke characteristics matter, too.
That certainly proved to be the case in research Nogueira recently led published in the New England Journal of Medicine in November. Researchers found that a select group of patients suffering from stroke-caused blockage, or occlusion, of prominent arteries (the intracranial internal carotid artery or proximal middle cerebral artery) still benefited from thrombectomy six to 24 hours after a stroke.
A key characteristic of the patients was that they had a “mismatch” between the severity of the clinical deficit, or difficulties they were experiencing — which could be observed — and the volume of infarct, or dead tissue, in the brain revealed using MRI or CT scanning technology with specialized software. “We used this … mismatch between the clinical examination and the size of the stroke on CT scan and MRI to characterize a stroke that was still growing,” Nogueira says. That information was used in determining who might benefit from a thombectomy, a catheter-based procedure, during the expanded six to 24 hour treatment window. “You mechanically remove the blood clot with a device that looks like a stent attached to a wire,” Nogueira explains. “You essentially fish the clot out of the brain.”
[See: What Only Your Partner Knows About Your Health.]
The results in the targeted patient population were stark. Of 206 enrolled in the trial, who’d last been known to be well six to 24 hours prior to treatment, 107 were assigned to the thrombectomy treatment group, while the other 99 received standard medical care. About half of those in the thrombectomy group — or 49 percent — demonstrated functional independence 90 days thereafter, compared with just 13 percent of those who didn’t have a thrombectomy. While rehabilitation to regain function lost after a stroke is a normal part of continuing care for survivors, generally speaking, those who’ve had a stroke span a broad continuum from being able to live independently afterward and essentially picking up where they left off at home and work to needing 24-hour, intensive long-term care and support.
“This is an extremely important study because it does tell us that for very selected patients they may benefit from extraction of a clot that is blocking an artery even beyond the standard time windows,” Brown says. “Because of this potential for extending the window of successful [treatment] — this has a major impact on our approach to our acute stroke patients, even when seen after awakening with a stroke — so in other words, since we would not know the time of onset in that circumstance.”
Experts emphasized for the majority of patients, the standard time windows are still relevant and — even for patients who meet the study’s criteria — getting more quickly into treatment is always better. The natural progression of a large stroke as time passes is that it causes higher degrees of disability or death. “So the treatment of the stroke early on prevents the progression of the stroke and reestablishes the function,” Nogueira says.
But very much like forest fires, Nogueira adds that strokes behave differently. “So every minute counts. But the window of opportunity is different across different individuals,” he says. “There are people that will benefit even in the six- to 24-hour window. But that same person that would benefit at eight or 12 or 16 hours, [and] had that person come earlier, the benefit would likely have been even greater.” So, he adds, “You open up the window of opportunity. But that doesn’t mean that time is not important.”
In addition to letting doctors know when symptoms began, it’s important to answer other questions that might affect treatment decisions for yourself or a loved one. “Other things that are important to clinicians, especially when talking about clot-busting medicine, is whether the patient is on blood thinners,” Urrutia says. Blood thinners can put patients at increased risk of bleeding, as can recent surgeries or having had another recent stroke. Similarly, experts say, doctors should be made aware of medications stroke patients are taking and their medical histories. Such individual factors — along with timing — are critical to improve the response to a stroke, whether or not treatment involves the administration of clot-busting medicine or removal of a clot.
[See: 6 Signs You’re Having a Heart Attack.]
“If then we get beyond six hours and if a person is not a candidate for thrombectomy, then standard … aggressive medical and nursing care oftentimes in a primary stroke center or comprehensive stroke center will give the patient the best possible outcome,” Brown says. That includes “appropriately addressing blood pressure, elevated blood sugars — if present — assisting in their recovery as early as possible with appropriate therapies and instituting the best prevention for another stroke by assessing what caused the first stroke.”
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Every Stroke Is Different. What That Means for Treatment originally appeared on usnews.com
