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Stroke

stroke brainStroke care is a chief focus of the Lourdes/DNI neurosurgery program. Given the toll that this condition takes on life and function within the population, the neurosurgery program at Lourdes has declared top-level prevention and care of stroke as a priority.

At Lourdes, a DNI neurosurgeon is on call 24 hours a day, seven days a week, throughout the year.   These experienced specialists attend to all patients who arrive for stroke care.   And “time is brain” in stroke treatment in terms of saving tissue and function, so the Lourdes/DNI moves patients quickly into the treatment protocol.

Ischemic Stroke

In this image, a neurointerventional team has used high-resolution images to guide catheters through tight turns in blood vessels of the brain and re-establish blood flow in a brain artery that had been blocked by a clot.

In this image, a neurointerventional team has used high-resolution images to guide catheters through tight turns in blood vessels of the brain and re-establish blood flow in a brain artery that had been blocked by a clot.

If patients experiencing a stroke meet proper criteria, they may receive a clot busting drug called tissue plasminogen activator (tPA).   Radiologic imaging must confirm that the lack of blood flow to the brain is caused by a clot (ischemic stroke).   If the onset of the patient’s stroke is observed and the patient is within the required time frame, they may receive tPA by an intravenous drip to dissolve the clot.

When this treatment is not adequate, the team may use microcatheters to physically retrieve and remove the clot, in a procedure called intracranial thrombectomy.  If CT and/or MR imaging shows the clot near salveageable brain tissue, the team can undertake this interventional step to prevent further damage.  If this type of imaging is not definitive, the team will order a CT angiography (CTA) and a CT perfusion (CTP) study of the head and neck.   CTA uses a contrast agent injected to highlight the precise shape and position of blood vessels and to reveal any bleeding.   Also taking advantage of injected contrast agent, CTP similarly images the passage of blood through the brain, identifying areas with decreased blood flow.   Together, these studies help the team to determine how much brain tissue can be salvaged from an effort to treat the stroke.

The specialists can determine if the affected portion of the brain represents a core of irreversibly damaged tissue or an area impacted by low blood flow that is still viable and can be saved (a penumbra.)   Only if the compromised area is of this latter type will the team proceed with the intervention to remove the clot.

Image from animation of a clot retriever device inserted into clot in cerebral artery in preparation for withdrawal and removal of the clot to reopen blood flow within the vessel.

Image from animation of a clot retriever device inserted into clot in cerebral artery in preparation for withdrawal and removal of the clot to reopen blood flow within the vessel.

Intracranial thrombectomy is an endovascular stroke treatment that requires bi-plane imaging capability —— coming soon to Lourdes.   The images produced by the biplane system aid these dual-trained neurosurgeons in performing such neurointerventional procedures——through visualization of the brain, vessels and catheters before, during and after the intervention.   This approach is allowing neurosurgical stroke teams to extend the timeframe in which treatment can be performed far beyond that possible with tPA.   Partly as a result, endovascular treatment is quickly evolving to be a standard of care, just as cardiac catheterization with X-ray imaging did decades ago for coronary artery blockage.

Technology and expertise in today’s neurosurgery operation room permits the stroke team to treat patients that they could not intervene effectively with in the past. Using this technology, the Lourdes/DNI team can restore brain blood flow in nearly all ischemic stroke patients who qualify for the procedure.
Biplane imaging equipment

Biplane imaging equipment

The surgeons can also use endovascular techniques to open a blocked carotid artery (arteries that run along each side of the neck to the brain).   The team can advance catheters into carotid arteries to cut out plaque or use a balloon to expand the artery opening, sometimes also placing stents to support this opening.

Less commonly, the neurosurgeons may perform conventional surgery (from an external incision to the brain) to clip or embolize (clot) a bleeding location or reopen a carotid artery.

Hemorraghic Stroke

Strokes may also be caused by bleeding (hemorrhage) in or around the brain.   When a blood vessel has a weakened condition of some kind and bleeding occurs, the brain may develop pressure from the blood itself.   Intracranial bleeding also means direct contact of blood with brain tissue, which irritates the brain at these locations, resulting in swelling of the brain tissue.  In addition, the blood can collect into a mass called a hematoma.

In this way, vascular abnormalities of the brain are the cause of this second most common type of stroke.  To address stroke from intracranial bleeding, the Lourdes team works to try to control the bleeding by managing blood pressure and addressing intracranial pressure, on both cases primarily with drug therapy.

In some cases, though, the Lourdes/DNI neurosurgeons may use endovascular procedures similar to those used for ischemic stroke. They may place devices (such as a tiny coil) or surgical material (such as special glue) to stanch the flow of blood in tiny arteries within the brain.

In some cases, if pressure from swelling and/or hematoma is severe and perhaps life threatening, the Lourdes/DNI neurosurgical team will perform a procedure directly through the skull to prevent or stop further bleeding (for example, to clip an aneurysm) or remove blood to reduce pressure on the brain inside the skull.

The team also treats a less common form of stroke called subarachnoid hemorrhage.

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