Acute Stroke: Therapy

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Acute Stroke: Therapy
Acute Stroke: Therapy
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Acute stroke: therapy

So-called thrombolysis is still considered the standard acute therapy for ischemic stroke. The clot that blocks the cerebral artery is dissolved with the help of an intravenously administered drug. In recent years, however, it has become increasingly clear that there are decisive advantages for patients if the blood clot is removed with the help of a small catheter and a wire mesh…

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  • Drug thrombolysis
  • Mechanical clot removal
  • Emergency operation
  • General therapeutic measures for stroke
  • How are the costs going to be covered?

This so-called mechanical thrombectomy has been shown to be successful in several studies, especially in occluding larger cerebral arteries. Often both methods are combined. In many cases, this makes it possible to regain sufficient blood flow to the brain quickly and to minimize the extent of the damage.

Drug thrombolysis

The sooner the therapy is applied, the greater the benefit of thrombolysis. The optimal period for a lysis therapy is within the first 4.5 hours after the onset of symptoms. This therapy window can be extended to a maximum of six hours in individual cases and in the case of intra-arterial lysis.

Drug thrombolysis can be carried out systemically by intravenous infusion of the clot-dissolving drugs (e.g. with the active ingredient rt-PA = recombinant tissue plasminogen activator or recombinant tissue plasminogen activator). This generally reduces blood coagulation - not just locally. In contrast, with intra-arterial lysis, the drug is administered directly into the closed blood vessel - at the location of the clot in the brain - using a small probe. This procedure is preferred for patients in whom the whole body should not be exposed to strong blood thinning, for example after surgery. In addition, the intra-arterial lysis has a faster and stronger effect, which can be particularly advantageous in the case of large blood clots.

Lysis therapy is currently used in around three to ten percent of stroke patients. Carrying out thrombolysis, for example with rt-PA, requires experience that is only available in Austria in stroke units and neurological intensive care units. See Stroke Unit for more information.

Benefits of lysis therapy

If the lysis therapy is carried out in the first 4.5 hours, it is highly effective and increases the chance of surviving the stroke without disability. The best conditions for this are given if the lysis therapy is administered within 90 minutes of the start of the event. The degree of disability is also significantly lower than in patients who are not receiving thrombolysis.

Limitations of lysis therapy

In addition to the time factor and the existence of a cerebral haemorrhage, a number of other situations rule out lysis therapy. This can be the case, for example, if the patient has an allergy to components of the drug or has had an operation within the last three weeks or has a coagulation disorder. Since the drug greatly reduces blood clotting, cerebral hemorrhage must be clearly ruled out before the lysis therapy (computer tomography). In addition, lysis therapy does not always achieve reopening of the vessel in the event of a very severe stroke with an occlusion of a larger brain vessel.

Mechanical clot removal

A relatively new approach is the mechanical removal of the blood clot (mechanical thrombectomy, endovascular therapy) with so-called "stent retrievers".

Endovascular therapy is recommended as a supplement to intravenous thrombolysis (if indicated) in the case of large occlusions of cerebral vessels within six hours of the onset of symptoms. Management is carried out by the neurologists at the respective special wards for stroke treatment (stroke units); the minimally invasive procedure is carried out by interventional radiologists. In endovascular therapy, a wire mesh in a catheter is passed over the bar directly to the vascular occlusion in the brain and the clot is pulled out with it. There should be no more than 90 minutes between the indication and the implementation of the procedure.

Note Several large studies show that patients in whom this therapy is used have a significantly higher chance of an improvement in symptoms, optimal rehabilitation and a significantly lower degree of disability after three months. This method has recently been able to be carried out around the clock in Austria.

Emergency operation

Emergency surgery is rarely required in the event of a stroke. If subarachnoid hemorrhage is present, the affected person is further clarified with catheter angiography. On the basis of these recordings it can be decided whether an underlying aneurysm (vascular sac) is to be switched off neurosurgery with a clip or whether the minimally invasive method of coil embolization is possible using interventional (neuro) radiology. The head vessel is reached from the inside via an access in the inguinal artery. Then platinum coils are placed in the aneurysm. Today, this minimally invasive method can be used in around 60 to 80 percent of aneurysms. Other types of cerebral haemorrhage only require surgery if there is a risk of excessive pressure in the brain.If a severe narrowing of the carotid artery is found to be the cause of a TIA or an ischemic stroke, the narrowing is either surgically or endovascularly (within the vessel) removed within the next few days.

General therapeutic measures for stroke

Basically, the following goals are pursued:

  • to limit the damaged brain area as much as possible,
  • To a large extent avoid complications and
  • start rehabilitation as early as possible.

These therapy goals require close monitoring of the vital functions (cardiovascular system, possibly intracranial pressure, breathing, kidney and brain function, body temperature, water-electrolyte balance, etc.) and the neurological status. Particular attention is paid to keeping the airways free and providing additional oxygen. Furthermore, the blood sugar is checked in order to avoid excess or hypoglycaemia. It is also important to check the body temperature on a regular basis, because a rise in temperature above 37.5 ° C can enlarge the infarct area and worsen the overall prognosis. Antipyretic drugs are given if necessary.

TIA must be treated

There are a number of treatment options that can help prevent another stroke in TIA. Medicines are used that inhibit the clumping of blood platelets (thrombocytes) - e.g. ASA (acetylsalicylic acid, contained in aspirin) or other platelet inhibitors. In TIA patients with cardiac arrhythmias, drugs with anticoagulant agents are used

Drug therapy and secondary prophylaxis

Which medication to use after a stroke is a very individual decision. It depends on various factors, such as:

  • what causes led to the stroke
  • whether the patient has diabetes and / or heart disease,
  • whether there are other underlying diseases.

The main focus of drug therapy is on blood pressure and sugar control as well as long-term blood thinning with medication. In principle, early secondary prophylaxis and the prevention and treatment of complications of acute stroke are closely linked. For more information, see Secondary Stroke Prophylaxis.

How are the costs going to be covered?

The treatment takes place in the hospital and is billed to the hospital costs that are covered by social insurance. Further medication treatment at home is carried out by prescription from the general practitioner or the specialist.

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