A UVA Heart & Vascular Center Initiative

New Recommendations for Stroke Treatment

Posted April 15, 2015

Stroke is an emergency situation. Thus, the closest hospital may be your best option. However, if you have a choice, there’s now even more evidence that you should select a hospital that offers the full spectrum of stroke treatments, including endovascular thrombectomy or minimally invasive clot removal.

Based on the results of four multi-center clinical trials, this minimally invasive procedure has been shown to improve survival and lower the risk of lasting disability in select patients experiencing ischemic stroke (the most common form of stroke caused by the blockage of blood flow to the brain).

For the past decade, the first line of treatment for ischemic stroke has been the injection of a clot-dissolving medication called tissue plasminogen activator (tPA). While effective in dissolving clots in some patients, tPA is not effective in all cases. For those with clots blocking the large vessels of the brain, it has now been confirmed that outcomes improve when clots are removed under X-ray guidance with special devices designed to ensnare the clot.

Two studies published in the New England Journal of Medicine revealed that the incidence of death was cut in half in those ischemic stroke patients undergoing endovascular thrombectomy. These patients were also much more likely to return to normal activities and maintain their independence (71 percent compared to 40 percent of those who were treated with tPA alone in one study, and 53 percent versus 29 percent in another study).

Stents for the Brain 

Many clot removal methods have been evaluated over the years. One of the reasons endovascular thrombectomy is now proving safer and more effective is due to the continued evolution of devices called stent retrievers, according to UVA interventional neuroradiologist Mary Jensen, MD. 

Similar to the stents used to open clogged arteries in the heart, the stents used to remove clots in the brain are mesh cages that are threaded through a leg artery up to the blockage in the brain. However, unlike those used in the heart, the stents used in stroke treatment do not remain in the body. Instead, they are used to trap and contain the clot, and then are removed.

Candidates for Clot Removal 

Endovascular thrombectomy is recommended for those patients with an emergency large vessel occlusion (ELVO) or blockage. “It is not recommended for those with clots in the smaller vessels of the brain,” says UVA endovascular neurosurgeon R. Webster Crowley, MD. Distinguishing between these two categories of stroke patients — those who would benefit from clot removal and those who require only tPA — will be one of the hurdles stroke neurologists and neurointerventionalists face as they work to implement this new treatment strategy.

Timing Is Everything 

To be most effective, the average timeframe for a patient to qualify for endovascular thrombectomy is approximately six hours from the onset of symptoms. For tPA, that window is four-and-a-half hours or less. “This does not mean a patient has four to six hours to seek treatment,” stresses Jensen. Stroke symptoms should be treated as an emergency.

In every instance of stroke, the sooner a patient receives treatment the better the outcome. Neurologists often use the phrase “time equals brain,” which emphasizes that every minute the brain is devoid of blood flow, the greater the damage. So do not wait to see if symptoms resolve on their own. If you or a loved one is showing any signs of stroke — drooping face, arm weakness, slurred speech, vision loss — seek help immediately.

The Choice In Stroke Treatment 

UVA is a certified Primary Stroke Center designated by the Joint Commission, American Heart Association and American Stroke Association. It not only offers all current recommended stroke treatments, but also has the protocols in place to do so quickly and safely.

The UVA acute stroke team includes stroke neurologists, interventional neuroradiologists, neurosurgeons and emergency department doctors all on call to provide advanced care when stroke happens. Plus, there is an entire network of specially trained support staff, including nurses and therapists, who can respond to the unique needs of stroke patients.

Learn more about the UVA Stroke Center.