As we have talked about in class, there are two types of stroke: hemorrhagic and ischemic. Hemorrhagic is a massive bleed in the brain while ischemic is from a clot blocking off a vessel so that there is lack of oxygenation of an area of brain tissue. When someone comes to the emergency department with symptoms like unilateral weakness, facial asymmetry, and/or slurred speech; one of the first thoughts is stroke. A head CT is ordered as emergent and neurology is at bedside almost immediately, every now and then they beat the patient to the room. If it is determined that it is an ischemic stroke and is within 6 hours of known symptom onset, among other qualification such as medical history, the patient could be eligible for TPA, Tissue Plasminogen Activator.
TPA is an IV anti-coagulant that is given to dissolve the clot and thus allow blood flow to return to that area of the brain. Maximum efficient of the drug is noted if it is given as close to the onset of symptoms as possible. One of the most crucial factors for stroke is time. If you wait too long, there can be other cellular damage from the clot that would make the return of blood flow to that area, with the use of TPA, very dangerous and could cause potential bleeding in the cranium/brain (depends where the clot is located). The biggest concern with the medication is internal bleeding. Because of how potent the drug is, there is a very specific dosage a patient can received based on the person's weight and prior medications. If a patient is already taking blood thinners, such as Coumadin, it would be highly risky to give them the same dosage as someone who is not taking a blood thinner. Other side effects are fever and low blood pressure. Personally, while in the ED I have only seen TPA given 1-2 times over the past 2 years. It is very difficult to meet all the qualifications to be eligible to receive TPA.
If TPA is administered, as requested usually by the neurologist that is at bedside, the patient is admitted and is VERY carefully monitored with repeat INR (international normalization ratio), clotting measurement lab study, to make sure it decreases correctly over time. a CBC, complete blood count will also be frequently rechecked to monitor hemoglobin and hematocrit levels. They will also check leukocyte counts with the CBC to check for underlying infections as well.
"Tissue Plasminogen Activator (t-PA) for Stroke." WebMD. WebMD, n.d. Web. 03 Oct. 2014. <http://www.webmd.com/stroke/tissue-plasminogen-activator-t-pa-for-stroke>.
***other information came from talking with TMC neurologists and ED physicians on patient stroke (neuro-red) cases***
TPA is one of the few treatments used in the case of ischemic stroke, but this is an active area of research at the moment. I am lucky enough to work as a Research Associate at UAMC and they are involved in multiple clinical trials for new stroke treatments. These seem to involve interventions which may improve outcomes but are targeting not the clot itself - for example, intracranial pressure or blood glucose levels. It will be interesting to see if controlling these secondary issues will be able to improve outcomes significantly, but at the moment re-perfusion is the gospel for TIA and stroke treatment.
ReplyDeleteTime is of the essence, especially when it comes to stroke. I feel most people know that stroke can cause death, but what they may not realize is that if it takes too long for an individual to be treated, disability is also a possible consequence. Stroke is a life changer. According to the CDC, stroke is the number one cause of “serious long-term disability”. Also, people who already have had a stroke are more likely to suffer from another.
ReplyDeleteI think what even more people don’t realize is that stroke can happen at any age, even though increased age is a risk factor. I have a friend who underwent a hemorrhagic stroke at the age of 23. It was a normal day, she was seated, and she was in Flagstaff with family getting ready to ski. Thankfully her family knew what to do because they read up on issues such as stroke. They sought help to get her to the hospital quickly. Her parents made sure she had the best care they could get her in Tucson. I was interested in the remark you made, Alison, about the neurologist sometimes beating the patients to their room. That kind of response is really necessary. The doctor found out the cause of the stroke was a tumor, and she went into surgery. What is also amazing is she was showing no other symptoms from her tumor, other than her stroke, so it was almost a blessing that she was able to have that sign so the tumor could get removed. Three years later she is mostly independent and is able to move in ways the doctors told her she never would.
What I take from this is that none of us should think we are invincible because of age or other factors. A stroke can hit anyone, and we need to be conscious and accepting of this so we are able and ready to respond in an appropriate time to increase the chances of life and recovery after stroke.
For more information about my friend’s story, I have the link to her blog posted below:
http://upstairsstories.blogspot.com/
I actually realized it was the AHA, not the CDC, that stated stroke is the leading cause of disability in adults. The CDC was referencing the AHA. My mistake, sorry.
DeleteThat's great! There are unfortunately those kinds of exceptions (age), but it's great that they did find the tumor and were able to help her.
ReplyDeleteHey Alison, I was unaware of TPA treatment for stroke, I really wish had known what I know now 3 years ago when my grandfather suffered his stroke which has limited his left side's motor abilities completely. Perhaps he wouldn't have been eligible for TPA, but he didn't receive any kind of treatment for at least a day. Daily physical therapy has not improved the situation almost at all. I hope information gets out there, so more cases like my grandfather's can be prevented.
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