Sunday, June 24, 2012

Jan's Journal Part 2 - Stroke Diagnosis and Treatment

by Jan Jahnel

Jan Jahnel RN, CNRN is the Stroke Nurse Coordinator for the INI Stroke Center and INI Stroke Network at OSF Saint Francis Medical Center in Peoria, Illinois. Jan has 14 years of neuroscience nursing experience with the last five years focusing on stroke processes and care. Her commitment and dedication has been an important part of Stroke Camp. She works very closely with Retreat and Refresh Stroke Camp, attending many weekend camps, helping with some of our fund raisers, and providing us with technical knowledge about strokes. 

                                       Stroke Diagnosis

The diagnosis we're covering here is that which comes after the stroke survivor has entered the hospital. I am assuming you already know the F.A.S.T. and the "Give Me 5" method from Part 1 for telling if someone is experiencing a stroke and that you have rushed immediately to the hospital within three hours of the first symptom. 

Once in the hospital, it is critical for the medical personnel on site to diagnose the stroke in progress. Timing is very important. 

                     Time lost is brain lost!! 

That is why timing is so important. Time lost is brain lost.  It is important to quickly recognize, diagnose and treat the stroke while it is happening.

                       Types of Diagnosis

* CT-or Cat scan is a key test. It is usually the first test given to
   patients with stroke symptoms. Determines whether there is
   bleeding in the brain. 

* Angiography- groin area puncture with dye injected into the 
   vessels. This gives a picture of the blood flow to the brain. It will 
    show size, location of blockage, aneurysms and malformed    
    blood vessels.

* Carotid doppler- this is an ultrasound of the neck vessels to 
   assess for narrowing of the neck vessels. 

* Echocardiogram- ultrasound of the heart assessing for

   problems with the heart or poor pumping action. 

* MRI –like the cat scan it produces an image of the brain. This 
   image is used to diagnose small deep injuries. 

* Lab work-up – This helps determine other possible causes for 

   ischemic strokes. 

                                   Acute Stroke Treatment

MERCI device- FDA approved device: catheter with a small corkscrew device that grabs the clot. The Merci device is a catheter that is threaded up through the vessel to the clot.  Then a small corkscrew device is threaded through the catheter and into the blood clot.  The corkscrew device and the clot are then pulled back into the catheter and out of the blood stream

Penumbra device- FDA approved device: a catheter with a separator and a vacuum that separates the clot into small pieces that are then vacuumed into the catheter. 

Intra-arterial t-PA: t-PA is injected directly at the site of the clot. This also involves taking the person to have an angiography.  The catheter is threaded up to the clot site and the medicine is injected directly at the clot.

The only FDA approved acute drug treatment for an ischemic stroke is IV t-pa (ischemic stroke are those strokes caused from a blocked vessel). Time is also important for determining treatment for strokes. This drug must be given within 180 minutes of symptom onset.  Symptom onset is the last known time the person was “normal”. This means the person must get to the hospital, obtain a CT scan and have the medication available. Strict guidelines are used to decide if a patient qualifies for this treatment. Many factors may disqualify a patient from receiving this treatment. It cannot be given to everyone, especially for hemorrhagic strokes, (those strokes caused from bleeding into the brain.) Complications with IV t-pa include hemorrhage in the brain so patients receiving IV t-pa will be in the ICU for at least 24 hours with hourly assessments.

                        Treatment for Hemorrhagic Strokes 

Intracerebral hemorrhage-There is no approved acute drug treatment for a hemorrhage in the brain.  The doctors will want to keep the blood pressure controlled and not let it get too high.  They may administer blood products such as plasma or platelets to help the blood clot especially for those on any type of blood thinners. Surgery or catheters (Ventriculostomy) may be used to drain or remove fluid and blood from the brain.

                                                   Aneurysm Treatment

There are two types of treatment available for strokes caused by an aneurysm rupture; 


Endovascular Coiling - A tiny catheter is threaded from the groin artery up into the brain artery and into the aneurysm. Tiny platinum coils are released into the aneurysm to seal it off. Endovascular treatment originated in the 1980’s by an Italian physician Dr. Gugleilmi.  With the origination of this new treatment some patients who were told the aneurysm was inoperable now have hope for a treatment. Other patients because of advanced age, medical condition, or other factors who could not tolerate open brain surgery this could be an alternative to their treatment.
Clipping - Surgical Clipping is still the most common surgical treatment for brain aneurysms.
This requires general anesthesia, incision into the skull and removal of a section of bone.
Under a microscope the aneurysm is carefully separated from the normal blood vessel, it is then clipped with a tiny clip somewhat like a clothespin. With the clip in place no more blood can enter the aneurysm.

That's it for Part 2. I hope this was not too technical, but I did find it interesting and thought it was worth passing on to you. Next, in Part 3, I'll cover what the stroke survivor can expect from the Brain Attack and what will happen after being admitted to the hospital.

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