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Interventional Radiology; Revolutionizing Stroke Outcomes


A doctor is looking at CT and MRI scans to determine eligibility for stroke intervention in interventional radiology
Evaluation of Brain Imaging

Upon graduating from nursing school, stroke care primarily involved supportive measures. Our efforts were directed towards preventing aspiration, providing comfort, and allowing the stroke to progress naturally before dealing with the consequences through occupational therapy, physical therapy, and speech therapy. Ultimately, the major concern was determining how much brain tissue would be lost before the blockage cleared or new neural pathways developed.

 

We are fortunate to live in an era where stroke treatment is highly proactive. Modern medicine now uses swift interventions similar to the techniques utilized by cardio-interventionalists during a heart attack (myocardial infarction, or MI).

 

A significant aspect of this transformation is the expansion and innovation within Interventional Radiology (IR). This remarkable medical specialty employs minimally invasive methods to access veins and arteries in the body, enabling a wide range of procedures that can enhance and save a patient's life. 

 

Thrombectomy is now available for specific stroke patients. Before discussing stroke treatments, let's briefly chat about the two different types of strokes that patients may experience.

 

Types of Stroke

  1. Ischemic Stroke - This is the most prevalent form of stroke, accounting for approximately 87% of all cases. Ischemic refers to the death of tissue, which happens when blood flow is obstructed and cannot reach the affected tissues or cells. Without blood flow, any part of the body will experience tissue atrophy and death. An ischemic stroke results in the death of brain tissue in a specific area, and this tissue cannot be regenerated.

  2. Hemorrhagic Stroke - Hemorrhage is our fancy medical term for bleeding. This occurs when a blood vessel, whether venous or arterial, bursts. In a hemorrhagic stroke, there is no blockage; instead, there is a rupture that prevents blood from reaching essential tissues and can lead to increased pressure on the brain.

IR is more commonly used in ischemic stroke- but also can be a player for hemorrhagic stroke. 

 

Eligibility for Intervention

The neurologist will evaluate the patient's eligibility for an interventional procedure, specifically a mechanical thrombectomy (MT), which involves the physical removal of the clot. This evaluation is contingent upon the location of the clot within the brain's arteries.

 

Time is brain.  This is a well understood phrase in the world of medicine. The longer blood flow is obstructed or pooling, the less chance your tissue has of being fed and dying.  Unlike other tissues in the body, the brain is extremely sensitive and needs a continuous oxygen supply from the blood.

 

From Start to Finish

Now, let's walk through the entire process that occurs when a patient experiences a stroke, is deemed eligible for mechanical thrombectomy, and is subsequently admitted to an ICU bed after the interventional radiology (IR) procedure.

 

A patient arrives at the hospital exhibiting stroke symptoms.  A NIH Stroke Scale assessment is conducted, and the patient is taken to the CT scanner. The CT scan can be completed in about five minutes, and both the neurologist and radiologist are notified as soon as the scan is finished. The neurologist will review the scan to determine if the patient is a candidate for thrombectomy, which involves busting up the blockage with enzyme medication, as well as considering MT. 

 

There is a very small window  in which intravenous clot-busting medication can be administered—typically within 3 to 4.5 hours from the onset of symptoms.

 

Interventional radiology procedures may be performed up to 24 hours from symptom onset per provider discretion.  These procedures are minimally invasive, usually involving an incision the size of a pencil head, most often in the groin area.  A catheter is inserted and navigated to the site of the clot, which is when things really start to gets really cool.

 

There are several primary ways to get that clot out.  IV administration is the first-line treatment for ischemic stroke and should be administered regardless if mechanical thrombectomy is being considered for treatment or not.  Two common techniques are used to extract the clot: applying suction through catheter aspiration devices, or using a stent retriever to trap and pull the clot out.

 

 

Intravenous thrombolysis

 Alteplase (TPA)  and Tenecteplase (TNK) are recombinant tissue plasminogen activators.  These medications help convert plasminogen into plasmin, which then digests fibrin-the substance that acts like glue holding blood cells together.  Once the glue is dissolved, the clot is shaken loose, allowing the blood cells to be freed, subsequently allowing for normal blood flow.

 

The downside to this treatment is the increased risk of intracranial hemorrhage. For this reason, patients undergo thorough assessments before these medications are administered to ensure their safety.

 

Clot Extraction Devices

 Stent retrievers- These are flexible mesh devices that open up at the site of the clot.  The device will be placed in the middle of the blood clot, where they expand like a cage around it. This allows the neurointerventional doctor to pull the clot out safely.

 

Catheter aspiration Devices- This is a device that is parked at the end of the clot, and when suction is applied, it helps to draw the clot into the catheter tube. The healthcare provider can then remove both the catheter and the clot.

 

Often these 2 methods are used in conjunction with each other for more effective treatment.

 

Care After the Procedure

Once the clot is removed, blood flows to the neglected area of the brain, and restores tissue health.  Often, a patient enters with full aphasia (not talking or difficulty talking), hemiplegia (one sided paralysis) and leave with only minor issues.  The neuro interventionalist will withdraw the catheter and either apply pressure to the groin puncture site until the  bleeding stops or place a closure device, which is like a patch over the artery access point. 

 

The patient must lay flat for at least two hours to minimize the risk of bleeding and is moved to the ICU for neuro monitoring.  Depending on the medications given and the individual needs of the patient, some may also be placed on IV drips to manage blood pressure for optimal blood flow to the brain.

 

Patients will be placed on blood-thinning medications, such as IV heparin, which will be managed based on the procedures performed, whether stents were placed, and the individual patient's needs.

 

The risk of complications is extremely low. Infection risks are minimal due to the small incision made to access the artery. Additionally, bleeding risks are low for the same reason.  Pain is also minimal .

 

Outcomes to Write Home About

The outcomes for interventional procedures for strokes are off the charts.  Patients who are candidates for and undergo stroke intervention are significantly more likely to regain their independence and experience less cognitive impairment. Additionally, the length of hospital stays is much shorter.

 

Interventional Radiology is on the cutting edge of stroke treatment- what they offer is fast. It provides fast, safe, minimally invasive, and effective options for managing strokes. Just another reason that Interventional Radiology has swagger and is the coolest place in the hospital. 

 

Early Recognition of Stroke

So what is your part to play in this? Well, early recognition of stroke symptom is key! Noting that a patient is having a stroke and getting them to a health care facility is key to having good outcomes post stroke. 

 

Signs of a Stroke- Just remember FAST:

F: Face drooping or weakness on one side of the face

A: Arm weakness or numbness in one arm or leg

S: Speech difficulty or slurring

T: Time to call 911 immediately

 

 

References

 

 
 
 

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