Ischemic strokes account for about 85% of all stroke types and are caused by a blockage of blood flow in an artery leading to brain tissue. When the blockage occurs, the brain tissue that is not getting enough blood flow will start to become permanently injured. Restoring blood flow to brain tissue at risk of injury is the first priority in an ischemic stroke. The first treatment to try and open the vessel is the use of medication to break the clot up. This medication is called intravenous recombinant tissue-type plasminogen activator (r-tPA) or alteplase. The earlier this medication is administered the more likely it can open the vessel before there is permanent brain tissue loss.
In some cases, the blockage may not be opened up with the use of tPA (alteplase) alone. Many strokes occur as the result of blockage of a large artery and there is more brain tissue at risk of injury. In these types of stroke, the symptoms are likely to be the even more severe. For some patients that have a large vessel occlusion, a second line therapy must be considered. This is called mechanical endovascular reperfusion therapy.
As in the use of intravenous tPA, mechanical endovascular reperfusion therapy must be provided as early as possible to provide the most benefit to those who are suffering an ischemic stroke.
An acute ischemic stroke occurs when a blood clot blocks an artery that brings blood to the brain. Deprived of oxygen and nutrients the brain cells start to die at a rate of two million neurons per minute, increasing the risk permanent brain damage, disability or death. Recognizing stroke symptoms and acting fast to get medical attention can save a life and minimize disability.
During a mechanical thrombectomy, a small catheter (small plastic tube) is placed into a vessel over the wrist or hip. Using X-ray guidance additional catheters are advanced through the blood vessels of the body to the blocked vessels of the head. Once the catheters are advanced to the blockage, either a special stent is used to remove the clot or a technique called ADAPT is used to remove the clot using aspiration (or vacuum). Doctors at Prisma Health-Upstate were the pioneers of this technique which has been shown to be just as effective as a stent but safer, faster and less expensive. The goal is to remove the clot and restore blood flow to the affected part of the brain.
After the procedure, patients usually spend a couple of days in the neurocritical care unit and then in a step-down unit and, if needed, rehabilitation. Mechanical thrombectomy is considered to be a breakthrough in stroke treatment. Removing the blood clots from the brain leads to better outcomes for stroke patients, including greater independence and mobility.
A hemorrhagic stroke occurs when there is bleeding in the brain. This bleeding maybe into the substance of the brain called an intracerebral hemorrhage or into the spaces around the brain called a subarachnoid hemorrhage. Both of these can be treated with minimally invasive methods.
A subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM. An aneurysm is a weak spot on a blood vessel and looks like a sac or a ballooning out from the vessel wall. An AVM (arteriovenous malformation) is an abnormal tangle of vessels with high flow from the arteries to the veins. Both can be treated by traditional open surgery where an incision is made in the skin, a small window is made in the skull by removing part of the bone and then either an aneurysm clip is placed across the aneurysm neck, or the AVM is removed. However, newer, minimally invasive methods have been shown to be equally effective and better tolerated by patients. An aneurysm can be treated by a number of different minimally invasive techniques:
There are three major treatment methods that may be useful either alone or in combination to treat an AVM. The specific treatment for an individual is based on the patient’s history, symptoms, and anatomy of the AVM including its size, feeding arteries, draining veins, and location within the brain. Treatments include: endovascular embolization (closure of the AVM from within the blood vessels), open surgical removal of the AVM, radiosurgery or a combination of techniques.
Intracerebral hemorrhage (ICH)
An intracerebral hemorrhage is bleeding in the brain. This is most commonly caused by uncontrolled hypertension.
Intracerebral hemorrhage treatment
When small, ICH can be managed medically. However large bleeds (hematoma) compress vital structures of the brain and the blood itself is toxic to the brain. These large may need to be removed surgically. Your doctors at Prisma Health-Upstate may elect to perform a minimally invasive procedure to remove the hematoma. Studies shows that if you can remove the hemorrhage in a minimally invasive manner, the patients will leave the hospital sooner and achieve a better outcome. The team at Prisma Health-Upstate were early pioneers of this surgery and have the one of the highest experiences with this surgery in the US. Due to this expertise, they have access to the latest FDA approved devices and are currently one of only a handful of hospitals in the country that have the latest technology to treat this disease.
These procedures are performed through a small dime sized-hole in the skull. Using image guidance, small camera is used to see as the bleed is controlled and the blood clot is removed.
Idiopathic Intracranial Hypertension
Idiopathic intracranial hypertension (IIH) also known as pseudotumor cerebrii or benign intracranial hypertension is a disease that most commonly affects obese females in their 40s. Patients commonly present with frequent headaches, visual changes (blurred vision, double vision) and occasionally ringing in their ears. Left untreated visual changes may progress to blindness. These symptoms are due to raised intracranial pressure. Treatment revolves around reducing the pressure of the CSF (the fluid that covers the brain).
Treatment for IIH:
What are congenital vascular anomalies?
The congenital vascular anomalies can essentially be divided into two groups: tumors and malformations. Tumors are characterized by cellular growth and these lesions can grow at a rapid pace. The malformations however do not grow, per se, but grow in conjunction with the growth of the child.
Venous Vascular Malformations
What are Hemangiomas?
Hemangiomas are the most common benign tumor of infancy and occur in up to 10% of Caucasian infants and are 3-5 times more common in females. The majority of hemangiomas occur in the head and neck area. Less than 25% occur in the trunk and 15% occur in the arm or legs. Hemangiomas while most commonly grow on the skin, can grow on any internal organ such as the liver, gastrointestinal tract, lung and even the brain.
Hemangiomas are usually first noticed shortly after birth. Rarely, they can be present at birth. Hemangiomas have a classic rapid period of growth (proliferative phase) followed by a period of regression (imvolution phase). Large hemangiomas and hemangiomas that have not regressed should be treated.
What do hemangiomas look like?
Hemangiomas vary from small raised redish lesions to large firm masses.
What is a congenital vascular malformation?
Vascular malformations are benign lesions of the lymphatics, arteries and veins. All vascular malformations are present at birth although they may not be visible. Vascular malformations, unlike hemangiomas, do not have a rapid period of growth but grow slowly though out life, growing in conjunction with the growth of the child. The most common types of vascular malformations are:
How are hemangiomas and vascular malformations different?
All vascular malformations are present at birth while most hemangiomas appear shortly after birth. Hemangiomas have a period of rapid growth (over months) and then regress (over years), while vascular malformations grow slowly and never disappear. Vascular malformations can experience periods of rapid growth during times of infection and hormonal change (puberty and pregnancy).
How are Hemangiomas and vascular anomalies treated?
The majority of small hemangiomas disappear on their own; most small hemangiomas can be treated conservatively, that is with careful observation. Large hemangiomas or hemangiomas in cosmetically sensitive locations that are disfiguring or those that hinder important functions such as vision or breathing should be evaluated by a vascular anomalies specialist. Treatment may consist of medical therapy with propranalol, surgery, embolization or sclerotherapy.
Treatment of the vascular anomalies depends on the type. Laser therapy can be used to treat capillary malformations. Arteriovenous malformations are treated with embolization while lymphatic malformations and venous malformations can be treated with sclerotherapy.
What is sclerotherapy?
Sclerotherapy is a minimally invasive, image guided treatment used to treat certain types of vascular anomalies. It involves injecting a special material, called a sclerosant, directly into a vascular anomaly in order to bring about scarring.
Who treats hemangiomas and congenital vascular anomalies?
Hemangiomas are can be treated by pediatricians, pediatric ENT, dermatologists, plastic surgery and radiology.