Surgery to remove blood clots

A hematoma is a collection of blood (the blood can be clotted or mostly

clotted) found in the brain after a hemorrhagic (bleeding) stroke. Because
there is not much extra room in the skull, a hematoma can dangerously
increase pressure on the brain, causing more brain damage. Surgery may
be needed to remove the hematoma and relieve the pressure on the
brain.
Surgery to repair blood vessels
Some hemorrhagic (bleeding) strokes are caused by a burst or ruptured
blood vessel in the brain. The two common types of ruptures are
aneurysms (a weak spot in the wall of the blood vessel) and arteriovenous
malformation (AVM), an area where the blood vessels have thin walls and
are prone to leaking or breaking. In some cases, surgery may be needed
to repair the ruptured blood vessels. Non-surgical procedures are also
sometimes an option to repair these ruptures.
Surgery to remove plaque from the carotid artery
When the carotid artery in the neck is partially blocked by plaque (the
buildup of fatty materials, calcium and scar tissue that narrows the
artery), surgery called carotid endarterectomy might be used to remove
the plaque. The procedure helps prevent a first stroke or reduces the risk
of a second or third stroke. It works best for people whose artery is
narrowed but not completely blocked.
The risks of this surgery include stroke, heart attack and, rarely, a brain
hemorrhage caused by the surge of blood released by the surgery. People
with high blood pressure are at greater risk of a hemorrhage. Carotid
endarterectomy is usually recommended for people who have had a TIA
(transient ischemic attack or mini stroke) or stroke, have severe blockage
of the carotid artery or are likely to recover well from surgery.

Non-surgical procedures
These procedures use a thin, narrow, flexible tube called a catheter, which
is inserted into the body, usually in the groin, and threaded through the
blood vessels to the carotid arteries in the neck.

Carotid angioplasty and stenting

This is a newer type of procedure that is similar to angioplasty and
stenting often done in the coronary arteries of the heart. The procedure
involves using a balloon-like device to open a clogged artery. Then, a
small metal stent is put in place to help keep the artery open.
Coiling aneurysms
Aneurysms are weak spots in the walls of blood vessels that can rupture
and cause bleeding (hemorrhage) in the brain. If an aneurysm ruptures
(causing a subarachnoid hemorrhage), immediate surgery may be
required. If an aneurysm has not ruptured, it can sometimes be treated by
filling the blood vessel with tiny flexible coils made of platinum. This
procedure can only be performed if the aneurysm has not yet ruptured
and the patient has an appropriate neck size. The coils are put into place
by a catheter that is threaded through the blood vessels.
ypes of surgery
After receiving emergency care, some stroke patients may be helped by surgery.

For Strokes from Blockage

Most strokes occur when a blood vessel in the brain is blocked and blood flow stops. This type of stroke is called
an ischemic (iss-KEYmik) stroke. The blockage may be caused by a blood clot, and severe brain swelling may
result. Life-saving surgery may be necessary to remove the clot and the brain tissue that has died from lack of
oxygen.
A blockage also can occur when the artery itself narrows. A harmful fatty deposit, called plaque (PLAK), may
build up in an artery and then block it. Sometimes clots form, which can then break off and travel to block another
artery in the brain. Some patients can be helped by a procedure called angioplasty (AN-jee-oh-plass-tee). During
the procedure, a tiny balloon at the end of a long, thin tube is pushed through the artery to the blockage. When
the balloon is inflated, it opens the artery. In addition, a mesh tube may be placed inside the artery to help hold it
open. The tube is called a stent. The procedure usually requires a hospital stay of several days.
For Blockage in the Neck
The main arteries in the neck help supply the brain with blood. They are called the carotid (kuh-RAW-tid) arteries.
When patients have a serious blockage in these arteries, surgery may be done to prevent a stroke or a
ministroke, which is also called a TIA. The operation is called a carotid endarterectomy (en-dar-ter-EK-tuh-mee).
This procedure cleans out and opens up the narrowed artery. During the operation, the surgeon scrapes away
plaque from the wall of the artery. Blood can then flow freely through the artery to the brain. A patient usually
stays in the hospital 2 to 3 days for this operation.

For Strokes from Altered Blood Flow

Blood flow to the brain may decrease temporarily in some patients. This is called a ministroke
or a TIA, which stands for transient (TRANS-yent) ischemic (iss-KEY-mik) attack. While the brain is not getting
enough blood, it cannot work properly. Patients who have TIAs get symptoms for a short time that make it difficult
for them to function.
Bypass surgery may be advised for some patients who continue to have TIAs. During the operation, an artery on
the outside of the scalp is re-routed to the part of the brain that is not getting enough blood flow. When blood flow
is restored, the brain works normally, and the symptoms disappear. The hospital stay for this type of bypass
surgery is about one week.
For Strokes from Bleeding
Bleeding in the brain causes some strokes. These strokes are called hemorrhagic (HEMer-RAJ-ik). The bleeding
may occur when a weakened blood vessel leaks or bursts. This is called an aneurysm (AN-your-izm). When an
aneurysm occurs, the weakened artery may become like a balloon filled with blood. Patients usually describe an
aneurysm as the worst headache of their life.
There are several types of surgery to repair an aneurysm. A clip may be placed across the
neck of the aneurysm (like a clip at the end of a balloon) to stop the bleeding. A newer approach
is to thread a long, thin tube through the artery that leads to the aneurysm. Then a tiny coil is fed through the tube
into the aneurysm balloon to fill the space and seal off the bleeding. Based on the type of surgery, the hospital
stay ranges from several days to a week or longer.

Carotid Endarterectomy
Carotid endarterectomy, also called carotid artery surgery, is a procedure in which blood vessel
blockage (fatty plaque) is surgically removed from the carotid artery.
View a detailed illustration of carotid endarterectomy (opens in new window).

Angioplasty/Stents
Doctors sometimes use balloon angioplasty and implantable steel screens called stents to treat
cardiovascular disease and help open up the blocked blood vessel.

When a Stroke Occurs: Quick Stroke Treatment Can Save Lives

If youre having a stroke, its critical that you get medical attention right away. Immediate treatment may minimize
the long-term effects of a stroke and prevent death.
There are two types of strokes: hemorrhagic or ischemic. An ischemic stroke occurs as a result of an obstruction
within a blood vessel supplying blood to the brain. It accounts for 87 percent of all stroke cases. A hemorrhagic
stroke occurs when a weakened blood vessel ruptures and spills blood into brain tissue. The most common
cause for the rupture is uncontrolled hypertension (high blood pressure). There are two other types of weakened
blood vessels that also cause hemorrhagic stroke: aneurysms and arteriovenous malformations (AVMs).
Treatment differs depending on the type of stroke.
Ischemic Stroke Treatment
tPA, the Gold Standard

The only FDA approved treatment for ischemic strokes

is tissue plasminogen activator (tPA, also known as IV
rtPA, given through an IV in the arm). tPA works by
dissolving the clot and improving blood flow to the part
of the brain being deprived of blood flow. If
administered within 3 hours(and up to 4.5 hours in
certain eligible patients), tPA may improve the chances
of recovering from a stroke. A significant number of
stroke victims dont get to the hospital in time for tPA
treatment; this is why its so important to identify a
stroke immediately.
Endovascular Procedures
Another treatment option is an endovascular
procedure* called mechanical thrombectomy, strongly
recommended, in which trained doctors try removing a
large blood clot by sending a wired-caged device
called a stent retriever, to the site of the blocked blood
vessel in the brain. To remove the brain clot, doctors
thread a catheter through an artery in the groin up to
the blocked artery in the brain. The stent opens and
Stent retrieving device used to remove large clots*
grabs the clot, allowing doctors to remove the stent with
the trapped clot. Special suction tubes may also be
used. The procedure should be done within six hours of acute stroke symptoms, and only after a patient receives
tPA.
*Note: Patients must meet certain criteria to be eligible for this procedure.
Image courtesy of Medtronic
Hemorrhagic Stroke Treatment
Endovascular Procedures
Endovascular procedures may be used to treat certain hemorrhagic strokes similar to the way the procedure is
used for treating an ischemic stroke. These procedures are less invasive than surgical treatments, and involve
the use of a catheter introduced through a major artery in the leg or arm, then guided to the aneurysm or AVM; it
then deposits a mechanical agent, such as a coil, to prevent rupture.
Surgical Treatment
For strokes caused by a bleed within the brain (hemorrhagic stroke), or by an abnormal tangle of blood vessels
(AVM), surgical treatment may be done to stop the bleeding. If the bleed is caused by a ruptured aneurysm
(swelling of the vessel that breaks), a metal clip may be placed surgically at the base of the aneurysm to secure
it.

Surgery
When surgery is being considered after a stroke, your age, prior overall health, and
current condition are major factors in the decision.

Surgery for ischemic stroke

If you have serious blockage in the carotid arteries in your neck, you may need
a carotid endarterectomy. During this surgery, a surgeon removes plaque buildup in

the carotid arteries. The benefits and risks of this surgery must be carefully weighed,
because the surgery itself may cause a stroke.
Stroke Prevention: Should I Have a Carotid Artery Procedure?

Surgery for hemorrhagic stroke

Treatment for hemorrhagic stroke may include surgery to:

Drain or remove blood that is in or around the brain.

Repair a brain aneurysm.

In an endovascular embolization, soft metal coils or mesh is inserted into

the aneurysm to block it off and stop or prevent bleeding.

In a craniotomy, a small metal clip is placed around the base of the aneurysm

to block it off. This stops the bleeding in the brain.

Remove or block off abnormally formed blood vessels (arteriovenous

malformation) that have caused bleeding in the brain.

Stroke

Stroke is an abrupt interruption of constant blood flow to the

brain that causes loss of neurological function. The
interruption of blood flow can be caused by a blockage,
leading to the more common ischemic stroke, or by bleeding
in the brain, leading to the more deadly hemorrhagic stroke.
Ischemic stroke constitutes an estimated 87 percent of all
stroke cases. Stroke often occurs with little or no warning,
and the results can be devastating.
It is crucial that proper blood flow and oxygen be restored to
the brain as soon as possible. Without oxygen and important
nutrients, the affected brain cells are either damaged or die
within a few minutes. Once brain cells die, they generally do
not regenerate, and devastating damage may occur,
sometimes resulting in physical, cognitive, and mental
disabilities.
Ischemic Stroke

Thrombotic (cerebral thrombosis) is the most common type of ischemic

stroke. A blood clot forms inside a diseased or damaged artery in the brain resulting
from atherosclerosis (cholesterol-containing deposits called plaque), blocking blood flow.
Embolic (cerebral embolism) is caused when a clot or a small piece of plaque
formed in one of the arteries leading to the brain or in the heart, is pushed through the
bloodstream and lodges in narrower brain arteries. The blood supply is cut off from the
brain due to the clogged vessel.

Transient ischemic attack (TIA)

This is a warning sign of a possible future stroke, and is
treated as a neurological emergency. Common temporary
symptoms include difficulty speaking or understanding
others, loss or blurring of vision in one eye, and loss of
strength or numbness in an arm or leg. Usually these
symptoms resolve in less than 10 to 20 minutes, and almost
always within one hour. Even if all the symptoms resolve, it is
very important that anyone experiencing these symptoms
call 911 and immediately be evaluated by a qualified
physician.
Hemorrhagic Stroke

Subarachnoid Hemorrhage: bleeding that occurs in the space between the

surface of them brain and the skull. A common cause of subarachnoid hemorrhagic
stroke is a ruptured cerebral aneurysm, an area where a blood vessel in the brain
weakens, resulting in a bulging or ballooning out of part of the vessel wall; or the
rupture of an arteriovenous malformation, a tangle of abnormal and poorly formed blood
vessels (arteries and veins), with an innate propensity to bleed.
Intracerebral Hemorrhage: bleeding that occurs within the brain tissue. Many
intracerebral hemorrhages are due to changes in the arteries caused by long-term
hypertension. Other potential causes may be delineated through testing.

Stroke Statistics

Stroke is the third leading cause of death in the United States.

Statistics indicate that an estimated 135,592 people in the United States died
from cerebrovascular disease in 2007.
Of all strokes, 87 percent are ischemic, 10 percent are intracerebral hemorrhage,
and 3 percent are subarachnoid hemorrhage.
While the incidence has increased, there has been a steady decline in mortality
rates since 2002.
Of the more than 795,000 people affected every year, about 610,000 of these are
first attacks, and 185,000 are recurrent.
About 25 percent of people who recover from their first stroke will have another
stroke within five years.
Stroke is a leading cause of serious long-term disability, with an estimated 5.4
million stroke survivors currently alive today.
In 2010, stroke cost about $73.7 billion in both direct and indirect costs in the
United States alone.

Source: American Heart Association, Heart Disease and

Stroke Statistics - 2010 Update.
Risk Factors
Although they are more common in older adults, strokes can
occur at any age. Understanding the factors that increase
your risk of a stroke and recognizing the symptoms may help
you prevent a stroke. Receiving early diagnosis and
treatment may improve your chances for complete recovery.

Controllable or treatable risk factors for stroke include:

Smoking: You can decrease your risk by quitting smoking. Your risk may be
increased further if you use some forms of oral contraceptives and are a smoker. There is
recent evidence that long-term secondhand smoke exposure may increase your risk of
stroke.
High blood pressure: Blood pressure of 140/90 mm Hg or higher is the most
important risk factor for stroke. It usually has no specific symptoms and no early
warning signs. Thats why it is important to have your blood pressure checked regularly.
Controlling your blood pressure is crucial to stroke prevention.
Carotid or other artery disease: The carotid arteries in your neck supply blood to
your brain. A carotid artery narrowed by fatty deposits from atherosclerosis (plaque
buildups in artery walls) may become blocked by a blood clot. Carotid arteries are
treated by neurosurgeons through carotid endarterectomy, a procedure in which an
incision is made in the neck and plaque is removed from the artery; or carotid artery
angioplasty and stenting, an endovascular procedure that requires no surgical incision in
the neck.
History of TIAs: About 30 percent of strokes are preceded by one or more TIAs
that can occur days, weeks or even months before a stroke.
Diabetes: It is crucial to control your blood sugar levels, blood pressure, and
cholesterol levels. Diabetes, especially when untreated, puts you at greater risk of stroke
and has many other serious health implications.
High blood cholesterol: A high level of total cholesterol in the blood (240 mg/dL
or higher) is a major risk factor for heart disease, which raises your risk of stroke.
Recent studies show that high levels of LDL (bad) cholesterol (greater than 100 mg/dL)
and triglycerides(blood fats, 150 mg/dL or higher) increase the risk of stroke in people
with previous coronary heart disease, ischemic stroke or TIAs. Low levels (less than 40
mg/dL) of HDL (good) cholesterol also may increase stroke risk. You can often improve
your cholesterol levels by decreasing the salt and saturated fat in your diet. However,
some people inherit genes associated with elevated levels of cholesterol. Although they
may eat well and exercise, they still may have high cholesterol, and must take
medication to control it.
Physical inactivity and obesity: Being inactive, obese or both can increase your
risk of high blood pressure, high blood cholesterol, diabetes, heart disease and stroke.
Getting 30 minutes of moderate exercise, five days a week can help reduce your risk of
stroke. Check with your doctor first before starting any exercise program if you have any
health problems or have been inactive.
Recent research shows evidence that people receiving hormone replacement
therapy (HRT) have an overall 29 percent increased risk of stroke, in particular ischemic
stroke.

Uncontrollable risk factors include:

Age: People of all ages, including children, have strokes. But the older you are,
the greater your risk of stroke.
Gender: Stroke is more common in men than in women. In most age groups,
more men than women will have a stroke in a given year. However, women account for
more than half of all stroke deaths. Women who are pregnant have a higher stroke risk.
Some research has indicated that women may experience and interpret stroke
symptoms differently than men, causing them to delay seeking medical care, and
contributing to their higher stroke mortality rates.
Heredity and race: You have a greater risk of stroke if a parent, grandparent,
sister or brother has had a stroke. African Americans have more than two times the risk

of stroke compared to Caucasians, partly related to the prevalence of hypertension.

Hispanics also have an elevated stroke risk.
Prior stroke or heart attack: If you have had a stroke, you are at much higher risk
of having another one. If you have had a heart attack, you are also at higher risk of
having a stroke.

Stroke Symptoms
The range and severity of early stroke symptoms vary
considerably, but they share the common characteristic of
being sudden. Warning signs may include some or all of the
following symptoms:

Dizziness, nausea, or vomiting

Unusually severe headache
Confusion, disorientation or memory loss
Numbness, weakness in an arm, leg or the face, especially on one side
Abnormal or slurred speech
Difficulty with comprehension
Loss of vision or difficulty seeing
Loss of balance, coordination, or the ability to walk
It is especially important to note that many strokes may cause an utterly painless
loss of neurological function, leading to potential hesitation to call 911 or visit an
emergency room.

Stroke Effects
The effects of a stroke depend primarily on the location of
the obstruction and the extent of brain tissue affected. One
side of the brain controls the opposite side of the body, so a
stroke affecting the right side will result in neurological
complications on the left side of the body. A stroke on the
right side may result in the following:

Paralysis on the left side of the body

Vision problems
Quick, inquisitive or purposeless behavior
Memory loss

A stroke on the left side may result in the following:

Paralysis on the right side of the body

Speech/language problems
Slow, cautious behavior
Memory loss

Stroke Treatment
Rehabilitation following a stroke may involve a number of
medical specialists; but the early diagnosis of a stroke, its
treatment or its prevention, can be undertaken by a
neurosurgeon. Rapid and accurate diagnosis of the kind of
stroke and the exact location of its damage is critical to
successful treatment. Such technical advances as digital
imaging, microcatheters and other neurointerventional

technologies, the use of the operating microscope

(microsurgery) and the surgical laser have made it possible
to treat stroke problems that were inoperable a few years
ago.
Ischemic Stroke Treatment
Ischemic stroke is treated by removing obstruction and
restoring blood flow to the brain. The only FDA-approved
medication for ischemic stroke is tissue plasminogen
activator (tPA), which must be administered within a threehour window from the onset of symptoms to work best.
Unfortunately, only 3 to 5 percent of those who suffer a
stroke reach the hospital in time to be considered for this
treatment, and the actual use of tPA is considerably lower.
This medication carries a risk for increased intracranial
hemorrhage and is not used for hemorrhagic stroke.
Emergency Surgical Stroke Treatment:
Neurointerventional Procedures
Microcatheter-based surgical interventions for stroke have in
common the use of a small microcatheter, delivered through
a larger guiding catheter inserted at the groin through a
small incision. A microguidewire is used to navigate the
microcatheter to the site of obstruction in the brain.
Thrombolytic medication such as tPA can then be
administered directly to the occluding thrombus. This kind of
treatment, which delivers thrombolytic medication
intraarterially, is more specific than IV (intravenous) tPA, and
consequently may require significantly lesser dosages of
medication. The time limit to implement this type of
intervention is also significantly (double) longer than that for
IV TPA. Generally, only Comprehensive Stroke Care Centers
offer this type of treatment.
Clot Retrieval Devices
The Merci Retriever, approved in 2004 by the FDA, is a
corkscrew- shaped device used to help remove blood clots
from the arteries of stroke patients. A small incision is made
in the patients groin, into which a small catheter is fed until
it reaches the arteries in the neck. At the neck, a small
catheter inside the larger catheter is guided through the
arteries into the brain, until it reaches the brain clot. A

straight wire inside the small catheter pokes out beyond the
clot and automatically coils into a corkscrew shape. It is
pulled back into the clot, the corkscrew spinning and
grabbing the clot. A balloon inflates in the neck artery,
cutting off blood flow, so the device can pull the clot out of
the brain safely. The clot is removed through the catheter
with a syringe.
Penumbra is also a microcatheter-based system device,
which works by an aspiration principle. It was approved by
the FDA in 2008.
Stentriever devices are the newest generation of
embolectomy devices for stroke. They are still in an
investigative phase, but work by breaking up the occluding
clot, combined with aspiration or withdrawal.
Medical Prevention
Medications used to help prevent stroke in high-risk patients
(especially those who have experienced a previous TIA or
ischemic stroke) fall into two major categories;
anticoagulants and antiplatelet agents.
Anticoagulants thin the blood and prevent clotting. Heparin
acts quickly and is given intravenously (through a vein) or
subcutaneously (beneath the skin) while a patient is in the
hospital. Slower-acting warfarin can be given orally and is
used over a longer period. Because these drugs affect the
blood's ability to clot, they require close monitoring by a
physician.
Antiplatelet drugs prevent platelet aggregation. Platelets are
specialized cells in the blood that initiate a healing process.
Large numbers of platelets clump together to form a clot,
which can sometimes block an artery or break loose, travel
through the bloodstream, and block a smaller artery.
Antiplatelet drugs make platelets less sticky and less likely to
form clots, reducing the risk of ischemic stroke in patients
who have had TIA or prior ischemic stroke.
Preventive Surgical Procedures
Carotid Endarterectomy Surgery (Carotid
Endarterectomy, CEA)
Patients will be given either a general or local anesthetic
before surgery. In this procedure, the neurosurgeon makes

an incision in the carotid artery in the neck and removes the

plaque using a dissecting tool. Removing the plaque is
accomplished by widening the passageway, which helps to
restore normal blood flow. The artery will be repaired with
sutures or a graft. The entire procedure usually takes about
two hours. One may experience pain near the incision in the
neck and some difficulty swallowing during the first few days
after surgery. Most patients are able to go home after one or
two days, and return to work, usually within a month.
Patients should avoid driving and limit physical activities for a
few weeks after surgery.
There are potential complications with carotid
endarterectomy surgery, just as there are with any type of
surgery. There is a 1 to 3 percent risk of stroke following
surgery. Another fairly rare complication is the reblockage of
the carotid artery, called restenosis. This may occur later,
especially in cigarette smokers. Numbness in the face or
tongue caused by temporary nerve damage is a possibility,
but uncommon. This usually clears up in less than one month
and most often does not require any treatment.
Carotid Angioplasty and Stenting
An alternative, newer form of treatment, carotid angioplasty
and stenting (CAS), shows some promise in patients who
may be at too high risk to undergo surgery. Carotid stenting
is a neurointerventional procedure in which a tiny, slender
metal-mesh tube is fitted inside the carotid artery to increase
the flow of blood blocked by plaques. Access is gained
through a small (0.5 cm) groin incision and no incision is
made in the neck. The stent is inserted following a procedure
called angioplasty, in which the doctor guides a balloontipped catheter into the blocked artery. The balloon is
inflated and pressed against the plaque, flattening it and
reopening the artery. The stent acts as scaffolding to prevent
the artery from collapsing or from closing up again after the
procedure is completed.
There are several potential complications of endovascular
treatment. The most serious risk from carotid stenting is an
embolism, caused by a disrupted plaque particle breaking
free from the site. This can block an artery in the brain,

causing a stroke. These risks are minimized using small

filters called embolic protection devices in conjunction with
angioplasty and stenting. There is also a slight risk of stroke
due to a loose piece of plaque or a blood clot blocking an
artery during or right after surgery. The risks are balanced
against the advantages of a shorter occlusion time (10
seconds, as opposed to 30 minutes for endarterectomy),
shorter anesthesia, and a small leg incision.
Hyperperfusion, or the sudden increased blood flow through
a previously blocked carotid artery and into the arteries of
the brain can cause a hemorrhagic stroke. Other
complications include restenosis and short periods of
medically treatable reduced blood pressure and heart rate.
These risks are similar for CEA and CAS.
Hemorrhagic Stroke Treatment
Hemorrhagic stroke usually requires surgery to relieve
intracranial (within the skull) pressure caused by bleeding.
Surgical treatment for hemorrhagic stroke caused by an
aneurysm or defective blood vessel can prevent additional
strokes. Surgery may be performed to seal off the defective
blood vessel and redirect blood flow to other vessels that
supply blood to the same region of the brain.
For a patient with a ruptured cerebral aneurysm, surgical
elimination of the aneurysm is only the beginning. Intensive
care recovery for the next 10 to 14 days is the rule, during
which time a multitude of complications related to SAH can
and do occur. At some time during that period (often
immediately upon completion of surgery), cerebral
angiography or a substitute study is done to document that
the aneurysm has been eliminated. The first 2 to 5 days after
SAH represent the greatest threat of brain swelling; at which
time special measures (both medical and surgical) are used
to diminish the effect of swelling on intracranial pressure.
Near the end of this initial period, the risk period for delayed
cerebral vasospasm begins, and lasts the better part of the
next 14 days. Intercurrent infections such as pneumonia are
common, and hydrocephalus may develop.
Surgery/Clipping

Prior to surgery, the exact location of the subarachnoid

hemorrhage or aneursym is identified through cerebral
angiography images. An operation to "clip" the aneurysm is
performed by doing a craniotomy (opening the skull
surgically), and isolating the aneurysm from the normal
bloodstream. In addition, a craniectomy, a surgical procedure
in which part of the skull is removed and left off temporarily,
may be done to help relieve increased intracranial pressure.
One or more tiny titanium clips with spring mechanisms are
applied to the base of the aneurysm, allowing it to deflate.
The size and shape of the clips is selected based on the size
and location of the aneurysm. Clips are permanent, remain in
place, and generally provide a durable cure for the patient.
Angiography is used to confirm exclusion of the aneurysm
from the cerebral circulation and the preservation of normal
flow of blood in the brain.
Endovascular (Neurointerventional) Treatment
Neurointerventional procedures for cerebral aneurysm share
the advantages of no incision made in the skull, and an
anesthesia time that is often dramatically shorter than for
craniotomy and microsurgical clipping.
In endovascular microcoil embolization, a needle is placed
into the femoral artery of the leg, and a small catheter is
inserted. Utilizing x-ray guidance, the catheter is advanced
through the bodys arterial system to one of the four blood
vessels that feed the brain. A smaller microcatheter is fed
into the aneurysm, and once properly positioned, a thin wire
filament or "coil" is advanced into the aneurysm. The flexible,
platinum coil is designed to conform to the shape of the
aneurysm. Additional coils are advanced into the aneurysm
to close the aneurysm from the inside. This prevents flow of
blood into the aneurysm by causing a clot to form on the
inside.
Balloon-assisted coiling uses a tiny balloon catheter to help
hold the coil in place. Although this has been shown in
several studies to increase risks, ongoing innovations in this
relatively new technology has helped improve its efficacy.
Combination stent and coiling utilizes a small flexible
cylindrical mesh tube that provides a scaffold for the coiling.

Intracranial stenting and other innovations are quite new,

and endovascular technology is in a constant state of
development. These adjuncts allow coiling to be considered
for cerebral aneurysms that may not have an ideal shape for
conventional coiling.
Stroke Rehabilitation
Recovery and rehabilitation are among the most important
aspects of stroke treatment. As a rule, most strokes are
associated with some recovery, the extent of which is
variable. In some cases, undamaged areas of the brain may
be able to perform functions that were lost when the stroke
occurred. Rehabilitation includes physical therapy, speech
therapy, and occupational therapy. This type of recovery is
measured in months to years

Physical therapy involves using exercise and other physical means (e.g.,
massage, heat) and may help patients regain the use of their arms and legs and prevent
muscle stiffness in patients with permanent paralysis.
Speech therapy may help patients regain the ability to speak.
Occupational therapy may help patients regain independent function and relearn
basic skills (e.g., getting dressed, preparing a meal, and bathing).

Conclusion
Modern treatments for ischemic and hemorrhagic stroke have
reached an advanced state of development in the modern era
of digital and device technology. Neurointerventional
treatments enable surgical procedures in the brain without
the need to open the skull surgically, and provide excellent
treatment alternatives for all forms of stroke and
cerebrovascular disease. These developments are timely,
occurring in an era when stroke incidence is on the rise as
the population ages.

urgical procedure appears to improve outcomes

after bleeding stroke
American Stroke Association Late-Breaking Science Report - Abstract: LB1
- Embargoed until 7 a.m. HT/ noon ET on Thursday, Feb. 7, 2013
February 07, 2013 Categories: Scientific Conferences & Meetings, Stroke News

This news release is featured in a news conference at 7 a.m., HT, Thursday, Feb. 7.
This news release contains updated numbers from the abstract.
Study Highlights:

A minimally invasive surgery appears safe and may reduce long-term disability after a bleeding stroke.

If the findings are confirmed in a larger study, the surgery would be a major advance for treating
hemorrhagic stroke.

HONOLULU, Feb. 7, 2013 A minimally invasive procedure to remove blood clots in brain tissue after
hemorrhagic stroke appears safe and may also reduce long-term disability, according to late-breaking research
presented at the American Stroke Associations International Stroke Conference 2013.
Of the hundreds of thousands of Americans who have intracerebral hemorrhages (ICH) each year, most are
severely debilitated, said Daniel Hanley, M.D., lead author and professor of neurology at Johns Hopkins School
of Medicine in Baltimore, Md.
ICH is the most common type of bleeding stroke. It occurs when a weakened blood vessel inside the brain
ruptures and leaks blood into surrounding brain tissue, causing neurological damage. There is not a specific
evidence-based targeted treatment recommended for ICH and there is no long-term randomized data on surgical
treatment.
In one-year results of the Phase II study, MISTIE (Minimally Invasive Surgery plus rtPA forIntracerebral
Hemorrhage Evacuation), researchers found that patients treated with surgery and a clot- busting drug had less
disability, spent less time in the hospital and were less likely to be in a long-term care facility than other ICH
patients.
There is now real hope we have a treatment for the last form of stroke that doesnt have a treatment brain
hemorrhage, said Hanley, who is also director of the Brain Injury Outcomes Division at Johns Hopkins.
The overall study involved 96 patients at 26 hospitals who had a bleeding stroke. The stage two arm of the trial
focused on 25 patients who had the surgical procedure and 31 who were given standard post-stroke medical
care, which is medical management only. Patients were average age 60 and 75 percent were men.
During the treatment, surgeons cut a hole the size of a dime in the patients skull. A catheter is passed into the
brain tissue, pushing it through the longest part of the clot, which has formed from blood that pooled during the
stroke. Next they apply the clot-busting drug recombinant tissue plasminogen activator (rtPA) to the clot via the
catheter every eight hours for about three days. As the clot liquefies, it is removed through the catheter.
The studys patients had blood clots with an average volume of 46 milliliters, about the size of a golf ball, Hanley
said. The procedure removed 57 percent of the clots on average, while clots naturally dissolved in only about 5
percent in the standard medical care group in the few days after stroke.
The normal healing processes may be occurring more rapidly when you remove the blood, Hanley said. We
believe were actually stopping brain injury and preserving brain tissue that would otherwise be lost.
Researchers found less fluid buildup (edema) in the brains of the surgical patients four days after the procedure,
compared with the usual care group.
In six-month results presented last year, researchers noted that the surgical group had 11 percent better
functional outcomes. The newest findings showed that a year after the stroke, the advantage in the surgery group
had increased to 14 percent.

Likewise, yearlong results among patients with mild disability also showed a 14 percent difference between the
treatment groups. Again, more patients from the surgical group improved during that time frame. And compared
with the usual care group, 14 percent fewer of the surgical patients were in long-term care a year later.
That 14 percent shift is occurring across the spectrum from long-term care to moderate disability to mild
disability, Hanley said.
For patients who underwent the surgical procedure, median time spent in any level of hospital or rehabilitation
care was 38 days shorter than for the usual care group. That difference could represent a cost savings per
patient of more than $44,000, the researchers estimated.
Researchers noted that no hemorrhage was too large or too deep in the brain to be helped by the procedure.
Patients who had surgery between 36 and 72 hours after their stroke fared as well as those treated sooner.
Women as well as men, blacks as well as whites, and people over and under age 65 appeared to benefit equally,
although a larger study is needed to validate the findings. The researchers hope next to conduct a 500-patient
Phase III study at more than 75 sites.
Hanley said the training for surgeons is simple and the equipment is readily available. If the MISTIE findings are
confirmed, then we have a practical treatment that can easily be done by all trained neurosurgeons, he said. It
could make a substantial difference in this disease.
The study was completed as a cooperative program with Mario Zuccarello University of Cincinnati as the surgical
leader and co-principle investigator. A full list of co-authors and author disclosures is available on the abstract.
The National Institute of Neurological Disorders and Stroke funded the research; Genentech provided the rt-PA
drug, Alteplase.
Follow news from ASA International Stroke Conference 2013 via Twitter @HeartNews; #ISC13.
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