Knowing the Signs of a Stroke, Evaluation and Treatment

 Stroke

 

A stroke occurs when blood flow to a part of the brain is interrupted as a result of a broken or blocked blood vessel. Stroke may be hemorrhagic or ischemic. A hemorrhagic stroke occurs when a blood vessel in the brain ruptures or breaks, allowing blood to leak into the brain. An ischemic stroke occurs when a blood vessel carrying blood to the brain is blocked or restricted by severely narrowed arteries or a blood clot.

Because treatment depends on the type of stroke, your doctor may use head CT or head MRI to help diagnose your condition. Other tests may include blood tests, electrocardiogram (ECG or EKG), carotid ultrasound, echocardiography or cerebral angiography. Immediate stroke treatment can help save lives and reduce disability by restoring blood flow for an ischemic stroke or controlling bleeding and reducing pressure on the brain in the case of a hemorrhagic stroke.

What is a stroke?

 A stroke happens when blood flow to a part of the brain is interrupted as a result of a ruptured or blocked blood vessel. Brain cells that do not receive a constant supply of oxygenated blood may die, causing permanent   damage to the brain.

 There are two types of strokes: hemorrhagic and ischemic.

 A hemorrhagic stroke occurs when a blood vessel in the brain ruptures or breaks, allowing blood to leak into the brain.

 An ischemic stroke occurs when a blood vessel carrying blood to the brain is blocked or restricted by severely narrowed arteries or a thickened mass of blood called a blood clot.

  • Clogged arteries: Fat, cholesterol and other substances can collect on the walls of blood vessels. Over time, these substances harden and form structures called plaque. The build-up of fat deposits and plaque clog arteries, narrowing the passageway for blood.
  • Blood clots: When a clot forms in a cerebral blood vessel that is already very narrow, it is called a thrombotic stroke. When a blood clot that has formed elsewhere in the body breaks away and travels to a blood vessel in the brain, the result is an embolic stroke, or cerebral embolism. An embolic stroke may also result from an air bubble or other foreign substance in the blood that moves into and blocks a cerebral blood vessel.

 A short episode of stroke-like symptoms is called a transient ischemic attack (TIA) or mini-stroke. Most often, no permanent damage results from a TIA; however, a TIA is often a warning sign that a stroke will occur.   Symptoms of a TIA may last from a few minutes to up to 24 hours.

 The symptoms of stroke depend on which part of the brain is affected. In some cases, a person may not know that he or she has had a stroke. Symptoms, which usually develop suddenly and without warning, include:

  • severe headache with no known cause
  • numbness or weakness of the face, arm or leg (especially on one side of the body)
  • confusion and trouble speaking or understanding speech
  • trouble seeing in one or both eyes
  • dizziness, loss of balance or coordination.

How is a stroke evaluated?

  • The first step in assessing a stroke patient is to determine whether the patient is experiencing an ischemic or hemorrhagic stroke so that the correct treatment can begin. A CT scan or MRI of the head is typically the first test performed.

    • Computed tomography of the head: CT scanning combines special x-ray equipment with sophisticated computers to produce multiple images or pictures of the inside of the body. Physicians use CT of the head to detect a stroke from a blood clot or bleeding within the brain. To improve the detection and characterization of stroke, CT angiography (CTA) may be performed. In CTA, a contrast material may be injected intravenously and images are obtained of the cerebral blood vessels. Images that detect blood flow, called CT perfusion (CTP), may be obtained at the same time. The combination of CT, CTA and CTP can help physicians decide on the best therapy for a patient experiencing a stroke.
    • MRI of the head: MRI uses a powerful magnetic field, radio frequency pulses and a computer to produce detailed pictures of organs, soft tissues, bone and virtually all other internal body structures. MR is also used to image the cerebral vessels, a procedure called MR angiography (MRA). Images of blood flow are produced with a procedure called MR perfusion (MRP). Physicians use MRI of the head to assess brain damage from a stroke.

    To help determine the type, location, and cause of a stroke and to rule out other disorders, physicians may use:

    • Blood tests.
    • Electrocardiogram (ECG,EKG): An electrocardiogram, which checks the hearts’ electrical activity, can help determine whether heart problems caused the stroke.
    • Carotid ultrasound/Doppler ultrasound: Ultrasound imaging involves exposing part of the body to high-frequency sound waves to produce pictures of the inside of the body. Physicians use a special ultrasound technique called Doppler ultrasound to check for narrowing and blockages in the body’s two carotid arteries, which are located on each side of the neck and carry blood from the heart to the brain. Doppler ultrasound produces detailed pictures of these blood vessels and information on blood flow.
    • Cerebral angiography. Angiography is a medical test that is performed with one of three imaging technologies—x-rays, CT or MRI, and in some cases a contrast material, to produce pictures of major blood vessels in the brain. Cerebral angiography helps physicians detect or confirm abnormalities such as a blood clot or narrowing of the arteries.

How is a stroke treated?

A stroke is a medical emergency. Immediate treatment can save lives and reduce disability. Treatment depends on the severity and type of stroke. Treatment will focus on restoring blood flow for an ischemic stroke and on controlling bleeding and reducing pressure on the brain in a hemorrhagic stroke.

If a stroke is caused by a blood clot, the patient may be able to receive a clot-busting drug such as tissue plasminogen activator (t-PA) to dissolve the clot and help restore blood flow to the damaged area of the brain. Clot-busting drugs, which can only be given within the first few hours of stroke onset, are typically delivered intravenously by emergency medical personnel or in the hospital emergency department.

Patients may also receive blood-thinning drugs such as aspirin or warfarin (also called by the brand name, Coumadin®), heparin or clopidogrel (also called by the brand name Plavix®).

Other stroke treatments include:

  • Surgery to remove blood from around the brain and repair damaged blood vessels.
  • Intracranial vascular treatments: Endovascular therapy is a minimally invasive procedure used to improve blood flow in the brain’s arteries and veins. In endovascular therapy, an image-guided catheter is navigated through the body’s blood vessels to the brain to deliver:
    • medications to dissolve blood clots.
    • mechanical retrievers and aspiration systems that help remove blood clots or debris in cerebral arteries.
    • devices such as balloons, which are used to open markedly narrowed blood vessels, and stents, small tubes used to keep blood vessels open. In this procedure, which is used to improve blood flow in the carotid arteries that supply blood to the brain, a balloon-tipped catheter is guided to where the artery is narrow or blocked and inflated to open the vessel. A small wire mesh tube called a stent may be placed in the artery to help keep it open.
    • tiny metal coils to repair a ruptured aneurysm in a cerebral artery.

Following a stroke, many patients will receive post-stroke rehabilitation to overcome disabilities that may occur as a result of the stroke. Post-stroke treatment may also include efforts to prevent another stroke by controlling or eliminating risk factors such as high blood pressure, high cholesterol and diabetes.


What is a Abdominal Aortic Aneurysm?

Abdominal Aortic Aneurysm (AAA)

Abdominal aortic aneurysm (AAA) occurs when atherosclerosis or plaque buildup causes the walls of the abdominal aorta to become weak and bulge outward like a balloon. An AAA develops slowly over time and has few noticeable symptoms. The larger an aneurysm grows, the more likely it will burst or rupture, causing intense abdominal or back pain, dizziness, nausea or shortness of breath.

Your doctor can confirm the presence of an AAA with an abdominal ultrasound, abdominal and pelvic CT or angiography. Treatment depends on the aneurysm’s location and size as well as your age, kidney function and other conditions. Aneurysms smaller than five centimeters in diameter are typically monitored with ultrasound or CT scans every six to 12 months. Larger aneurysms or those that are quickly growing or leaking may require open or endovascular surgery.

 

What is an abdominal aortic aneurysm?

The aorta, the largest artery in the body, is a blood vessel that carries oxygenated blood away from the heart. It originates just after the aortic valve connected to the left side of the heart and extends through the entire chest and abdomen. The portion of the aorta that lies deep inside the abdomen, right in front of the spine is called the abdominal aorta.

Over time, artery walls may become weak and widen, an analogy would be what can happen to an aging garden hose. The pressure of blood pumping through the aorta may then cause this weak area to bulge outward, like a balloon (called an aneurysm). An abdominal aortic aneurysm (AAA, or “triple A”) occurs when this type of vessel weakening happens in the portion of the aorta that runs through the abdomen.

The majority of AAAs are the result of atherosclerosis, a chronic degenerative disease of the artery wall, in which fat, cholesterol, and other substances build up in the walls of arteries and form soft or hard deposits called plaques.

Abdominal aortic aneurysms typically develop slowly over a period of many years and hardly ever cause any noticeable symptoms. Occasionally, especially in thin patients, a pulsating sensation in the abdomen may be felt. The larger an aneurysm grows, the greater the chance it will burst, or rupture.

If an aneurysm expands rapidly, tears, or leaks, the following symptoms may develop suddenly:

  • intense and persistent abdominal or back pain that may radiate to the buttocks and legs
  • sweating and clamminess
  • dizziness
  • nausea and vomiting
  • rapid heart rate
  • shortness of breath
  • low blood pressure.

Major risk factors for a AAA include family history, smoking and longstanding high blood pressure. According to the Centers for Disease Control and Prevention (CDC), men who have a history of smoking should receive a one-time screening for triple A between the ages of 65 and 75. Men with a family history of AAA should be screened at age 60.

How is an abdominal aortic aneurysm evaluated?

Many abdominal aortic aneurysms are incidentally found on ultrasound examinations, x-rays or CT scans. The patient is often being examined for an unrelated reason. In other patients who experience symptoms and seek medical attention, a physician may be able to feel a pulsating aorta or hear abnormal sounds in the abdomen with the stethoscope.

To confirm the presence of an abdominal aortic aneurysm, a physician may order imaging tests including:

  • Abdominal Ultrasound (US): Ultrasound is a highly accurate way to measure the size of an aneurysm. A physician may also use a special technique called Doppler ultrasound to examine blood flow through the aorta. Occasionally the aorta may not be completely seen due to overlying bowel which blocks the view of ultrasound or in very large patients.
  • Abdominal and pelvic computed tomography (CT): This exam is highly accurate in determining the size and extent of an aneurysm.
  • Angiography: This exam, which uses x-rays, CT or MRI and a contrast material to produce pictures of major blood vessels throughout the body, is used to help identify abnormalities such as abdominal aortic aneurysms.

How is an abdominal aortic aneurysm treated?

Treatment depends on a variety of factors, including size and location of the aneurysm within the abdominal aorta and the patient’s age, kidney function and other conditions.

Patients with aneurysms that are smaller than five centimeters in diameter are typically monitored with ultrasound or CT scans every six to 12 months and may be advised to:

  • quit smoking
  • control high blood pressure
  • lower cholesterol.

Surgical treatment may be recommended for patients who have aneurysms that are:

  • larger than 5 centimeters (two inches) in diameter
  • quickly growing
  • leaking.

There are two treatment options:

  • Traditional (open) surgical repair: In this type of surgery, an incision is made in the abdomen and the damaged part of the aorta is removed and replaced with a synthetic tube called a stent graft, which is sewn into place.
  • Endovascular surgery: In this procedure, which is less invasive than an open repair, the stent graft is attached to the end of a thin plastic tube called a catheter, inserted through an artery in the leg and maneuvered up into the abdomen, where it is positioned inside the aneurysm and fastened in place with small hooks.

The Importance of Peripheral Artery Disease — How to Detect it and Treat it

Peripheral Artery Disease (PAD)

Peripheral artery disease (PAD) refers to arterial disease that occurs outside of the heart or brain. In PAD, arteries become narrowed or blocked, usually as a result of atherosclerosis or plaque. It most commonly affects the arteries in the legs.

Vascular ultrasound, Doppler ultrasound, catheter angiography, CT angiography (CTA), or MR angiography (MRA) may be used to help evaluate your condition. Your doctor may recommend certain lifestyle changes to treat your condition. Bypass surgery or interventional procedures such as angioplasty, catheter-directed thrombolysis or atherectomy may be used to help improve blood flow.

What is peripheral artery disease (PAD)?

In Peripheral artery disease, the arteries that carry oxygenated blood throughout the body become narrowed or even blocked, usually as a result of atherosclerosis, or plaque. PAD most commonly affects the arteries in the legs, but it also can involve arteries that carry blood to the head, arms, kidneys and gastrointestinal (GI) tract.

Many people with PAD have mild or no symptoms; others experience occasional claudication, or leg pain when walking. The severity of intermittent claudication varies from mild to debilitating. Other PAD symptoms include sores or ulcers that don’t heal and persistent coldness in the feet and lower legs.

Among the risk factors for PAD are diabetes, smoking, high cholesterol and high blood pressure. Most cases occur in people older than 50

How is peripheral artery disease evaluated?

Several imaging tests can be used to diagnose PAD:

  • Vascular Ultrasound. This exam uses sound waves to create pictures of the arteries and locate blockages.
  • Doppler Ultrasound: Doppler ultrasound is a special ultrasound technique that can help detect areas of restricted blood flow through an artery.
  • Catheter angiography: This minimally invasive imaging exam relies on a contrast agent and x-rays to show blood flow in the arteries in the legs and to pinpoint any blockages that may be present. The contrast agent is injected through a tube or catheter that is usually placed through a blood vessel in the groin.
  • CT angiography (CTA): CT angiography uses a CT scanner to produce detailed views of the arteries in your abdomen, pelvis and legs. This test is particularly useful in patients with pacemakers or stents.
  • MR angiography (MRA): MR angiography is a noninvasive test that gives information similar to that of a CT without the ionizing radiation.

 

How is peripheral artery disease treated?

Lifestyle changes such as dietary modifications, exercise and smoking cessation often are the first choices for patients with early-stage PAD Other interventions may be needed to restore blood flow:

  • Angioplasty: In an angioplasty procedure, an interventional radiologist threads a catheter through a blood vessel to the affected artery and inflates a small balloon to reopen it. In some cases, the insertion of a stent is required to help keep the artery open. Stents are either balloon-expandable or self-expanding metallic scaffolds that remain permanently in the blood vessel after implantation.
  • Bypass surgery: Surgeons perform bypass surgery by grafting a vessel from another part of your body or using a synthetic graft made of fabric, allowing blood to flow around, or bypass, the blocked or narrowed artery.
  • Catheter-directed Thrombolysis: In this minimally invasive treatment, an interventional radiologist uses a catheter to reach the site of the blockage and injects a drug to dissolve the blood clot. This typically requires an overnight infusion.
  • Atherectomy: This minimally invasive procedure uses a catheter to reach the site of the blockage. There, a small blade or laser is deployed to remove the arterial plaque. The catheter captures the collected plaque in a chamber in the tip. The process can be repeated to treat additional plaque.