Transcription:
Surgical Options for Stroke Patients

Melanie Cole (Host):  If you or a loved one has suffered a stroke, for select patients, surgical procedures may aid in treatment and recovery. Who can benefit from these procedures? My guest is Dr. Webster Crowley. He is a neurosurgeon whose specialties include endovascular and cerebrovascular surgical procedures for conditions such as stroke. Welcome to the show, Dr. Crowley. First, can you briefly describe what is a stroke? 

Dr. Webster Crowley (Guest):  Sure thing. There are two types of stroke that most people think of, and the first one is something called an ischemic stroke, which is essentially a cut-off of the blood supply to a portion of the brain. That tends to be what most people think of. And then there’s also something called a hemorrhagic stroke, which effectively does the same thing, but it’s a bleed in the brain rather than a cut-off of blood to the brain. These can manifest as a number of symptoms, and it really depends on where the stroke is. So it’s difficult to determine when someone is having symptoms whether it’s a stroke caused by a cut-off of blood or by a bleed itself. 

Melanie:  What are the most common symptoms? Because stroke, time is absolutely essential in treatment and management of this disease. What are the main symptoms that somebody might notice that would really send them to the hospital as quickly as possible? 

Dr. Crowley:  The main symptoms tend to be focal neurologic deficits, such as weakness on one side of the body or speech difficulties. And again, that will depend on where it is. You also can occasionally have people with severe headache, particularly for the hemorrhagic type of stroke, and again, you can have anything you can imagine really be a symptom. But the main ones are the weakness and the speech difficulties, and sometimes someone becomes less conscious and not alert. 

Melanie:  Why is it so important to get to the hospital that quickly if you feel or if a loved one is suffering a stroke? 

Dr. Crowley:  Well, there are a number of reasons. First, for the ischemic type of stroke—again, the one where there is a cut-off of the blood vessel—time is really of the essence because we have medications that we can give intravenously, but those are only typically available within four and a half hours of the time of the symptom onset. For the surgical options that we have for the ischemic stroke, typically we need to get to it within eight hours to be able to operate safely. For the hemorrhagic stroke—again, where there’s a bleed, it could be a large bleed that needs to be evacuated surgically. It could be an aneurysm that is ruptured that needs to be treated before it re-ruptures. And so, again, a patient sitting there with thesymptoms isn’t going to know which type of stroke it is, and therefore, the sooner you get in, the more likely it is that we can treat it and hopefully reverse some of the symptoms, if not prevent new ones from occurring. 

Melanie:  Dr. Crowley, are there particular groups of stroke patients who may benefit from surgery? 

Dr. Crowley:  There are, in fact. The patients who had the cut-off of the blood vessel but usually by a clot that is clogging off the vessel. The main ones we think about are the patients that are ineligible for the intravenous treatments, which means that they are sometime between the four and a half and eight hour time window after the time of symptoms. Or, if they have another contraindication to the TPA, the tissue plasminogen activator, which is the medicine that you can give IV, those contraindications would be a recent major kind of hemorrhage or often a brain surgery, or perhaps they’re on different blood thinners, which makes giving IV tPA more risky. In those patients, certainly, the endovascular or the surgical treatment for the stroke are an option. For the other types of strokes, the hemorrhagic stroke, the things that we look for is their ability to recover in general from as large of a stroke as it is. The patients who are able to tolerate anesthesia that might need to undergo in order to get the aneurysm treated, or the blood clot removed, certainly. But in general, anyone who comes in with a head bleed is a candidate for treatment. Anyone who comes in with an ischemic stroke, one of these cut-off, is a candidate for surgical treatment if they don’t meet the qualifications for tPA, and occasionally, if they do, if the clot is quite large. 

Melanie:  Can you describe a little bit about the surgery that a stroke patient might undergo? What can they expect? We’ve heard a lot about heart disease and cardiac surgery. Tell us a little bit about stroke surgery. 

Dr. Crowley:  Yes, ma’am. When the clot is there present in the blood vessel in the brain -- again traditionally, the medicine that has been the only hope in this is try to break up the clot. We now have a number of what we call endovascular devices where we can go in through an artery in the leg and pass little tiny catheters up and try to remove the clot. Again, that typically needs to be done within eight hours of the time of onset. We are now with the newest devices. There’s one device which is essentially a stent that we open up within the clot and then capture the clot and bring it back, and we suction as well to try to bring the clot back. The latest data suggests that we can get that open between 85 and 90 percent of the time in patients if we get to it in time.  Then, of course, there are going to be a small subset of patients that we’re not able to remove that clot. That will cause a stroke or complete the stroke and can cause some swelling in the brain. In that case, as a neurosurgeon, we may have to remove a large piece of the bone in order to accommodate the swelling so that someone can survive their stroke. Lastly, for the hemorrhagic stroke, there are a number of different causes. Again, it can be an aneurysm. It could be something called an AVM, which is an arteriovenous malformation and those have treatments, both endovascularly, where you go into the groin and you either treat an AVM with glue-like material or treat an aneurysm with coils or stents. And surgically, we can remove an AVM or we can put a clip across the neck of an aneurysm. There are a number of options, but again, it depends on what it was that caused the stroke, obviously. 

Melanie:  What is the recovery period following a surgery to treat a stroke? What are the outcomes? After they’ve had something, whether it’s stenting or something, do they have a risk of reoccurrence of a stroke then? Are they at a higher risk? What’s the recovery like? 

Dr. Crowley:  They often do have a higher risk. The patients who have the blood clot that is within the blood vessel, there is often something that sent that clot to clog up the blood vessel, and often it’s a narrowing in the artery in the neck. It could be narrowing in the artery of the brain. So treating the stroke itself—meaning, getting that clot out—it doesn’t often end the chance of it happening again. For those patients, they may need, again, either stents in the neck to open up the narrowing which has caused the stroke, or sometimes a surgery called a carotid endarterectomy. The aneurysm ones, recovery from a bleed hemorrhagic stroke tends to be longer because the blood itself irritates the brain. Again, if we are able to successfully remove the clot within the blood vessel, you can see a pretty rapid return of function. Some people go home within a matter of two or three days. For the patients who have a completed stroke, it’s a longer course, certainly, that often needs a rehab. Again, for an aneurysm that’s ruptured, the recovery -- we often keep patients in the hospital for two weeks just to manage other possible sequelae that they run into. 

Melanie:  Dr. Crowley, why should patients come to UVA for their stroke care? 

Dr. Crowley:  Why? I think the University of Virginia has excellent experts in pretty much anything that you can think of, and I hope that you gathered from the things I was talking about that a stroke can be caused by a number of different things. There are a number of hospitals that may have the medicine to give the tPA in order to break up a clot, but they may not have the ability to operate on aneurysm or ability to operate on a large hemorrhage. Other places may have some but not the other. At University of Virginia, we have everything possible. My medical and surgical colleague, Dr. Kenneth Liu, and I are both neurosurgeons that do both endovascular and cerebrovascular, meaning that we can do the stent or we can do the surgery, either the endarterectomy or the clipping of the aneurysm. And the old adage that if the only thing you have is a hammer, everything looks like a nail, I think being able to do both of those or all of those eliminates a great amount of bias. And at University of Virginia, we have a number of people who are trained in a lot of these different things, and so we can tailor the treatments. We have a number of radiologists, we have a number of cardiothoracic surgeons, cardiovascular surgeons, neurosurgeons, that all treat different aspects of stroke. We have a great neurology team. Again, there are other centers in the country, certainly, that have everything. There are a lot of centers that don’t. I think when you’re looking to find -- like I said, when a patient has a stroke or has symptoms of a stroke, they can’t determine whether it’s a blood clot in the artery or a large hemorrhage on the brain. They just know their symptoms, and so I think it’s best to go to a place that has a capability of treating every single one of those, no matter what it turns out to be. 

Melanie:  Thank you so much, Dr. Webster Crowley. For more information on UVA neurosciences, brain, and spine care, you can go to uvahealth.com. That’s uvahealth.com. This is Melanie Cole. You are listening to UVA Health System Radio. Thanks so much for listening, and have a great day.