Page 17 - Boca Club News - January '24

Boca Club News, Page 17
Medical Matters: Stroke (Part Two)

By Richard Nagler, M.D., a member TPA. There are other victims who are too fragile, or who A cerebral hemorrhage occurs when a blood vessel in
of Broken Sound Club and retired suffer from other serious illnesses and for whom this the brain leaks or ruptures, spilling blood into surrounding
physician. After graduating from treatment is too risky. Of the 25% who are eligible, only brain tissue and severely damaging brain cells with
the University of Pennsylvania and 50% receive TPA nationwide, mainly because they are in a devastating complications. Most of these patients have
New York University’s School of hospital setting not prepared for TPA treatment. However, sustained uncontrolled hypertension. It may involve a
Medicine, Dr. Nagler served his 35% of the treated patients have very favorable outcomes preexisting brain aneurism or an AV cerebral malformation
internship and residency at Baltimore with significant improvement and return of most functions (an abnormal tangle of blood vessels), the use of an
City Hospital and Johns Hopkins. He with little or no lingering paralysis. uncontrolled anti-coagulant or trauma from a concussion. In
followed that with a Fellowship in A serious but small complication of intracranial bleeding addition to involving the brain directly, the hemorrhage may
Gastroenterology at Yale University School of Medicine, from TPA treatment involving 5% of cases can occur, and involve an artery at the surface of the brain. This is called a
and was then Chief of Gastroenterology at Fitzimmons patients must be carefully monitored. Failure of TPA by subarachnoid hemorrhage. Here a blood vessel bursts, and
General Army Hospital in Denver. He returned to the Yale injection to dissolve a clot can be improved with another blood is spilled into the space between the skull and the
Medical School for one year as an Assistant Professor of approach in which a catheter is inserted into an artery in brain, which puts intense pressure on the brain, displacing
Medicine before opening his own successful private practice the groin and threaded up to the brain to deliver the TPA critical structures and destroying brain cells.
in Internal Medicine and Gastroenterology. During that directly into the clot. With both these types of hemorrhagic stroke, the major
time, he also served for ten years as Chief of Medicine at Another method is to surgically insert a catheter with a initial symptom is a sudden excruciatingly severe headache
Huntington Hospital in Huntington, N.Y. clot remover attached and maneuver it into the offending followed in most cases by unconsciousness and, usually,
Eighty-seven percent of full-blown strokes are ischemic blood vessel in the brain trap to remove the clot. This is most death. If the patient survives, the neurologic defects are
or thrombotic in nature and are caused by complete useful when a large clot is not completely dissolved with like those of a severe ischemic stroke. Treatment involves
obstruction of an artery in the brain by a clot that has broken TPA. Once this has been accomplished, an endarterectomy efforts to control bleeding and to reduce pressure in the
away from plaque in a carotid artery or from the heart. The removing plaque from the carotids (if they are involved)—or brain. In some instances, bleeding may stop spontaneously,
other 13% are due to a cerebral hemorrhage. In contrast to angioplasty with balloon distension of the artery followed and a small area of blood accumulation can be absorbed
a TIA (transient ischemic attack), the symptoms are more by a stent—is very useful in appropriate instances. naturally; these patients are usually the survivors. Surgery
severe and sustained, such as slurred speech, confusion, When A Fib is involved, anticoagulant treatment to may be attempted to relieve pressure in the brain by sucking
difficulty swallowing, paralysis of one side of the body prevent further clot formation is implemented. In those out a large area of blood accumulation and clipping off the
(which may include the face, and extremities), a crooked patients who have a valve replacement, drugs like Eliquis ruptured blood vessel with a clamp. The quick use of drugs
smile with drooping of one side of the mouth, blurred or and Xeralto are not advised because of a heightened risk of to significantly reduce blood pressure is essential.
double vision, trouble or inability to walk − with staggering, bleeding and the effects of these drugs cannot be reversed When an aneurism is involved, endovascular embolization
loss of balance and coordination. A severe headache with until the drugs are out of the system, which can take as may be used: a catheter is inserted into an artery in the leg,
vomiting, dizziness and altered consciousness is common. long as 48 hours. Warfarin is the preferred alternative as it threaded up to the brain and positioned into one of the
Diagnostic evaluation is identical to that with a TIA. is an excellent anticoagulant, and its effect can be promptly feeding arteries where an embolizing agent is injected to
In the case of an ischemic stroke caused by a blood clot, neutralized by an infusion of potassium. seal off blood flow through that artery. An aneurism, if
it is vitally important to attempt to restore blood flow to If present, conversion of an abnormally rapid rhythm accessible, can be surgically removed. Stereotactic radio
the brain within a four-hour window of opportunity after of A Fib to a slower rate, or to a normal sinus rhythm, is surgery, which involves multiple beams of highly localized
the onset of symptoms in order to possibly prevent brain usually attempted with medications, or cardioversion using radiation to repair these vascular malformations, is another
death and permanent disability. After a CT scan or MRI to electric shocks. Ablation is another option in which heat or option. Blood transfusions containing blood clotting factors
rule out a cerebral hemorrhage, intravenous injection of cold energy is used to create tiny scars in the heart to block can stem bleeding. Any blood thinners must be stopped.
TPA (tissue plasminogen activator) directly into a vein in faulty electrical and restore a normal heartbeat. A pacemaker With any suspected stroke, symptoms can be mimicked
the arm is the gold standard of treatment, which is used to may be required. In some cases not caused by a heart valve by a brain tumor, migraine headache variants, seizures,
dissolve the offending blood clot. problem, a Watchman net-like implant placed between the multiple sclerosis, a brain infection (encephalitis), very
Unfortunately, 75% of these patients arrive in the ER atrium and ventricle blocks any clots in the left atrium from low sodium—as for example from over hydration—and
more than four hours after the onset of symptoms when entering the left ventricle, exiting into the aorta and then to
brain cells are already dead and there is no benefit from the brain. Medical Matters on page 18

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