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Current time:0:00Total duration:9:18

Acute treatment of stroke with medications

Video transcript

after you start to recognize that someone might be having a stroke right maybe they have some of the symptoms we know to be common stroke symptoms like maybe one side of their face starts to droop or maybe all of a sudden they have some vision loss or some numbness or weakness on one side of their body then you want to make sure that this person gets to the hospital as quickly as possible because remember more than any organ in the body our brains love oxygen brain tissue cannot live without it even for a few minutes so in a stroke when blood stops flowing to a part of the brain and thus deprives the brain of the oxygen it carries the brain tissue that's missing out on oxygen starts to die off so super important that whoever you're suspecting of having a stroke is taken to the hospital as quick as possible to save as much brain as possible so now that we're at the hospital what goes on there what's going to happen well a few things are going to happen so I mean the plan is to diagnose the stroke right with some tests and some imaging and then to treat the stroke with some medications so let's take a look so we know that part of diagnosis includes a physical exam to look for any physical signs that the person has had a stroke really importantly it also includes imaging like CT and MRI scans and it includes lab tests blood work to look for an underlying cause of the stroke or to rule out other diagnoses like hypoglycemia which can look like a stroke so the kind of treatment that the person gets really depends on the type of stroke that they had so let me show you what I mean here you could have had an ischemic stroke for example where a clot blocks off a bit of blood vessel in the brain and causes a stroke that way or you could have had a hemorrhagic stroke for example where a weakened blood vessel in the brain starts to leak maybe because of a ruptured aneurysm or some trauma to the head like from a fall or something unpleasant like that but how does the type of stroke you have influence treatment well because for ischemic strokes which you can usually identify on imaging actually let me clarify that you won't be a to see any brain changes on CT scan right after patients had an ischemic stroke that's why the CT up here looks pretty normal but the key is that it doesn't look like a hemorrhagic stroke CT scan which I'll show you in a few minutes so the patient in whom you're suspecting an ischemic stroke get certain medications that you definitely do not get in hemorrhagic stroke so let me show you what I mean here and let me bring up a blood vessel here to just show you how these medications work so if the patient had an ischemic stroke and came to the hospital quickly enough they'd often be given two types of medication so one is aspirin and aspirin doesn't actually do anything about the existing clot it can't break it up or anything like that but what it can do what it can do is prevent new clots from forming so it stops platelets in your blood from working properly because platelets in your blood are responsible for forming the initial component of a blood clot so it stops those from forming and really importantly you might be given a type of medication called a thrombolytic and this thrombolytic is the one that can potentially break up that clot that's causing the stroke right so you might have heard of clot-busting medication and this would be a type of that so thrombo means clot and lytic means to break something up and this one in particular is called tissue plasminogen activator or TPA and that sounds like a pretty confusing name but it's called tissue plasminogen activator because of what it does it activates a compound called plasminogen that's already naturally found floating around in your blood as part of the body's natural mechanism to break up any clots that shouldn't be hanging around so TPA sort of kick-starts this natural system already in your bloodstream to try to bust up the clotted that causes a stroke right and actually when plasminogen gets activated by TPA it turns into this compound called plasma and that's what's actually doing the busting up the clot busting that's why I wrote plasmon here and really importantly about this drug the benefit of TPA is the highest right after the stroke has occurred and then it just kind of gets less and less effective from there so again I'm just trying to highlight the fact that the earlier the patient gets to the hospital the better the outcome the better the TPA will work so that's ischemic strokes that's sort of acute management of an ischemic stroke with hemorrhagic strokes though it's a different story because when you have vessels that are bleeding out the first thing you want is for it to clot off and stop bleeding and therefore the last thing you want is to activate your plasminogen clot busting system so you won't be given TPA because if you are given TPA then your blood will be far less likely to clot right as we saw earlier and and blood will just continue to pour out of this deficiency in the blood vessel heresy and actually let me bring up a CT scan of a hemorrhagic stroke remember I said I was going to bring one up so you can see all of this blood here this is this bright spot is a big collection of blood that's been sort of leaking out of blood vessels in the brain that a bit of ruptured and so you can see that this looks really different from the CT scan over here on the left of an ischemic stroke and so this is why brain scanning is super important when you're diagnosing a stroke because it really has big implications on how you treat the stroke afterward so for hemorrhagic strokes the focus of initial treatment has to be a little different than with ischemic strokes so for example with hemorrhagic strokes it's really important to find out which blood vessels bleeding so where exactly in the brain the bleed is and that can be done by by the imaging tests like CT or MRI or angiography that we talked about because the goal is to stop the bleed so it's important to first know where it is and another thing anytime you're bleeding from a vessel right losing blood your heart starts to get a little worried right good old heart always looking out for you so it starts to pump blood out a little harder and and it's thinking that that's what it'll take to get blood going everywhere again so now your blood pressure has gone up but there's two main drawbacks to that one is that if a little clot has started to form right to seal up the initial tear in the blood vessel if that new maybe not so stable clot gets hit with blood racing along a high pressure it might get dislodged and rebleeding might happen the second drawback to blood pressure that gets too high is well let's say that a clot hasn't formed and the bleed is still it's still bleeding it's still active then now blood will just start coming out of the vessel even faster right and that's probably the last thing that we want so the patient might be given antihypertensives or blood pressure lowering drugs to try to keep the blood pressure from getting too high it's also really important with hemorrhagic strokes that the healthcare team stops or reverses the effects of any medication that the patient's regularly taking that might increase bleeding such as warfarin or the aspirin that we mentioned earlier also really important is that pressure building up in the brain and the skull from all this blood is controlled and for starters one simple way to do that is to just make sure that the head of the patients bed is elevated and this works just because of good old gravity when the patient's head is elevated then more blood will flow out of the head in the jugular veins right so that's one way of lowering pressure in the in the head a bit and you know one reason why keeping pressure in the head at a normal age level is really important is that when your brain starts to get pushed on or compressed it kind of disrupts the normal electrical activity in the brain and you could end up having a seizure so the doctors might consider giving an anticonvulsant which is a medication to prevent seizures from happening and another reason is just because some pretty vital areas in your brain particularly your brain stem they might get compressed with all of this pressure building up and that's pretty quickly fatal so we don't want that and there are some other surgical ways to keep pressure under control but we won't focus on that right now but you can definitely start to see that management of hemorrhagic stroke is really about managing patient until interventions like surgery can happen whereas with ischemic strokes while you might still need more invasive treatment down the line at least you can give TPA initially to try to get things resolved beforehand try to bust up that clot before you need sort of more invasive treatment so that's a quick look at some of the immediate management of ischemic and hemorrhagic strokes