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Stroke

A stroke is a condition that occurs when a blood vessel carrying blood to the brain is either blocked by a clot or bursts. When this happens, part of the brain cannot get blood and the oxygen it needs, so that portion of the brain and its cells die. According to the American Stroke Association, stroke is the No. 4 cause of death and a leading cause of disability in the United States.

Stroke Team

Washington University cerebrovascular surgeons work as part of a multidisciplinary team to offer treatment in the Comprehensive Stroke Center at Barnes-Jewish Hospital. The Center is the first in Missouri and one of the first in the country to be designated a Comprehensive Stroke Center by the Joint Commission and the American Heart Association/American Stroke Association. This certification recognizes hospitals that achieve higher standards and meet specific criteria for resources, staff and training that are essential to treat the most complex stroke cases. 

Physician members of the stroke and cerebrovascular center team include cerebrovascular surgeons and neurologists who specialize in stroke, interventional radiology, critical care and neuro-rehabilitation. 

The center has one of the fastest diagnosis-to-treatment times in the nation for administration of tPA (tissue plasminogen activator), a clot-busting drug that can significantly reduce long-term disability in patients with ischemic stroke (resulting from an obstruction within a blood vessel supplying blood to the brain). Cerebrovascular surgeons offer treatments to prevent ischemic stroke, as well.

Hemorrhagic stroke patients are treated with technically advanced treatments including endovascular techniques and aneurysm clipping.

Stroke patients also are given the opportunity to receive investigational drugs.

What makes a Stroke Center comprehensive? See Barnes-Jewish & Washington University Stroke Center.


Types of Stroke

There are two types of stroke — ischemic and hemorrhagic. 

Ischemic stroke: This type of stroke occurs as a result of blood clots that obstruct a blood vessel supplying blood to the brain and accounts for about 87% of all strokes (source: American Stroke Association). Patients who come to the emergency room with ischemic stroke may receive tPA, a drug that breaks up the clot, but it must be administered to a stroke patient within the first 4.5 hours after a stroke occurs.

Procedures to prevent ischemic stroke, when blockage is identified, include carotid endarterectomy and carotid stenting.

Carotid endarterectomy is a surgery to remove fatty deposits (plaque) that are narrowing the arteries in the neck. These are called the carotid arteries. They supply blood and oxygen to the brain. If plaque and other fatty materials block an artery, it slows or blocks the blood flow, possibly resulting in a stroke.

Carotid stenting is often recommended for people who are unable to undergo an endarterectomy. For example, they may not tolerate the side effects of anesthesia. Stenting restores adequate blood flow through the affected part of the body by enlarging the blood vessel from within.

Patients with moyamoya disease may be especially susceptible to stroke. Moyamoya is a progressive disorder in which the large arteries inside the skull narrow and often completely close off. Small branches of these arteries then enlarge to bypass the blockage. Washington University cerebrovascular surgeons perform surgical revascularization to treat moyamoya disease.

Hemorrhagic stroke: Hemorrhagic strokes account for 13% of all strokes. They are caused by an aneurysm or other blood vessel abnormality that ruptures and is bleeding. When there is bleeding into the brain, cells and tissues do not receive enough oxygen and nutrients. Hemorrhagic strokes comprise two groups:

  • Intracerebral hemorrhage, or bleeding from the small blood vessels within the brain.
  • Subarachnoid hemorrhage, or bleeding in the subarachnoid space (the space between the brain and the membranes that cover the brain). Most subarachnoid hemorrhages are caused by an aneurysm.

Hemorrhagic stroke also can be caused by several brain vascular malformation. These conditions include:

  • Cavernous malformation: an abnormal cluster of small blood vessels in the brain that resembles a raspberry or honeycomb.
  • Arteriovenous (AV) malformation: abnormal tangles of blood vessels within the brain — called arteriovenous malformations because abnormal arteries are connected to abnormal veins.
  • Arteriovenous (AV) fistula: abnormal connections between blood vessels in the coverings of the brain. The word arteriovenous refers to the direct connection between arteries and veins, and the medical term fistula indicates that two things are connected that should not be connected.
Some hemorrhagic strokes are treated with endovascular procedures, in which a small catheter is used to reach the aneurysm in the brain arteries. With this treatment option, small soft coils may be placed into the aneurysm to fill the space, or stents (metal mesh tubes) are placed in the artery across the entrance to the aneurysm. 

Neurosurgeons also offer the surgical option of aneurysm clipping – application of small metal clips around the aneurysm that aid in reducing the size of the aneurysm and in stopping the bleeding in the brain.

For brain vascular malformations, Washington University cerebrovascular surgeons, interventional radiologists, neurointensivists and neurorehabilitation specialists work as a team to provide treatment and care. Among the options for treating these types of malformations is Gamma Knife radiosurgery.

Conferences

Brain Attack Annual Conference

Held annually for emergency medicine physicians, neurologists, neurosurgeons, primary care physicians, internists, neuroscience and emergency medicine nurses, EMS providers, hospital administrators and other health professionals who want to enhance their knowledge of the management of patients with cerebrovascular diseases. More information on next Brain Attack conference.

Weekly Cerebrovascular Conference

Fridays, 8-9 a.m. Multidisciplinary, including vascular neurosurgeons, interventional neuroradiologists and stroke neurologists. Physicians wishing to submit cases for review should contact the Cerebrovascular Nurse Coordinator at 314-747-8882.

Evidence-based Management of Cerebrovascular Disease Series

Tuesdays at 12 p.m. in the Lower Level West Pavilion Auditorium.

Faculty

Neurosurgery Provider - Cerebrovascular Surgeons

Interventional Neuroradiology Providers

  • DeWitte T. Cross, MD
  • Colin P. Derdeyn, MD
  • Christopher J. Moran, MD

Vascular Neurology Providers

  • David A. Carpenter, MD
  • Andria L. Ford
  • Jin-Moo Lee, MD, PhD

Critical Care Neurology Providers

  • Rajat Dhar, MD
  • Michael Diringer, MD
  • Salah G. Keyrouz, MD
  • Terrance Kummer, MD, PhD

Neuro-Rehabilitation Providers

  • Alex Carter, MD
  • Maurizio Corbetta, MD
  • Robert Fucetola, PhD
  • Thy Huskey, MD

Highlights

First Joint-Commission accredited Comprehensive Stroke Center in Missouri

Our Comprehensive Stroke Center is the highest volume stroke center in St. Louis and the region, with more than 1,300 cases annually.

We have one of the fastest "door-to-needle" times in the nation — 37 minutes for intravenous tPA ("clot buster") treatment.