Expanding stroke treatment options

A stroke is a sudden and often unpredictable medical emergency that occurs when blood flow to a part of the brain is disrupted. Without oxygen-rich blood, brain cells begin to fail and die within minutes, making stroke a leading cause of death and disability in the United States.

However, according to Promod Pillai, MBBS, MCh, FAANS, a neurosurgeon at Loma Linda University Health, stroke treatments have significantly improved over the past decade.

"Emergency systems are much better prepared now. Stroke activation protocols have improved, along with diagnostics and the ability to transfer patients to specialized centers, like Loma Linda University Health, so treatment isn't delayed," Pillai says. "We're also using newer technologies, including AI-based imaging systems that alert physicians in real-time when a patient needs urgent treatment."

These innovations allow surgeons to reach more complex or difficult-to-access areas in the brain, improving both the precision of treatment and overall patient outcomes.

Types of strokes

There are two main types of strokes: ischemic and hemorrhagic.

Ischemic stroke

An ischemic stroke is the most common stroke, accounting for approximately 87% of all strokes, occurs when a blood vessel is blocked. These blockages typically arise from the heart or plaque buildup:

The heart: An abnormal heart rhythm, called atrial fibrillation, can cause a blood clot to form, break into pieces, and travel to the brain.

Plaque buildup: Atherosclerotic lesions, or fatty deposits in blood vessels, can narrow arteries and trigger blood clot formation.

Hemorrhagic stroke

A hemorrhagic stroke, which accounts for 13% of all strokes, occurs when a blood vessel ruptures, causing bleeding in the brain.

Read: Do strokes affect women differently?

Mini stroke

Some patients experience a transient ischemic attack (TIA), often referred to as a mini stroke. TIAs are relatively common and are an important warning sign.

"These are stroke-like symptoms that resolve on their own, typically within 24 hours. But they shouldn't be ignored as they're an important warning sign," Pillai says.

For example, a patient might experience temporary weakness on one side of the body that resolves. This is a warning sign of a higher risk of a future stroke.

These symptoms require prompt medical evaluation and risk factor management.

Read: Treating a stroke: how neurosurgeons save brain function

Time is brain: treating strokes

Stroke treatment has evolved dramatically over the past decade, but one principle remains unchanged: speed is critical.

"The brain starts to suffer permanent damage very quickly," Pillai explains. "The earlier we restore blood flow, the better the outcome."

The following stroke treatments are vital in minimizing brain damage and preserving function:

Clot-busting medications

For years, the primary treatment for ischemic stroke was an intravenous medication designed to dissolve clots. These drugs - including tPA (alteplase) and TNK (tenecteplase), both thrombolytic agents increasingly used in clinical practice - must be administered within 3 to 4.5 hours of symptom onset.

Mechanical thrombectomy

In recent years, several major studies examined a procedure known as thrombectomy. The findings showed that thrombectomy significantly improved outcomes for patients, including mortality and disability, compared to medical treatment alone.

"These results changed the way strokes are treated. Thrombectomy is primarily used for large vessel occlusions and is now recommended in selected patients up to 24 hours after symptom onset based on imaging criteria. This is especially applicable to vessels such as the carotid artery or middle cerebral artery, where clots can be safely accessed and removed," Pillai says. "During the procedure, physicians physically remove a blood clot from a blocked blood vessel to restore circulation."

Thrombectomy has become a standard approach for stroke patients and has transformed care by significantly improving recovery outcomes.

Read: Treating a stroke: how neurosurgeons save brain function

Managing reperfusion

Restoring blood flow in already infarcted tissue increases the risk of hemorrhagic transformation and may not provide benefit.

"That's why timing is critical. To guide this, we use imaging such as MRI or CT scans, often with perfusion imaging, to determine how much of the brain is already permanently damaged and how much is still viable. The focus is on saving the at-risk tissue while avoiding reperfusion of tissue that is already irreversibly damaged," Pillai explains.

A helpful way to think about this is like a blocked pipeline. If an area has gone too long without blood supply and the tissue is already dead, suddenly restoring flow can disrupt the damaged area and lead to complications, including bleeding.

Although these patients were previously not considered candidates for thrombectomy, advances in technology now show that selected patients with larger infarct cores may benefit, based on advanced imaging and evolving clinical evidence.