Related Topics-Aneurysms Etc

8/14/2019 Related Topics-Aneurysms Etc

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What is a B rai n Aneu rysm?A brain aneurysm, also called a cerebral or intracranial aneurysm, is an abnormal bulging

outward of one of the arteries in the brain. It is estimated that up to one in 15 people inthe United States will develop a brain aneurysm during their lifetime.

Brain aneurysms are often discovered when they rupture, causing bleeding into the brain

or the space closely surrounding the brain called the subarachnoid space, causing a

subarachnoid hemorrhage. Subarachnoid hemorrhage from a ruptured brain aneurysm canlead to a hemorrhagic stroke, brain damage and death.

The main goals of treatment once an aneurysm has ruptured are to stop the bleeding and

potential permanent damage to the brain and to reduce the risk of recurrence. Unruptured

brain aneurysms are sometimes treated to prevent rupture. Learn more about treatmentoptions for a brain aneurysm.

In cidenc e Rates of Br ain Aneu rys ms Approximately 0.2 to 3 percent of people with a brain aneurysm may suffer from

bleeding per year

The annual incidence of aneurysmal subarachnoid hemorrhage in the U.S.

exceeds 30,000 people. Ten to 15 percent of these patients will die before

reaching the hospital and over 50 percent will die within the first thirty days after

rupture. Of those who survive, about half suffer some permanent neurologicaldeficit

Brain aneurysms can occur in people of all ages, but are most commonly detected

in those ages 35 to 60 Women are actually more likely to get a brain aneurysm than men, with a ratio of

3:2

Symp toms o f Br ain Aneur ys msRuptur ed Cer e br al Aneur ysm Sym ptom sSometimes patients describing "the worst headache in my life" are actually experiencingone of the symptoms of brain aneurysms related to having a rupture. Other ruptured

cerebral aneurysm symptoms include:

Nausea and vomiting

Stiff neck or neck pain

Blurred vision or double vision

Pain above and behind the eye

Dilated pupils

Sensitivity to light

Loss of sensation
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Unruptured Cerebral Aneurysm Symptoms

Before an aneurysm ruptures, patients often experience no symptoms of brain aneurysms.

In about 40 percent of cases, people with unruptured aneurysms will experience some orall of the following cerebral aneurysm symptoms:

Peripheral vision deficits

Thinking or processing problems

Speech complications

Perceptual problems

Sudden changes in behavior

Loss of balance and coordination

Decreased concentration

Short-term memory difficulty

Fatigue

Because the symptoms of brain aneurysms can also be associated with other medicalconditions, diagnostic neuroradiology is regularly used to identify both ruptured and

unruptured brain aneurysms.

Dia gnos is of Br ain Aneu rys msDiagnosis of a ruptured cerebral aneurysm is commonly made by finding signs ofsubarachnoid hemorrhage on a CT scan (Computerized Tomography, sometimes called a

CAT scan). The CT scan is a computerized test that rapidly X-rays the body in cross-

sections, or slices, as the body is moved through a large, circular machine. If the CT scan

is negative but a ruptured aneurysm is still suspected, a lumbar puncture is performed todetect blood in the cerebrospinal fluid (CSF) that surrounds the brain and spinal cord.

To determine the exact location, size and shape of an aneurysm (ruptured or unruptured),

neuroradiologists will use either cerebral angiography or tomographic angiography.

Cerebral angiography, the traditional method, involves introducing a catheter (small

plastic tube) into an artery (usually in the leg) and steering it through the blood vessels of

the body to the artery involved by the aneurysm. A special dye, called a contract agent, is

injected into the patient's artery and its distribution is shown on X-ray projections. Thismethod may not detect some aneurysms due to overlapping structures or spasm.

Computed Tomographic Angiography (CTA) is an alternative to the traditional method

and can be performed without the need for arterial catheterization. This test combines a

regular CT scan with a contrast dye injected into a vein. Once the dye is injected into avein, it travels to the brain arteries, and images are created using a CT scan. These images

show exactly how blood flows into the brain arteries.


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Treatment of B rain Aneur ysmsSurgery or minimally-invasive endovascular coiling techniques can be used in the

treatment of brain aneurysms. It is important to note, however, that not all aneurysms aretreated at the time of diagnosis or are amenable to both forms of treatment. Patients need

to consult a neurovascular specialist to determine if they are candidates for either

treatment.

Sur gical T reatmentTo get to the aneurysm, surgeons must first remove a section of the skull, a procedure

called a craniotomy. The surgeon then spreads the brain tissue apart and places a tiny

metal clip across the neck to stop blood flow into the aneurysm. After clipping theaneurysm, the bone is secured in its original place, and the wound is closed.

Minimally-Invasive TreatmentCoil Embolization or Endovascular Coiling

Endovascular therapy is a minimally invasive procedure thataccesses the treatment area from within the blood vessel. In

the case of aneurysms, this treatment is called coil

embolization, or "coiling". In contrast to surgery,endovascular coiling does not require open surgery. Instead,

physicians use real-time X-ray technology, called

fluoroscopic imaging, to visualize the patient's vascular

system and treat the disease from inside the blood vessel.

Endovascular treatment of brain aneurysms involves insertion

of a catheter (small plastic tube) into the femoral artery in the

patient's leg and navigating it through the vascular system,

into the head and into the aneurysm. Tiny platinum coils arethreaded through the catheter and deployed into the

aneurysm, blocking blood flow into the aneurysm and

preventing rupture. The coils are made of platinum so thatthey can be visible via X-ray and be flexible enough to

conform to the aneurysm shape. This endovascular coiling, or

filling, of the aneurysm is called embolization and can be

performed under general anesthesia or light sedation. Morethan 125,000 patients worldwide have been treated with

detachable platinum coils


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Causes

The most common cause of a TIA is an embolus (a small blood clot) that occludes an

artery in the brain. This most frequently arises from an atherosclerotic plaque in one of

the carotid arteries (i.e. a number of major arteries in the head and neck) or from athrombus (i.e. a blood clot) in the heart due to atrial fibrillation

Other reasons include excessive narrowing of large vessels due to an atheroscleroticplaque and increased blood viscosity due to some blood diseases. TIA is related with

other medical conditions like hypertension, heart disease (especially atrial fibrillation,

migraine, cigarette smoking, hypercholesterolemia, and diabetes mellitus.

Prevention

Primary prevention

The use of anti-coagulant medications, heparin and warfarin; or anti-platelet medicationssuch as asprin.

Secondary preventionTertiary prevention

Treatment

The mainstay of treatment following acute recovery from a TIA should be to diagnose

and treat the underlying cause. It is not always immediately possible to tell the difference

between a CVA (stroke) and a TIA. Most patients who are diagnosed at a hospital'sAccident & Emergency Department as having suffered from a TIA will be discharged

home and advised to contact their primary physician to organize further investigations.

The initial treatment is Aspirin, second line is clopidogrel, third line is ticlopidine. If TIA

is recurrent after Aspirin treatment, the combination of Aspirin and dipirydamole is

needed (Aggrenox).

An electrocardiogram (ECG) may show atrial fibrillation, a common cause of TIAs, or

other arrhythmias that may cause embolisation to the brain. An echocardiogram is useful


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Ar teri oveno us Malf or mation

From A cerebral arteriovenous malformation (AVM) is acongenital disorder of

blood vessels within thebrain, characterized by tangle(s) ofveins and arteries.

While an arteriovenous malformation can occur elsewhere in the body, this article

discusses malformations found in the brain.

Symp tomsThe most frequently observed problems related to an AVM are headache and

seizure. Moreover, AVMs in certain critical locations may stop the circulation of the

cerebrospinal fluid, causing accumulation of the fluid within the skull and giving

rise to a clinical condition called hydrocephalus.

Symptoms of bleeding within the brain (intracranial hemorrhage) include loss of

consciousness, sudden and severe headache, nausea, vomiting,incontinence, and

blurred vision. A stiff neck can occur as the result of increased pressure within the

skull and irritation of the meninges. Impairments caused by local brain tissue

damage on the bleed site are possible, including seizure, one-sided weakness

hemiparesis, a loss of touch sensation on one side of the body, or deficits in language

processing (aphasia). A variety of other symptoms can accompany this type of

cerebrovascular accident.

Generally, intense headache, perhaps coincident with seizure or loss of bodilyconsciousness, is the first indication of a cerebral AVM. Estimates of the number of

AVM-afflicted people in the United States range from 0.1% to 0.001%.[1][2] of the

population.

Dia gnos isAn AVM diagnosis is established byneuroimaging studies. A computed tomography

scan of the head (head CT) is usually performed; this can reveal the site of the bleed.

More detailed pictures of the tangle of blood vessels that compose an AVM can be

obtained by using radioactive reagents injected into the blood stream, then observed

using a fluoroscope orMagnetic Resonance Imaging (MRI). A spinal tap (lumbar

puncture) can be used to examine spinal fluid for red blood cells; this condition is

indicative of leakage of blood from the bleeding vessels into the subarachnoid space.

The best images of an AVM are obtained through cerebral angiography. This

procedure involves using a catheter, threaded through an artery up to the head, to

deliver a contrast agent into the AVM. As the contrast agent flows through the AVM

structure, a sequence of X-ray images can be obtained to ascertain the size, shape

and extent of that structure.
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Pathoph ysio log yWhile the cause of AVMs remains unknown, the main risk is intracranial

hemorrhage. This risk is difficult to quantify. Approximately 40% of cases with

cerebral AVM are discovered through symptoms caused by sudden bleeding due to

the fragility of abnormally-structured blood vessels in the brain. However, some

patients may remain asymptomatic or have minor complaints due to the local effects

of the tangle of vessels. If a rupture or bleeding incident occurs, the blood may

penetrate either into the brain tissue (cerebral hemorrhage) or into the

subarachnoid space. This space is located between the sheaths (meninges)

surrounding the brain (subarachnoid hemorrhage).

Once an AVM bleeds, the probability of rebleeding may increase. However, as long

as the AVM is unruptured, the risk of hemorrhage may be relatively low.

AVMs that do not bleed may cause symptoms such as epileptic seizures, headaches,

or fluctuating neurological symptoms. Many of them may even remain

asymptomatic.

Trea tmentThe treatment in the case of sudden bleeding is focused on restoration of vitalfunction. Anticonvulsant medications such as phenytoin are often used to control

seizure; medications or procedures may be employed to relieve intracranial

pressure. Eventually, curative treatment may be required to prevent recurrent

hemorrhage. However, any type of intervention may also carry a risk of creating

new neurological deficits in about 10%.

In the U.S., surgical removal of the blood vessels involved (craniotomy) is the

preferred curative treatment for most types of AVM. While this surgery results in an

immediate, complete removal of the AVM, risks exist depending on the size and the

location of the malformation.
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Radiation treatment (radiosurgery) has been widely used on smaller AVMs with

considerable success. The Gamma Knife, developed by Swedish physician Lars

Leksell, is one apparatus used in radiosurgery to precisely apply a controlled

radiation dosage to the volume of the brain occupied by the AVM. While this

treatment is non-invasive, two to three years may pass before the complete effects

are known. Completeocclusion of the AVM may or may not occur, and 8%-10% of

patients develop long term neurological symptoms after radiation.

Embolization, that is, occlusion of blood vessels with coils or particles introduced by

a radiographically guided catheter, is frequently used as an adjunct to either

surgery or radiation treatment. However, embolization alone is rarely successful incompletely blocking blood flow through the AVM.

The benefit of invasive treatment for unruptured AVMs has never been proven, as

the risk of intervention may be as high as the spontaneous bleeding risk. An

international study is currently under way to determine the best therapy for

patients with unruptured AVMs
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CEREBROVASCULAR ACCIDENT

GENERAL INFORMATION:

What is a cerebrovascular accident? A cerebrovascular accident is also called aCVA, brain attack, or stroke. It occurs when blood flow to a part of the brain is

suddenly stopped and oxygen cannot get to that part. This lack of oxygen may

damage or kill the brain cells. Death of a part of the brain may lead to loss of certain

body functions controlled by that affected part.

What causes a cerebrovascular accident? A CVA may be caused by any of the

following:

A piece of fatty plaque (debris) that is formed in a blood vessel breaks away

and flows through the bloodstream going to the brain. The plaque blocks an

artery which causes a stroke. This is called an embolic stroke.

A thrombus (blood clot) formed in an artery (blood vessel) and blocked blood

flow to the brain. This is called a thrombotic stroke.

A torn artery in the brain, causing blood to spill out. This is called a cerebral

hemorrhage or hemorrhagic stroke. It often results from high blood pressure.

Blockage of certain small blood vessels inside the brain.

What puts me at a higher risk to have a cerebrovascular accident? The following

factors may put you at a higher risk of having a CVA:

Cigarette smoking, cocaine use, or drinking too much alcohol.

Diabetes (high blood sugar).

You or a close family member has had a stroke.

Atherosclerosis (hardening of the arteries) or fatty cholesterol deposits on

artery walls.

Heart disease, such as coronary artery disease.

High blood cholesterol (fat).

High blood pressure.

What are the signs and symptoms of a cerebrovascular accident? Signs and

symptoms of a stroke depend upon the part of the brain affected and how much

damage occurred. During a CVA, you may have numbness (no feeling), tingling,

weakness, or paralysis (cannot move) on one side of the body. You may have trouble


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Hemorrhagic (bleed) stroke: This type of stroke may require surgery.

Can a cerebrovascular accident be prevented?

Take your high blood pressure medicine regularly.

Do not smoke or drink too much alcohol. Alcohol is found in beer, wine,

liquor, like vodka or whiskey, and other adult drinks. Different people have

different ideas about what too much means. It is important to remember that

how often you drink is as important as how much you drink.

If you have atrial fibrillation (an irregular or fast heart beat), you may need

to take antithrombotic medicine. Having a recent heart attack may also

require you to take antithrombotics.

Keep your blood cholesterol level in a normal range. Eat foods low in fat to

decrease the risk of developing plaque (fatty deposits) in your blood vessels.

If you have hyperlipidemia (high blood cholesterol level), talk to your

caregiver about ways to lower it.

Monitor and control your blood sugar level if you have diabetes.

Head injury


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Is a trauma to the head, that may or may not include injury to the

brain (see also brain injury).

The incidence (number of new cases) of head injury is 300 per 100,000 per

year (0..3% of the population), with a mortality of 25 per 100,000 inNorth

America and 9 per 100,000 in Britain. Head trauma is a common cause ofchildhood hospitalization.

Types of head injury

Head injuries include both injuries to the brain and those to other parts of

the head, such as the scalp and skull.

Head injuries may be closed or open. A closed (non-missile) head injury is

one in which the skull is not broken. A penetrating head injury occurs when

an object pierces the skull and breaches the dura mater. Brain injuries may

be diffuse, occurring over a wide area, or focal, located in a small, specificarea.

A head injury may cause a skull fracture, which may or may not be

associated with injury to the brain. Some patients may have linear or

depressed skull fractures.

If intracranial hemorrhage, or bleeding within the brain occurs, a hematoma

within the skull can put pressure on the brain. Types ofintracranial

hematoma includesubdural,subarachnoid,extradural, and

intraparenchymal hematoma.Craniotomy surgeries are used in these cases

to lessen the pressure by draining off blood.

Brain injury can be at the site of impact, but can also be at the opposite side

of the skull due to a contrecoup effect (the impact to the head can cause the

brain to move within the skull, causing the brain to impact the interior of the

skull opposite the head-impact).

If the impact causes the head to move, the injury may be worsened, because

the brain may ricochet inside the skull (causing additional impacts), or the

brain may stay relatively still (due to inertia) but be hit by the moving skull.

Specific problems after head injury can include:

o Skull fracture

o Lacerations to the scalp and resulting hemorrhage of the skin

o Traumatic subdural hematoma, a bleeding below the dura mater

which may develop slowly

o Traumatic extradural, or epidural hematoma, bleeding between the

dura mater and the skull

o Traumatic subarachnoid hemorrhage
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o Cerebral contusion, a bruise of the brain

o Concussion, a temporary loss of function due to trauma

o Dementia pugilistica, or "punch-drunk syndrome", caused by

repetitive head injuries, for example in boxing or other contact sports

o A severe injury may lead to a coma ordeath

Symptoms

Presentation varies according to the injury. Some patients with head trauma

stabilize and other patients deteriorate. A patient may present with or

without neurologic deficit.

Patients with concussion may have a history of seconds to minutes

unconsciousness, then normal arousal. Disturbance of vision and equilibrium

may also occur.

Common symptoms of head injury include those indicative of traumatic

brain injury:

o loss of consciousness,

o confusion,

o drowsiness,

o personality change,

o seizures,

o nausea and vomiting,

o headache,

o a lucid interval, during which a patient appears conscious only to

deteriorate later

Symptoms of skull fracture can include:

o leaking cerebrospinal fluid (a clear fluid drainage fromnose, mouth

or ear) may be and is strongly indicative ofbasilar skull fracture and

the tearing of sheaths surrounding the brain, which can lead to

secondary brain infection.

o visible deformity or depression in the head or face; for example a

sunken eye can indicate a maxillarfracture

o an eye that cannot move or is deviated to one side can indicate that a

broken facial bone is pinching a nerve that innervates eye muscles

o wounds or bruises on the scalp or face.o Basilar skull fractures, those that occur at the base of the skull, are

associated with Battle's sign, a subcutaneous bleed over the mastoid,

hemotympanum, and cerebrospinal fluidrhinorrhea and otorrhea..

Because brain injuries can be life threatening, even people with apparently

slight injuries, with no noticeable signs or complaints, require close

observation. The caretakers of those patients with mild trauma who are
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released from the hospital are frequently advised to rouse the patient several

times during the next 12 to 24 hours to assess for worsening symptoms.

The Glasgow Coma Scale is a tool for measuring degree of unconsciousness

and is thus a useful tool for determining severity of injury. The Pediatric

Glasgow Coma Scale is used in young children.

Management

Unfortunately, once the brain has been damaged by trauma, there is no quick

fix. However, there are some steps that can be taken to prevent secondary

damage. If left untreated many patients with head injury will rapidly develop

complications which may lead to death or permanent disability. Prompt

medical treatment may prevent the worsening of symptoms and lead to a

better outcome. Medical treatment should begin at the scene of the trauma.

Paramedics will generally immobilize the patient to insure no further

damage to the spine or nervous system, insert an airway to insureuninterrupted breathing, and perform endotracheal intubation if indicated.

One or more IVs will be inserted to maintain perfusion status. In some cases

medications may be administered to sedate or paralyze the patient to prevent

additional movement which may worsen the brain injury. The patient should

be delivered promptly to a hospital with neurosurgical capabilities. The

management of brain injury requires the involvement of subspecialists who

are generally available only at larger hospitals. Primary treatment involves

controlling elevated intracranial pressure. This can include sedation,

paralytics, cerebrospinal fluid diversion. Second line alternatives include

decompressive craniectomy (Jagannathan et al. found a net 65% favorable

outcomes rate in pediatric patients), barbiturate coma, hypertonic saline andhypothermia. Although all of these methods have potential benefits, there has

been no randomized study that has shown unequivocal benefit.

Delirium- disturbance of consciousness and cognition
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- usually reversible, with acute onset

- usually secondary to some other condition or problems such as intoxication,

withdrawal, medical condition, severe stressors

CausesDelirium may be caused by severe physical or mental illness, or any

process which interferes with the normal metabolism or function of the

brain. For example, fever, pain, poisons (including toxic drug reactions),

brain injury, surgery, traumatic shock, severe lack of food or water or sleep,

and even withdrawal symptoms of certain drug and alcohol dependent states,

are all known to cause delirium.

In addition, there is an interaction between acute and chronic symptoms of

brain dysfunction; delirious states are more easily produced in people

already suffering with underlying chronic brain dysfunction.

A very common cause of delirium in elderly people is a urinary tract

infection, which is easily treatable with antibiotics, reversing the delirium.

A mnemonic for the myriad causes of Delirium is:

- Infections (Pnuemonia, Urinary Tract Infections)

- Withdrawal (Ethanol,opiate)

- Acute Metabolic (acidosis, renal failure, imbalances, alkalosis)

Trauma (acute severe pain)

- Central nervous system pathology (epilepsy, cerebral haemorrhage)Hypoxia

- Deficiences (vit b12, thiamine)

- Endocriopathies (thyroid, parathyroid, hypopituitarism,

hyper/hypoglycemia, Cushing's)

- Acute vascular (Stroke, MI, PE, heart failure)

- Toxins/drugs (prescribed - Tramadol, recreational)

Heavy metals

Assessment in clients with delirium


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- Review MMS exam in text

- Scrutinize the underlying cause

- Orientation to time (1st to go)

-Orientation to place

- Orientation to person (last to go)

- Distractibility

- Ability to converse

- Level of consciousness (alert, drowsy, stupurous)

- Illusions and hallucinations (type, specific, timing)

-Awareness of own deficit

S/SX of clients with delirium

- inability to focus attention, confusion and disorientation

- Memory formation and disturbance

- Abnormalities of awareness and effect

Nursing Intervention for clients withDelirium

- careful assessment, do what is appropriate to eliminate the cause

- meet physiologic needs: nutrition, hydration, sleep, appropriate level of

stimulation and pain relief

- safety: falls, wandering, IVs NGs pulled out easily, may strike out in fear

- Judicious use of antipsychotic anti-anxiety meds


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Communication with clients with delirium

- Short questions, instructions, no big words. Be patient

-

Check for comprehension, give instructions more than once, not in

condescending manner

- Face to face, normal tone voice, good light

- No sweet and meaningful calling etc.

Reality Orientation with clients with delirium

- Clocks, calendars, cues place prominently. Talk about it

-

Names on doors, Big

- Familiar routine, structure and staff

- Verbal reorientation to PPT as a naturation


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THROMBOLYTIC THERAPY

What is thrombolytic therapy?

Thrombolytic therapy is a treatment used to break up dangerous clots inside your

blood vessels. To perform this treatment, your physician injects clot-dissolving

medications into a blood vessel. In some cases, the medications flow through your

bloodstream to the clot. In other cases, your physician guides a long, thin tube,

called a catheter, through your blood vessels to the area of the clot. Depending on

the circumstances, the tip of the catheter may carry special attachments that break

up clots. The catheter then delivers medications or mechanically breaks up the clot.

Thrombolytic therapy commonly is used to treat an ischemic stroke, which is

another name for a clot in blood vessel in your brain. It can also be used to treat

clots in:

A lung artery, called a pulmonary embolism

The deep veins of your leg, called deep vein thrombosis (DVT)

Your heart, which may cause a heart attack

An artery elsewhere in your body, such as in an arm or leg artery; or

A bypass graft or dialysis catheter that has become blocked

Your blood is normally a liquid that travels smoothly through your arteries and

veins. Sometimes, however, blood components, called platelets, can form clumps

and, together with other blood components, can cause the blood to gel. This process

is called clotting or, more technically, coagulation. This is a normal process thatprotects you from excessive bleeding from even a minor injury. However, in certain

circumstances blood clots can build up inside a blood vessel and block blood flow. At

other times, pieces of these clots can break off, travel through your bloodstream,

lodge in a blood vessel somewhere else in your body and obstruct normal blood flow.

Blood clots in your heart or lungs, for example, can starve the organ and be life

threatening.

Depending upon the situation, your physician may decide to provide thrombolytic

therapy, also called thrombolysis, as an emergency treatment or as a scheduled

procedure to dissolve the blood clots. For example, you may receive emergency

thrombolysis if you are having a stroke. In some circumstances, if you have DVT ora blocked bypass graft, your physician may schedule thrombolytic therapy for you.

How do I prepare?

First your physician will ask questions about your general health, medical history,

and symptoms. In addition, your physician will conduct a physical examination.


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Together these are known as a patient history and exam. As part of your history and

exam, your physician will ask you to list any medications, including vitamins or

dietary supplements, you take. Some of these substances may affect your blood's

clotting ability. Your physician will also want to know when your symptoms occur

and how often.

Next, your physician will order tests to make sure that you are able to receive

thrombolysis safely. For example, he or she will check to see if your blood is clotting

properly and that other factors, such as the mineral salts in your blood, are normal.

The tests you will receive depend on which blood vessel is blocked and your medical

condition. For example, your physician may order an echocardiogram test to find

out whether there is a blood clot in your heart or an electrocardiogram (ECG) to

evaluate your heart rhythm.

Your physician will give you the necessary instructions you need to follow before the

thrombolysis procedure, such as fasting. Usually, your physician will ask you not to

eat or drink anything 12 hours before your procedure. Your physician will alsodiscuss with you whether to reduce or stop any medications that might increase your

risk of bleeding or other complications.

You will usually undergo a test called angiography either before or as part of

thrombolytic therapy. Angiography creates a picture of your blood vessels (called an

angoigram), and uses a dye, called contrast, which is eventually flushed out through

your kidneys. If you have kidney trouble, or if you have had a test that uses contrast

before and had an allergic reaction to the contrast, you should tell your vascular

surgeon. He or she may prescribe medications designed to minimize the chance of

problems with the contrast material.

Am I a candidate for thrombolytic therapy?

You may be a candidate for thrombolytic therapy if you have symptoms of a stroke,

heart attack, pulmonary embolism, DVT, or a clot in an artery or bypass graft in a

limb. These symptoms may include:

Chest pain

Numbness or tingling on one side of the body

Blurred vision in one eye

Slurred speech

Sudden weakness Severe swelling of an arm or leg; or

Pain, numbness, or coldness in a limb

If you have a life-threatening clot, your physician will attempt to establish

thrombolytic therapy as soon as possible after symptoms begin, preferably within 1

to 2 hours.


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To deliver the thrombolytic therapy, your physician will make a

small puncture over an artery or vein in your groin, your wrist,

or your elbow. This place is called the access site. Before inserting

the catheter through this puncture, he or she will clean your skin

and shave any hair. This reduces your risk of infection. Your

physician then will numb your skin with a local anesthetic andthen sometimes makes a small cut or puncture to reach the blood

vessel below. Although you may be given some mild sedation, you

will usually stay awake during the procedure.

Next, your physician will usually inject contrast through the

catheter to map your blood vessels with angiography and to

locate the clot. You may feel a warm sensation during the

injection, which is normal. As the contrast flows through your

blood vessels, x-rays are taken. The x-rays do not pass through

the contrast, so pictures of your blood vessels appear on a screen.

An indication of the clot location will appear as well.

Once your physician locates the clot, depending on the particular circumstances, he

or she may inject the thrombolytic drugs through an IV catheter. More commonly,

your vascular surgeon will guide a longer catheter through your blood vessels to the

vicinity of the clot and then inject the drugs near or into it. Because you have no

nerve endings in your blood vessels, you will not feel the catheters as they move

through your body.

Currently, the most common thrombolytic agents (clot-busting" drugs) are:

Streptokinase Urokinase; and

Tissue plasminogen activator (t-PA)

Other drugs include recombinant, or genetically engineered, t-PA (a newer version

of t-PA) and TNK (Tenecteplase.)

Your physician will periodically monitor the x-ray screen to see the clot breaking up.

However, depending on the size and location of the clot, the drugs your physician

chooses, and other factors, this process can take several hours. Sometimes, if you

have a severe blockage, the treatment could last for several days. Once the clot has

been dissolved or if it cannot be dissolved further, your physician will stop themedication. When the tests used to monitor your blood's coagulation ability are in a

satisfactory range, your physician will then remove the IV or catheter, and press on

the access site for 10 to 20 minutes to stop any bleeding. During the process, and for

several hours afterwards, your physician will ask you to remain still to minimize the

risk of bleeding from the access site.

The technique for mechanical thrombectomy is similar, except that small devices are

attached to the catheter tip remove the clot or even break it up physically. These


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devices include a suction cup, a rotating device, and a high-speed fluid jet.

Mechanical thrombectomy can work faster than thrombolytic drugs in some cases,

and in favorable circumstances the procedure may take as little as 30 minutes. You

physician will advise you if you are a good candidate for mechanical thrombectomy.

What can I expect after thrombolytic therapy?

Usually, you will stay in bed as you recover from thrombolytic therapy. During this

time, your physician and the hospital staff closely watch you for any complications.

You may receive fluids, antibiotics, or painkillers. If your physician inserted the

catheter through an artery in your arm or leg, you may have to hold the limb

straight for several hours. Once any bleeding from the access site stops, and your

vital signs are normal, you may be discharged. Often, however, you will require

further hospitalization for treatment of the underlying reason for the clot, or for

adjustment of anticoagulation doses if needed to prevent clots from reforming.

If you notice any unusual symptoms after or during your procedure, you should tellyour physician immediately. These symptoms may include:

Arm or leg pain that lingers or gets worse

A fever

Shortness of breath

An arm or a leg that turns blue, develops swelling or feels cold; or

Problems around your access site, such as bleeding, swelling, pain, or

numbness

Before your discharge, your physician will give you instructions about everyday

tasks to follow after you return home. For example, you should not lift more thanabout 10 pounds for the first few days after your procedure. You should drink

plenty of water for 2 days to help flush the contrast dye out of your body. You can

usually shower 24 hours after your procedure, but you should avoid baths for a few

days.

During your recovery, you may experience nausea, vomiting, or coughing. You

should tell your physician if any nausea, back pain or lightheadedness lingers,

because these symptoms could mean you have internal bleeding.

If you received thrombolytic therapy in an emergency, you may receive additional

care for your condition. For example, if you had a stroke, your physician mayprescribe medications, a special diet, or physical therapy. If you had a heart attack,

your physician may need to examine your heart to see if any other arteries are

blocked. If you had a blocked bypass graft, you may need further treatment or

anticoagulation to keep the bypass open.


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Are there any complications?

Complications are not unusual with thrombolytic therapy, which is why it should be

carried out under close supervision. However, your physician can manage most of

them, including:

Bleeding in the access site or elsewhere

Low blood pressure; or

Allergy to thrombolytic drugs

Bleeding in the brain leading to stroke, can also occur, but it is rare and affects

fewer than 1 in 100 patients.

Thrombolytic therapy is not always successful. In up to 25 percent of patients, the

treatment is unable to break up the clot. This is especially true if the clot has been

established for a long time. In another 12 out of every 100 patients, the clot or

blockage will re-form in the blood vessel, especially if an underlying reason for the

clot to form in the first place is not found and treated.

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