Stanford Stroke Center - Stanford Hospital & Clinics - Stanford University Medical Center

Stanford Stroke Center

Location:	Stanford Hospital 300 Pasteur Drive Stanford, CA View a map

Room/Suite:	A301

Mailing Address:	701 Welch Road, Suite 325B Palo Alto, CA 94304

Contact Phone:	(650) 723-4448

Fax Number:	(650) 723-4451

Days and Hours:	Monday-Friday 8:30 am - 8:30 am

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Stroke Treatment

Surgical Navigation for locating and treating AVMs

CyberKnife radiosurgery

The Stanford Stroke Center brings together physicians from multiple specialties, including neurology, neurosurgery, neuroradiology, internal medicine and emergency medicine to provide comprehensive evaluation and management of patients with cerebrovascular diseases.

Neurology Faculty

Greg Albers, MD
David Tong, MD
Christine Wijman, MD
Mimi Yenari, MD

Neurosurgery Faculty

Gary K. Steinberg, MD
Steven Chang, MD

Neuroradiology Faculty

Michael Marks, MD
Huy Do, MD
Barton Lane, MD

Treatments include medical therapies, advanced surgical techniques and neuroradiology procedures. The Center is at the forefront of new developments in drug therapy for emergency treatment of stroke and stroke prevention. Patients have access to the latest medical therapies, some in clinical trials, including thrombolytics, neuroprotective agents, anticoagulants, and antiplatelet agents.

Stanford has pioneered several new surgical techniques for patients with arteriovenous malformations and aneurysms: stereotactic microsurgery, cerebral revascularization, and hypothermia. Stereotactic radiosurgery and interventional neuroradiology are also offered. The Stroke Center emphasizes acute intervention for optimal results.

The Stanford Stroke Center, one of the first centers of its kind in the United States, is pioneering new approaches to the diagnosis and treatment of stroke, and offers patients significantly improved chances for recovery. The center brings together scientists and clinicians from a variety of backgrounds who are working to provide improved diagnoses and more effective treatments for victims of stroke. New medications, advanced surgical techniques, and innovative interventional neuroradiology procedures are among the effective options now available for stroke patients.

Stroke Diagnosis and Evaluation
A stroke occurs when blood vessels carrying oxygen to the brain burst or become blocked, damaging the brain cells' ability to control sensation, movement, or function, and eventually causing the nerve cells to die. The most important risk factor for stroke is hypertension (high blood pressure), which weakens artery walls and promotes atherosclerosis (thickening of the arterial lining). Atherosclerosis, in turn, narrows the arteries and reduces blood flow.

The ability to pinpoint quickly the precise location of a stroke and determine the extent of damage is critical in making treatment decisions during a stroke emergency. For instance, the physician must be able to quickly determine whether the stroke is ischemic (arising from a blocked blood vessel) or hemorrhagic (bleeding caused by bursting of a blood vessel) before the appropriate therapy can begin.

The Stanford Stroke Center is one of the few places in the country that has more than a dozen state-of-the-art brain diagnostic devices available to obtain in-depth information about a patient's status. These highly sensitive tools are of critical importance in diagnosing abnormalities that place a patient at high risk for stroke, such as a blocked blood vessel or the presence of an aneurysm or AVM.

To obtain complete diagnostic information, several (but not all) of the following diagnostic studies may be performed during an evaluation for stroke or stroke risk.

Computerized Tomography (CT) Scan is generally the first diagnostic test done after a patient with a suspected stroke arrives in the emergency room. It is used to quickly distinguish between ischemic and hemorrhagic strokes. The test involves the use of low-dose X-rays to visualize the brain.

Magnetic Resonance Imaging (MRI) is an advanced diagnostic tool that provides a high level of anatomic detail for precisely locating the stroke and determining the extent of damage. Due to its high level of sensitivity, MRI is especially useful when the stroke involves small blood vessels. The technology involves use of a strong magnetic field, and is performed in a special room free of metallic equipment. Recently, there have been great advances in the early detection of stroke using diffusion (DWI) and perfusion (PWI) weighted imaging. These methods allow early and more accurate detection of acute stroke, improving our ability to treat patients with cerebrovascular problems. Stanford has been a leader in the development of this technique.

Magnetic Resonance Angiography (MRA) is a noninvasive technology for imaging the cerebral blood vessels, and yields valuable information regarding blood supply to the brain. The use of intravenous contrast agents has provided great improvements in accurately viewing the cerebral blood vessels. Many such techniques have been pioneered by researchers at Stanford.

Transcranial Doppler (TCD) is a new, noninvasive ultrasound procedure that allows the assessment of blood flow through the cerebral vessels via a small probe placed against the skull. TCD is a portable test that can be performed frequently at the patient's bedside to follow the progress of medical treatment for stroke.

Xenon CT Scanning is another new noninvasive imaging method that uses the inhalation of the inert gas xenon to measure blood flow in various brain regions.

Carotid Duplex Scanning is a noninvasive study to diagnose blockage in the carotid arteries. This technology involves recording sound waves that reflect the velocity of blood flow.

Radionuclide SPECT Scanning provides data on relative blood flow using the radionuclide Technetium99.

Positron Emission Tomography (PET) Scanning, which measures brain cell metabolism, can determine if brain tissue is functioning even if blood flow to that area appears to be diminished.

Cerebral Angiography (angiogram) requires injection of a contrast dye through a major artery (usually the femoral artery in the thigh) for evaluation of blood flow to the brain. This procedure is completed in Stanford's Cath/Angio lab. The procedure time is approximately two to three hours; bed rest for six hours is required after the procedure.

Transesophageal Echocardiography involves placing a flexible tube in the esophagus (tube to stomach) to directly image the heart.

New Pharmaceutical Treatments and Emergency Care
Stanford neurologists, neurosurgeons, and radiologists are collaborating on studies to develop and evaluate effective medications for stroke prevention and emergency treatment. Drug therapy is a relatively recent approach to the treatment of stroke, and such research is based on the belief that drugs can minimize stroke damage.

The Stanford Stroke Center is participating in FDA-approved clinical trials of a number of promising pharmaceuticals.

Drugs for Emergency Care
Much of the damage caused by a thrombotic or embolic stroke occurs in the first few hours after the event. Research has focused primarily on the development of new clot-dissolving drugs and medications (neuroprotective agents) that make the brain more resistant to stroke.

Medications that dissolve clots are known as thrombolytic agents. Experimental data and pilot clinical studies suggest that if given within the first few hours after stroke onset, these drugs may dramatically minimize stroke damage. Following is a brief description of these and two other promising therapeutic approaches:

Thrombolytic Agents. Tissue plasminogen activator [tPA], widely used to dissolve clots that cause heart attacks, is now being used to dissolve artery-blocking clots in the brain during the critical early stages of stroke. Administration of tPA early after a stroke reduces neurological damage significantly. The drug is most effective when administered within the first three hours of stroke onset but is being tested at Stanford for selected patients up to six hours after stroke onset.

Neuroprotective Agents. Medications that make the brain less susceptible to the damaging effects of a stroke are called neuroprotective agents. Several of these new drugs are being evaluated in clinical trials at Stanford.

Hypothermia. In experimental models, cooling of the body is one of the most effective therapies for stroke. Stanford is involved in clinical trials of acute hypothermia.

It is not yet known which stroke patients are the best candidates for these neuroprotective drugs or whether the drugs will be consistently effective. The medications are investigational and authorized by the FDA for use only in randomized clinical trials; as a result, not every eligible emergency stroke patient will be able to receive them.

Drugs for Prevention
Researchers at the Stanford Stroke Center are evaluating a number of medications that help prevent stroke in high-risk patients, particularly those who have had a previous transient ischemic attach (TIA) or minor stroke. These drugs fall into two major categories: anticoagulants (such as heparin and warfarin) and antiplatelet agents (such as aspirin and ticlopidine).

Anticoagulants may be given orally or intravenously. These drugs work by thinning the blood and preventing clotting. They are also used for deep vein thromboses and pulmonary emboli.

Antiplatelet agents work by preventing or reducing the occurrence in the bloodstream of a phenomenon known as platelet aggregation. When there is damage or injury to a blood vessel, platelets (one type of blood particle) migrate to the scene to initiate a healing process. Large numbers of platelets clump together (aggregate) and form what is essentially a plug. This aggregation can sometimes result in formation of a thrombus (blood clot) that may block the artery or break loose and block a smaller artery. By preventing this, antiplatelet agents can reduce the risk of stroke in patients who have had TIAs or prior ischemic strokes. Antiplatelet studies are underway at Stanford to determine the most effective ways to administer these agents.

A number of other drug therapies are also under investigation at Stanford. The development of effective preventive medications will continue to be a major goal of the Stanford Stroke Center.

Advanced Surgical Techniques
Surgery is an accepted way of preventing stroke for patients with certain conditions. A number of conventional surgical techniques have been in use for some time, including "clipping" aneurysms to prevent further bleeding and removing AVMs. Clinicians at the Stanford Stroke Center are pioneering several new surgical techniques for patients with AVMs or aneurysms once considered impossible to treat because of their location or size.

Carotid Endarterectomy. Carotid endarterectomy is used to remove atherosclerotic plaque from the carotid artery when this vessel is blocked. It has recently been proven that for certain patients with minor strokes or TIAs, carotid endarterectomy is highly beneficial in preventing future strokes. This procedure is also beneficial for some patients with blockage of the carotid arteries who have not had previous symptoms.

Stereotactic Microsurgery for AVMs and Aneurysms. Stereotactic microsurgery is one of the most dramatic new surgical procedures for AVMs and certain aneurysms that were once considered untreatable. It employs sophisticated computer technology to pinpoint the precise location of the AVM. This technique allows neurosurgeons to locate the AVM within one or two millimeters so they can operate, using microscope-enhanced methods and delicate instruments, without affecting normal brain tissue.

Stereotactic Radiosurgery for AVMs. Stereotactic radiosurgery is a minimally invasive, relatively low-risk procedure that uses the same basic techniques as stereotactic microsurgery to pinpoint the precise location of the AVM. Once located, the AVM can be obliterated by focusing a beam of radiation that causes it to clot and then disappear. Due to the precision of this technique, normal brain tissue usually is not affected. The procedure is generally performed on an outpatient basis.

Hypothermia. During surgical treatment of aneurysms and AVMs, there is a small risk that the patient may have a stroke while on the operating table. Stanford physicians are using a technique known as hypothermia (cooling of the body), to prevent stroke during surgical treatment of giant and complex aneurysms or difficult AVMs. Dropping the brain temperature gives the surgeon the necessary time to operate with minimal risk of surgery-induced stroke. Special equipment known as a cardiopulmonary bypass machine is sometimes used to completely shunt blood flow away from the brain while the body is placed under deep hypothermia.

Revascularization of the Blood Supply. Revascularization is a surgical technique for treating aneurysms or blocked cerebral arteries. The technique essentially provides a new route of blood to the brain by grafting another vessel to a cerebral artery or providing a new source of blood flow. Stanford is at the forefront of advances in revascularization techniques.

Interventional Neuroradiology Techniques In addition to new medications and surgical techniques, the Stanford Stroke Center is pioneering a number of new interventional radiology procedures to prevent stroke in patients with selected high-risk AVMs, aneurysms, and partially blocked arteries. These endovascular procedures are performed within the blood vessel.

Endovascular Treatment of Aneurysms. Endovascular treatment of aneurysms is a new interventional neuroradiologic technique that greatly benefits patients with serious medical conditions who are unable to sustain the stress of surgery. Platinum coils developed at Stanford are guided into the aneurysm via a catheter, creating a clot that effectively closes the aneurysm off from the surrounding circulation, preventing the risk of hemorrhagic stroke in the future.

Endovascular Treatment of AVMs. Endovascular treatment of AVMs is also available at Stanford. One innovative form of treatment involves use of a "super glue" substance introduced via a tiny catheter to reduce the size of the AVM and facilitate further microsurgical or radiation treatment. In some cases, it is possible to completely block off and cure the AVM with endovascular treatment alone.

Angioplasty and Stenting of Vessels in the Neck and Brain. Angioplasty and stenting of vessels in the neck and brain are other new endovascular procedures available at only a few institutions nationwide. Cerebral angioplasty is similar to a widely used cardiology procedure, and is used to open partially blocked vertebral and carotid arteries in the neck, as well as blood vessels within the brain. Stenting of carotid or vertebral arteries and large cerebral veins involves use of a fine, tubular wire mesh to hold the vessel open.

Patient Care
In addition to the diagnostic and therapeutic services offered by the Stanford Stroke Center, a full spectrum of allied patient care services is available. To ensure that emergency care is administered as expeditiously as possible in the case of stroke victims, Stanford offers 24-hour emergency helicopter and fixed-wing transport through its Life Flight program. The Emergency Department staff provide an early and essential communications link in the identification and treatment of stroke patients.

After care in the Emergency Room or the Intensive Care Unit (ICU), stroke patients are generally admitted to the Inpatient Neurology or Neurosurgery Unit for continued observation, treatment, and eventual rehabilitation. During their hospital stay, patients receive care from a dedicated interdisciplinary team.

Stanford Stroke Rehabilitation Services
Stanford offers a wide variety of rehabilitation services for stroke patients, including inpatient services in the Comprehensive Inpatient Rehabilitation Unit and several types of outpatient therapies. The program features an interdisciplinary team approach, including the following:

Physicians
Physical, occupational, and recreational therapists
Speech/language pathologists
Neuropsychologists
Clinical social workers/case managers
Dietitians
Rehabilitation nurses

Because of tremendous advances in stroke treatment, along with the ever-increasing sophistication of rehabilitation techniques, the outlook for stroke patients has never been more hopeful.

The ultimate goal of rehabilitation is to return the patient to as independent a lifestyle as possible. Successful stroke rehabilitation is dependent on many factors, including the severity of brain damage and the cooperation of family and friends. Not surprisingly, the attitude of the patient is a key factor in speed and degree of recovery. A positive outlook and high level of determination may facilitate recovery.

Depending on the area of the brain affected by the stroke, physical and mental damage may be mild or severe, ranging from dizziness and confusion, to sensory loss, to paralysis and even death. Patients with mild strokes or those who obtained successful medical therapy may need little or no rehabilitation.

After a stroke, other blood vessels may be able to take over for the damaged blood vessel. This allows some cells to recover, although others may still die. If the blood supply is cut off due to a clot, the body works to dissolve the clot. This means that the damaged part of the brain can sometimes improve or return to normal without rehabilitation. Most stroke patients, however, will benefit from some type of rehabilitation.

Stroke Disabilities
Different areas of the brain control different bodily functions. When certain brain cells are not able to function due to stroke, the parts of the body controlled by those cells are also unable to function. For instance, if the left hemisphere of the brain is damaged, most of the effects will occur on the right side of the body. It's also important to note that most areas of the brain will continue to function normally, despite substantial damage in other areas.

Some of the most common results of a stroke are hemiparesis (paralysis on one side of the body), aphasia (the loss of ability to speak or to understand language), spatial-perceptual deficits, learning difficulties, memory loss, behavioral/emotional changes, and loss of motor skills.

If someone you know has suffered some of these disabilities as a result of stroke, there are many community resources available that can help you cope with the situation and learn how to provide the proper support and encouragement. The Stanford Stroke Center can provide you with an up-to-date list of community resources.

Support Groups
Stanford offers a Stroke Support Group for patients and their families. Participants have the opportunity to increase their knowledge of diagnostic and treatment options, and develop problem-solving and coping skills. The support group is intended to be a forum where patients and their families can share experiences and concerns about rehabilitation, depression, and other daily concerns. All patients, at any stage of treatment, are encouraged to participate.