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Bill Klaproth (Host): When it comes to treatment of stroke, the administration of TPA can be a lifesaver. So let's learn more about TPA and when it's given. So, here to talk with us about stroke and the administration of TPA is Dr. Ilkcan Cokgor, a Neurologist and a member of the medical staff at MarinHealth. This is The Healing Podcast brought to you by MarinHealth. I'm Bill Klaproth.

Dr. Cokgor, thank you so much for your time. We really appreciate it on such an important topic. So what is TPA? Can you explain that to us? How, and when is it given?

Ilkcan Cokgor MD (Guest): Sure. So, thank you for having me for the program. I agree that stroke is a very important part of our lives, throughout our life. TPA is a tissue plasminogen activator in other words. T is the tissue and plasminogen activator. This is a generic name and it is given intravenously, and it is the only FDA approved thrombolytic agent for ischemic stroke for now. It came as Activases or alteplase. So you may hear those terms as well. Alteplase, Activase, and it is most of the time given for non-hemorrhagic strokes, which is called ischemic stroke. And it is a very strong, powerful blood clot buster. It is a lytic agent. Wherever there is a clot, it lysis as the clot, and that's why it has to be given fast. And it is given within the four and a half hours of the patients with ischemic stroke, most of the time in the emergency room.

Host: Got it. So, an ischemic stroke is one where the blood vessel is blocked. A hemorrhagic stroke is one where the blood vessel has burst. Is that right?

Dr. Cokgor: That's correct. There are two different strokes and the ischemic means a blood clot is obstructing the blood flow from passing to a brain tissue. And that brain tissue is being jeopardized to die.

Host: And the TPA then helps dissolve that blood clot.

Dr. Cokgor: Yes, exactly.

Host: Got it. Okay. So, then when a patient is having a stroke, how do you decide on the administration of TPA versus no TPA?

Dr. Cokgor: The history is exactly what we need right away. We always try to talk to the patient. If they are not able to respond, if they are not able to speak because of their speech difficulty effected from the stroke or altered mental status, we try to reach the family right away. It is extremely crucial to learn the timing when the stroke symptoms exactly started. So that's the first thing. Then we start asking the questions. If the patient is already on potent blood thinners, not aspirin or Plavix, but Coumadin, warfarin, heparin, like the blood thinners. The third question we ask is when exactly, what the patient was doing. Did they have any head injury?

Did they have any surgery recently? Did they go through any kind of cancer treatment or trauma? These are the history questions that we have to go through to be able to see if the patient is eligible or not. The eligible patients usually are within the four and a half hours when the stroke started.

And we prefer sooner because every few minutes, 2 million neurons are dying. And that's why the goal is to give the TPA within 90 minutes of showing to ER and from the initial states of the symptoms. The patient must not be on any blood thinners, must not have had a heart attack, spinal surgery, brain surgery, or injury within the three weeks time. Main artery's must not be interrupted by punctures or surgeries either.

And if the patient is having clinically neurologically proven stroke like symptoms; like one-sided weakness, numbness, speech, difficulty, and so on, that's when we decide to TPA.

Host: So you've got to go through a whole checklist then to evaluate the patient before deciding on whether to give TPA or not.

Dr. Cokgor: That's correct. For example, blood pressure cannot be too high because that can cause hemorrhagic stroke from the TPA. We check the heart rate. We check the blood pressure. We check the platelet count and the bleeding time, and we are trying to do everything against the time as well. Our goal is within 60 minutes, to administer the TPA.

Host: Okay, so then let me ask you this, Dr. Cokgor, what is a thrombectomy? What is that? And when is it performed and how?

Dr. Cokgor: Thrombectomy means to take the thrombus out of the blood vessels. It is only done in big University centers or where there is an interventional neuro radiologist. These are stent like devices where the neuro radiologist goes through the groin, like we do angios, but they go all the way to the brain vessels.

And it could be from groin or from axilla, from the carotid artery. We try to reach the brain and we try to retract the clots. Thrombectomy is first done by giving intra-arterial TPA right at the blood clot site. And we see, we are looking through angio at the same time to see if the clot being lysed. If the clot is not lysed with the direct TPA to the blood vessel or to the clot, then we retrieve retract a clot by stent like devices.

Host: So the thrombectomy is usually done in conjunction with the TPA?

Dr. Cokgor: Unfortunately, not always, it is only and only done when there is a large vessel occlusion. There are patients, most of the patients come with smaller vessel, small vessel strokes, they are called lacunar strokes. They may not affect the big arteries, but the small arteries. Small arteries are not very visible and the clot cannot be retrieved easily because there is a hemmorhagic risk more. So, the study is based on the main biggest arteries, and usually are, they are the middle cerebral artery, anterior cerebral artery or internal carotid artery. These strokes are usually massive. They are devastating to the patient and that's when thrombectomy is the best effective.

Host: So when there's a large vessel occlusion, or what is known as an LVO, that is when you usually perform the thrombectomy?

Dr. Cokgor: Yes. That's correct.

Host: Got it. Okay. Tell us about stroke imaging techniques and how that helps you. Of course, there's the CT scan, the CTA and the CT perfusion. Tell us about stroke imaging techniques.

Dr. Cokgor: When a patient comes to the emergency room, the very, very first test they do is a CT scan. This is plain, no dye, nothing, because we want to rule out the hemorrhagic stroke. So to CT of the brain can show you either normal looking brain or a bleed or a stroke already in evolution. It gives us information about the timing, the type of the stroke and so on.

Then we administer TPA, if it is safe. And then we send a patient to CTA, which is called CT angiogram. CT angiogram is done to look for small vessel or large vessel occlusion. It salso shows arterial dissections, arterial trauma, aneurisms and venous and arterial malformation. So it is very important to see what is causing the stroke by CT angio. Third technique is rather newer. Not every hospital has it, but almost every community hospital, now is getting it, CT perfusion. CT perfusion is done to see if there is a salvageable tissue. It is a very good computer program and it is color coded that even every doctor can see what we call mismatch. Mismatch means already dying tissue versus penumbra, which means unfortunately getting ischemic, but still salvageable tissue. CT perfusion gives us a mismatch where we notice scar tissue can't be saved, but the salvageable tissue can. If there is a mismatch in the perfusion, then we are faster in giving the TPA or sending the patient to get the thrombectomy. Embolectomy, transferring the patient to bigger hospitals to salvage that tissue. That's where the CT perfusion is valuable.

Host: Yeah, this is very important, the tools that you use, especially these stroke imaging techniques. Well, Dr. Cokgor, this has really been fascinating. Anything else you want to add about the administration of TPA for someone listening?

Dr. Cokgor: TPA is a strong medicine, which may cause a 7% bleeding in any part of the body or even in the brain. However, it's a very potent medicine and it definitely dramatically helps us to reverse the stroke symptoms, reverse the mortality, improve the disability within three months.

So the studies showed quite a bit improvement thanks through the TPA within the last 20 years. However, the patients have to keep in mind as soon as they feel like they may have some stroke,symptoms. They should call the 911 or run to the emergency room right away. Otherwise it may be too late to give TPA.

Time is brain. It is essence. Everybody should read about the stroke symptoms, keep them in mind and think of TPA.

Host: Absolutely. And remember, speed is important. Time is brain like Dr. Cokgor just said, thank you so much for your time. This has really been informative. We appreciate it. Thank you again.

Dr. Cokgor: Thank you for having me.

Bill Klaproth (Host): And once again, that's Dr. Ilkcan Cokgor. And for more information, please visit mymarinhealth.org. And if you've found this podcast helpful, please share it on your social channels. And check out the full podcast library for topics of interest to you. This is The Healing Podcast brought to you by MarinHealth. I'm Bill Klaproth. Thanks for listening.