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All seven Medical Spheres ›If a blood clot blocks a vessel in the brain, a clot-dissolving medicine can reopen it. Thrombolysis is an option in the first few hours – usually up to four and a half hours after symptoms begin – and only if there is no bleeding.
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Guide values based on the guideline. Whether thrombolysis is an option is decided by the medical team case by case.
Thrombolysis
Most strokes happen because a blood clot blocks an artery in the brain. The tissue beyond it no longer receives a blood supply. At the core it dies quickly; at the edges it is at risk for a while, but not yet lost. Thrombolysis – dissolving the clot with medication – is all about this border zone: if blood flows again in time, brain tissue there can be preserved.
The medicine is given through a vein and boosts the body’s own breakdown of clots. Because it affects blood clotting throughout the body, it must first be established that no blood has leaked into the brain. This is shown by a CT or MRI scan of the head. Blood tests, a blood pressure measurement and questions about pre-existing conditions, recent operations and current medication are also part of the assessment.
The specialist societies’ guideline generally provides for thrombolysis within four and a half hours of symptom onset. If the time of onset is unknown – for instance because someone woke up with the signs – what counts is the time the person was last seen without symptoms. In such cases, and sometimes even after more than four and a half hours, special imaging can show whether salvageable tissue remains and thrombolysis is an option. The basic rule is: the earlier treatment starts, the greater its potential benefit.
If a large artery in the brain is blocked, the medicine is often not enough. The clot can then also be removed with a catheter. This thrombectomy is standard at larger stroke centres; smaller stroke units work with such a centre for this purpose and transfer patients there after the initial diagnostic tests.
The treatment
The medicine is intended to dissolve the clot so that blood flows back into the affected area of the brain and the nerve cells receive oxygen.
The aim is to reduce paralysis and problems with speech and vision, and to preserve independence. How much it achieves varies from person to person.
Before any thrombolysis, the benefits are weighed against the risk of bleeding. With certain pre-existing conditions or medications, it is not an option.
The procedure
As little time as possible should pass between arrival and the start of thrombolysis. That is why many things happen at the same time.
The ambulance service alerts the hospital in advance. In the emergency department, a brief neurological examination follows, and staff ask exactly when the symptoms began.
A CT scan of the head shows whether there is any bleeding. Often, a contrast agent is used at the same time to image the blood vessels in the brain and detect a major blockage.
Blood test results, blood pressure, pre-existing conditions and medication are all taken into account. Where possible, patients or their relatives are briefly informed about the benefits and risks.
The clot-dissolving medicine is given through a vein. Blood pressure and symptoms are monitored continuously throughout.
Close monitoring follows on the stroke unit, especially during the first 24 hours. During this time, blood pressure is kept below an upper limit.
Repeat imaging of the head shows how the tissue has responded and whether there has been any bleeding. After that, measures to prevent a further stroke begin.
Insurance
Statutory health insurance
Thrombolysis, monitoring on the stroke unit and any necessary transfer to a specialist centre are covered by German statutory health insurance. In Wertheim, treatment takes place at the Bürgerspital, the hospital with a public healthcare mandate.
In an emergency, treatment comes first. Relatives can bring the health insurance card and medication list later.
Private insurance or self-pay
Private health insurance and Beihilfe (the German civil service healthcare allowance) cover medically necessary emergency treatment according to their terms; self-pay patients are billed directly.
Acute treatment is the same for everyone. Afterwards, privately insured and self-pay patients in Wertheim can also choose the Main-Tauber-Klinik, the private clinic in the same building.
Specialists
The emergency department and neurology decide together whether thrombolysis is an option. Listed here are the two neurologists from the team at the Bürgerspital and the Main-Tauber-Klinik.
Locations
Each clinic shows on its own website how the treatment works there.
Germany
Thrombolysis on the local stroke unit of the Bürgerspital, a hospital with a public healthcare mandate, with a central emergency department open around the clock; the Main-Tauber-Klinik in the same building is there for privately insured and self-pay patients.
Frequently asked questions
Because thrombolysis is only possible within a limited period. So make a note of when the signs began. If this is unclear, what counts is the last time the person was definitely free of symptoms – for example, when they went to bed.
For example, people with bleeding in the brain, those who have recently had major surgery or bleeding, people with certain clotting disorders and those taking some blood-thinning medicines. Very mild deficits that do not interfere with everyday life also often count against it. The team assesses every case individually.
The main risk is bleeding, most seriously in the brain itself. The gums, puncture sites or the stomach and bowel can also bleed. Rarely, the lips or tongue swell up due to an allergic reaction. That is why patients are closely monitored during and after thrombolysis.
Not always. Some people notice an improvement during the treatment itself, for others it only becomes apparent in the following days, and sometimes there is none. How much recovers varies from person to person.
The removal of the clot using a catheter that is advanced through the artery in the groin up into the blocked blood vessel in the brain. It is an option when large arteries in the brain are blocked, often in addition to thrombolysis. For this, patients are transferred from Wertheim to a cooperating centre that performs the procedure.
Tell the ambulance crew and the emergency department, ideally showing your medication list. Which medicine, what dose and when it was last taken: this determines whether thrombolysis is possible or whether a thrombectomy is more likely to be considered.
A few days on the stroke unit follow: searching for the cause, a swallowing test, therapy that starts early and prevention of a further stroke. After that, patients move to a general ward, go home or go to rehabilitation.
Consultation
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Alster-Klinik Hamburg · Original in GermanÜber die ehrliche Einschätzung
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