Stroke victims can receive treatment up to 24 hours later
Published 12:00 am, Sunday, February 18, 2018
Paul Lee woke up two weeks ago unable to move his left arm or leg. He had suffered a major stroke.
By 2 p.m. that Saturday, Lee, lying awake on the operating table at Yale New Haven Hospital, realized he could move his limbs. He was back at his New Milford home that Tuesday, “99 percent back,” according to his wife, Ann Marie Lee. “It’s just a miracle what Yale did over the weekend,” she said.
Just a few months ago, Lee, 69, wouldn’t have had a chance.
With stroke, timing is everything. And the time available to save patients from severe paralysis or worse has recently been extended so far that Dr. Charles Matouk, who took out the clot from Lee’s artery, said it’s nothing short of a revolution in public health. Matouk is chief of neurovascular surgery at Yale New Haven.
“To crystallize it, the main issue with treatments that are geared toward acute stroke is the time window in which therapies need to be administered to effect a good outcome,” Matouk said.
There are two basic treatments for ischemic stroke, which are caused by blood clots and account for 87 percent of incidents, according to the American Stroke Association. (The rest are hemorrhagic strokes, caused by bleeding in the brain.)
The first, which became available only in 1996, is tissue plasminogen activator, known as tPA, which is a blood thinner. But it can only be used within 41/2 hours of when symptoms occur, or 41/2 hours since the patient had last shown no symptoms. After that, there is too great a risk of hemorrhaging, said Dr. Hardik Amin, a Yale New Haven vascular neurologist.
The second method is mechanical thrombectomy, in which a catheter is pushed up the arteries from the groin to the clot. A device at the end of a metal wire, called a stent retriever, is pushed into the clot and expands, then is pulled out of the body along with the clot. That was the procedure that Matouk used on Lee. But while thrombectomy has been available for 10 years, only Yale New Haven and Hartford hospitals are equipped to do it.
Also, until the publication of two studies in the last three months and the development of specialized imaging software that helps determine who is eligible for the procedure, a thrombectomy could only be performed within six hours of when the patient was last known to be stroke-free.
Lee had gone to bed at 2 a.m. Saturday and woke up at 9. He had already gone past the previous deadlines for both treatments. But the new guidelines, issued Jan. 24 by the American Heart Association, the American Stroke Association and the Joint Commission, which accredits health care organizations, increase the window of time in which a thrombectomy can be performed to as much as 24 hours.
Lee’s chances were improved by his overall good health, his anatomy, which allowed blood to get to the part of his brain through blood vessels other than the blocked carotid artery, and the decision by doctors at New Milford Hospital, consulting with Matouk and Amin, to send him by Life Star helicopter to New Haven. Amin is part of Yale New Haven’s Telestroke program, a group that consults with doctors at other hospitals in Connecticut.
But the flight would not even have been a consideration until just recently.
“The main gist is that in the past, patients were selected for treatment for stroke purely based on time criteria,” Amin said. “And now we’re able to use physiological data to treat patients who in the past would not have been offered anything.”
in stroke care
Once thrombectomies began to be used to treat stroke, “that extended the time window and people got a lot better,” Matouk said. “So what this therapy was geared at … was those strokes that caused the big problems, like paralysis or not being able to talk or not being able to understand people,” what Matouk calls “nursing home strokes.”
With the time window extended to six hours, “our stroke volumes in terms of doing this procedure” rose from 10 in 2013 to 180 in 2017, Matouk said. “It’s been a revolution in our ability to care for acute stroke. What’s different now is what these latest trials showed is up to 24 hours out for selected patients this treatment can be massively beneficial.”
The rate at which neurosurgeons were able to “reverse the course of terribleness” in stroke symptoms more than doubled. From being able to help one in seven patients, doctors were able to improve the quality of life of one in 2.8 patients. For surgical procedures, “that’s actually very good; that’s amazing,” Amin said.
‘A quick decision’
On that Saturday, when Paul Lee woke up, “I couldn’t figure out why I couldn’t get out of the bed,” he said. “I reached over and picked up my arm and it was like a dead body.”
The ambulance took a half-hour to get to Lee’s house before bringing him to New Milford, which is “kind of a little country hospital,” Lee said. But once they realized the situation, “it was pretty much a quick decision that the doctors made there,” Ann Marie Lee said. “The doctor at the ER, as soon as I got there he was on the phone with Yale. He called Yale right away to see if my husband was a candidate and they said yes, and they wanted him to come by a helicopter. … They wanted him there immediately.”
He arrived at 12:30 p.m., Amin said.
Soon after Ann Marie Lee arrived by car, “the doctors came out and they had smiles on their faces,” she said. “They were just so proud of themselves.”
“I was laying there on the table and all of a sudden I could move my hand,” Paul Lee said. It happened “almost instantaneously,” he said. “Even though the artery was completely blocked, I was getting blood from other vessels. There was enough getting there to survive.”
Besides not being able to move his left side, Lee’s “face was drooping and his speech was slurred,” Amin said. Before the new guidelines were issued, “He would have just been admitted to the hospital and would likely have gone on to have a full stroke (and) remain paralyzed on his left side.”
“What’s changed is there’s been new technology called perfusion imaging,” which shows how well blood is traveling through the body, Amin said. “We’re able to determine how much of a patient’s brain has died as the result of a stroke … or has not completed the full infarct,” or permanent death of the brain cells.
The CT scan shows how much of the brain has been “shocked” but not deadened by the lack of blood and how much is irretrievably lost, he said. “If we see that there’s a very small area of brain that’s completely infarcted from stroke but there’s a large area that’s at risk, then we select those patients for this delayed treatment because they’re the ones who are more likely to benefit.
“With our patient here, I was contacted by New Milford Hospital shortly after he arrived,” Amin said. “He arrived (in New Haven) within about an hour and he was taken straight to the scanner and on the perfusion imagery that he had we were able to see he had very little dead tissue and a significant amount of tissue at risk.”
and ‘back roads’
Matouk said Lee was fortunate in that he had a network of blood vessels, which he called “back roads” or collateral vessels, that brought blood to the areas that the blocked carotid, a “main road,” would have supplied.
“If the brain is getting some blood but not enough blood, it stops working and you get a dead arm and a dead leg,” Matouk said. “That area that wasn’t getting enough blood isn’t dead yet; (it) can be salvaged.”
But the collateral vessels are unable “to maintain the supply of blood indefinitely. Eventually the brain will die because it’s not enough blood to keep it alive,” he said. And while Lee has a good supply of collateral blood vessels, “some people are born without any back roads,” Matouk said.
The perfusion imaging lets the doctors see the difference between tissue that’s in a “stunned state” and brain cells that have died and cannot be revived.
In Lee’s case, “We saw he had very little irreversible injury and a large area of reversible injury,” Amin said. “We only learned that after he got that scan.”
“What’s new is we’re using it clinically to make decisions,” Matouk said. “There’s something to do about Grandma’s stroke now up to 24 hours later. … We just learned that a couple of months ago. … From my perspective this is a public health issue.”
One trial testing the effectiveness of thrombectomies over an extended time, called DAWN, was published online by the New England Journal of Medicine in November. The other, DEFUSE 3, was published in the journal Jan. 24.
“What’s shocking is that their outcomes are nearly as good as patients who get this treatment and are within six hours,” Matouk said. “From a public health point of view this is something people really need to know about.”
As soon as his surgery was complete, Lee wanted to get started right away with rehabilitation. “Things that didn’t work quite right I came up with things to improve them,” he said. He was having issues with balance and with his speech so he came up with ways to improve.
“I’ve always liked tongue twisters so I kept doing them out loud over and over,” he said. To improve his balance, “I kept walking in circles and figure eights and I would walk backwards.”
Now, “the only problem I have is when I floss my teeth” using his left hand.
“He went from not being able to move to almost perfect,” Ann Marie Lee said.
Paul Lee said, “They kind of lassoed this thing and pulled it out and that was it.”