New technologies make clearing blocked arteries quicker and easier, helping minimize brain damage and facilitating more rapid and complete recovery.
Three years ago, 31-year-old Brandon Klinetobe ran seven miles with a friend to calm his nerves before taking his wife, Janel, to Edward Hospital the next day for a scheduled Caesarian section to deliver the couple’s second child.
The next morning, Janel Klinetobe rushed her husband to Edward after he woke up with symptoms of a stroke.
“I was already having the stroke when we woke up,” the Romeoville resident recalls. “I knew we were supposed to go to the hospital to have our daughter, but I couldn’t seem to get dressed. Janel drove while I sat there in the car, disoriented and not knowing what was happening. When we got there, I got out of the car and immediately had to hold myself up on a trash can because my whole right side was weak. I tried to walk in the doors, but I couldn’t coordinate my arms and legs, so someone put me in a wheelchair and took me to a nurse. Then I tried to talk to the nurse, but she looked at me like I was an idiot, and that’s what told me I wasn’t really speaking coherently.”
Klinetobe had a blood clot blocking his basilar artery, a major blood vessel in the back of the brain, explains Dr. Ali Shaibani, director of the Edward Neuroscience Institute and the neurosurgeon who operated on Klinetobe. After an intravenous infusion of the clot-dissolving drug tissue plasminogen activator (tPA) failed to break up the clot, Shaibani removed it surgically with one of the latest advances in stroke treatment — the stent retriever, commonly called “stentriever,” that let him snag the clot and pull it out of the artery.
“Stentrievers are one of the newest, best tools we now have to extract clots,” Shaibani asserts. “They’ve enabled us to stop strokes within minutes of first seeing the patient.”
Many other advances are also helping west suburban neurologists stop strokes in their tracks and help patients recover afterward. In fact, more patients than ever are leaving the hospital a day or two after their strokes with few or no side effects.
“If a patient recognizes the first symptoms of a stroke and comes into the ER right away, he can save millions of brain cells and experience a much more positive outcome than if he waits and lets the stroke progress,” says Dr. Ryan Cramer, a neurosurgeon at Advocate Hinsdale Hospital. “The biggest challenge we face is educating the public just how important that is. Time is the most important aspect of stroke treatment. Once the artery is blocked, the clock starts ticking because neurons start dying immediately.”
The first thing ER nurses and doctors do is evaluate the patient’s symptoms to be sure he’s having a stroke rather than another type of brain bleed or a severe migraine.
As in Klinetobe’s case, they’re looking for disorientation, weakness or paralysis primarily on one side of the body, trouble speaking and trouble controlling facial muscles. They also repeat their observations while patients are undergoing tPA treatment. “I had to look at pictures and try to describe what was happening in them,” recalls Klinetobe. “I had to read sentences from the kind of kiddy books that my son is reading now in kindergarten. And every few minutes people were asking me to smile so they could see if I was getting my facial control back.
“I was so tired, I just wanted it all to stop,” continues Klinetobe. “Then my father brought in my son, Cameron, who was 3 at the time. He said, ‘Daddy got ouchie,’ and kissed me on the cheek. At that moment, I told myself, whatever happens, this is not how I’m going to go out.”
Before starting a potentially life-saving intravenous tPA drip, doctors have to determine whether it will do more harm than good. First, they have to figure out whether the patient’s stroke is ischemic — caused by an arterial blockage that’s preventing blood from reaching part of the brain — or hemorrhagic, which happens when a blood vessel in the brain ruptures and floods the brain tissue with blood. Although about 85 percent of all strokes are ischemic, they have to be sure because giving tPA to a hemorrhagic stroke patient could be deadly.
“Administering a powerful blood thinner like tPA to a patient who’s bleeding into the brain is like adding fuel to a fire,” explains Dr. Harish Shownkeen of Cadence Health Systems, which includes Delnor Hospital in Geneva and Central DuPage Hospital in Winfield. “It would increase the rate of bleeding instead of stopping it.”
In the past, neurologists had to rely on outside observation to determine which type of stroke a patient had. Now they can use CT scanning to see inside the brain and look for bleeding. Some area hospitals, like Edward, now offer biplane angiography equipment that can provide detailed views of the brain in two planes at once, helping doctors pinpoint the exact site of a clot or brain bleed so they can reach it surgically as quickly as possible. “It can make a big difference in the time it takes to stop a stroke and stabilize the patient,” notes Shaibani.
If the patient’s stroke turns out to be ischemic, CT scans can also help doctors pinpoint when the stroke started. Research shows that tPA doesn’t help patients unless it’s administered within four and a half hours of the stroke’s onset, so it’s critical to know when the patient first experienced symptoms. Other disqualifying circumstances include recent use of blood thinners such as warfarin, sold as Coumadin, and recent surgery. “We’re exploring new ways to extend the four and a half hour window with other clot-busting drugs and procedures,” says Dr. Jose Biller of Loyola Medical Center in Maywood.
About two-thirds of patients who receive tPA need no further emergency treatment. The remaining third, plus patients who don’t qualify for tPA, go into surgery to have their arteries cleared endoscopically.
The first endovascular device hit operating rooms in 2004, says Cramer. Called the Merci device, it looks like a tiny corkscrew placed at the tip of a surgical catheter. A neurosurgeon inserts the device into the patient’s femoral artery near his groin, then threads it through the arterial system until it reaches the clot blocking a cerebral artery. Then the surgeon twists the corkscrew into the clot and pulls it back out through the body, much like removing a cork from a wine bottle with a very long, twisting neck.
While the Merci device offered new hope to thousands of patients, it’s sometimes hard to implant firmly into the clot. In 2008, the Penumbra aspiration system provided a catheter-mounted suction device to vacuum clots out of blocked arteries. “It’s a powerful type of straw,” explains Cramer. “It’s also successful, but nowhere near perfect.”
The last two years have seen the advent of stentrievers — flexible wire mesh stents that a neurosurgeon can compress and insert at the tip of a catheter like the Merci and the Penumbra, then push into a clot. Once the stentriever is firmly lodged in the clot, the surgeon can expand it, which not only enmeshes the clot in the stent for easy removal, but restores circulation immediately by opening a channel through the clot for blood to proceed into the brain.
A different type of stent, called a coil, can help stop brain bleed in some types of hemorrhagic stroke. When a cerebral artery develops an aneurysm or a hole, a surgeon can implant a tiny coil of platinum wire — usually about the width of a human hair — to plug the hole or seal off the aneurysm and divert blood flow through the artery, Shownkeen explains. Unlike stentrievers, the coil remains in the blood vessel permanently. Introduced in the mid-1990s, coiling is now used in 70 to 80 percent of brain bleed cases, he adds.
While hemorrhagic strokes are far rarer than ischemic strokes, they’re often much harder to treat. Heavier bleeds caused by head trauma or severe high blood pressure often require full brain surgery, explains Dr. William Ashley, a neurosurgeon at the Stroke Center at Loyola University Health System in Maywood.
Hemorrhagic strokes hurt the brain in two ways. First, pooling blood in the brain compresses arteries, blocking blood flow much like an ischemic stroke does. Second, blood and spinal fluid becomes trapped in the brain tissue, forcing it to swell. Without surgery to relieve the pressure, swollen brain tissue can be crushed against the inside of the skull, permanently damaging it.
“Sometimes we’ll perform a hemicraniectomy, in which we remove part of the skull to relieve the pressure until the brain shrinks back to normal size,” Ashley explains. “It not only saves lives but reduces the amount of brain damage.”
During a hemicraniectomy, the surgeon usually removes about a quarter of the skull dome over the site of the stroke. The skull section is either frozen until it’s replaced or, more rarely, stored inside the patient’s abdomen where it can stay viable by being bathed in bodily fluids.
Once the scalp incisions heal, patients can spend most of the six-week recovery period at home before returning to have the bone surgically restored, though some patients choose not to have their missing skull sections replaced at all.
“People can do fine without the missing bone over their brains,” says Ashley. “Many patients choose to have the bone replaced for safety or cosmetic reasons, but some simply don’t want to go through another surgery.”
Once a stroke is over, most patients face rehabilitation lasting anywhere from a few days to the rest of their lives. While patients with minor strokes who seek treatment right away often walk away with few or no side effects, the average patient will spend two or three weeks in an inpatient treatment facility like Marianjoy Rehabilitation Center in Wheaton, followed by six weeks of outpatient therapy and an indefinite amount of time doing exercises at home to continue regaining lost physical and mental abilities.
Like neurologists, rehab therapists have several new high-tech devices they can use to help patients improve as quickly as possible. “With all the recent advances, we’re being more aggressive in getting people mobile faster,” says Jennifer Matern, an occupational therapist at Edward Hospital’s rehabilitation and sports medicine clinic. “We try to get them walking or at least moving in bed 24 hours after they’re treated.”
Therapists use magnetic resonance imaging to see which parts of the brain respond and which don’t while patients are performing therapy — and while they aren’t. “The MRIs allow us to see what the brain is doing even if the patient isn’t actually doing anything physical,” Matern explains. “Just imagining performing a motion activates the areas of the brain that control that motion, so we can get an idea of what type of therapy patients need to retrain their brains.”
Therapists have evolved their philosophy from relying on movement-based exercises to using more occupational therapy to help patients regain the motor functions they used most often before their strokes.
“We use functional tasks to retrain motions, with a greater focus on repetition,” Maltern says. “At first it’s very frustrating for the patients. They’re constantly asking why we keep telling them to do something they can’t do. But then the miracle occurs — their bodies suddenly regain the ability because their brains have trained new neurons to take over. It’s such a thrill as a therapist seeing people drink or write for the first time after their strokes. They’re always so happy.”
Klinetobe spent about 18 months in therapy, both in treatment and on his own, before he felt fully recovered from his stroke. Unlike many stroke patients, he left the hospital four days after his stroke without going through inpatient therapy. Though he did not lose the ability to walk, he did have to regain strength and balance in his legs. After four months, Klinetobe tried running for the first time since the seven-mile stretch he did the day before his stroke. “It took me 35 minutes to run one mile, but I felt a real sense of achievement because I hadn’t let the stroke take running away from me,” he asserts. He has since gone on to run two marathons.
But Klinetobe felt the most elation and gratitude five days after the stroke, when he and Janel returned to Edward to give birth to daughter Parker Grace.
“I can’t say enough in praise of the doctors and nurses,” he says. “They made it possible for me to be there for my new daughter, my son and my wife. I’m thankful for that every day of my life.”