Stroke of good fortune
A new technique that allows doctors to remove clots from the brain is being hailed as the biggest revolution in stroke treatment in 20 years.
A new technique that allows doctors to remove clots from the brain is being hailed as the biggest revolution in stroke treatment in 20 years.
Frank Blum has the body of a whippet and the handshake of a wrestler. Given the stroke that paralysed his right arm in June 2015, it is extraordinary that his “hello” is such a bone crusher. Blum, 53, was having a morning coffee with his family at their Huapai, Auckland, home when the blood clot in the middle cerebral artery on the left side of his brain took his speech, and his movement, mid-sentence.
He watched as the cup he held in his right hand dropped and smashed, while his arm, seemingly with a life of its own, flailed back and forth across the table before falling limply at his side. He opened his mouth to speak but no words came.
“He was looking straight through me,” says wife Yvonne, “and then he started to fall.” She rushed to his chair, wrapping her arms around him to keep him upright.
The timing of the stroke was Frank Blum’s first piece of luck. Many happen at night, during sleep, meaning by the time the patient wakes hours later, it’s usually too late to reverse the damage.
But Blum’s happened at 9.50am and by 10.35, he was being wheeled into North Shore Hospital’s emergency department for a CT scan.
Yvonne was told the clot was so large it was unlikely the usual treatment – a clot-busting
About 1.9 million neurons and 14 billion synapses are lost every minute after a stroke.
drug called alteplase given into a vein – would effectively dissolve it. His only hope was a new technique to remove the clot through a mesh-like retrieval device inserted through a catheter fed up into the brain from the femoral artery in the groin. Doctors gave him the drug anyway, then despatched him by ambulance to Auckland City Hospital – the only place nationally where the procedure is routinely done.
Blum arrived at 12.05, and within 40 minutes was under general anaesthetic in the angiography suite. By 3pm, Blum – who just a few hours before couldn’t speak or walk – was awake, fully functioning, and asking when he could go home. Within a fortnight, he was back doing the books for Yvonne’s pretzel business.
“It’s a miracle,” she says.
The Blums, who emigrated from Germany in 2007, say the procedure is available in their homeland in only a few centres, not including Hamburg where they lived. “You think Europe is quite ahead, but it’s awesome here,” she says.
Frank, who’s now on a blood thinner and a statin, is back surfing and gardening. His only reminder of the stroke is that he feels less fluent in English when he’s nervous.
“We can’t be more grateful,” Yvonne says. “This was his only chance. It was his only option. Without the surgery, he wouldn’t be sitting there the way he is now.”
Stefan Brew, one of three interventional neuroradiologists who handled Blum’s case, says although it was unusual in that the clotbusting drug partly dissolved the blockage before Blum’s clot was retrieved, it was likely that without the procedure he would have been unable to walk or speak after his stroke. “It’s tremendously satisfying.”
Stroke patients in whom the treatment works well often have no idea how close they’ve come to death or severe disability, Brew says. In December, he had a similarly miraculous result in an octogenarian who would otherwise have died or been left bedridden. “He’d had a terrible stroke, was paralysed, couldn’t speak and was showing no sign of comprehension before the clot was removed. I went to see him the next
morning on the ward and thought it was inconceivable he wouldn’t have had at least some sign of a stroke. He was standing up, had a towel draped around his neck and when I asked how he was feeling, he said, ‘Do you mind coming back in 10-15 minutes, I’m about to have a shower.’ It’s better than being thanked – but he had no idea how lucky he was. He would have stayed in hospital for weeks or months, or died. Instead, he goes home at 48 hours to his normal life. You don’t have to achieve that very often to make it worth doing.”
“This was his only chance. Without the surgery, he wouldn’t be sitting there the way he is now.”
COST BENEFIT
The equipment for each procedure costs $22,000, but weeks or months of hospital care costs many times that.
Neurologist Alan Barber, who heads a committee of specialists trying to introduce the procedure in Wellington and Christchurch, and later Waikato, says the technique is the biggest advance in stroke treatment in 20 years. “I’m a stroke neurologist, so I’m excited, but trust me, this is a major advance.”
He likens it to the revolution that occurred in cardiac treatment when emergency angioplasties were introduced in the early 2000s. “When I started neurology training,
stroke patients were the last people seen on the ward round, because there was no acute treatment, nothing you could do. People came in and you just watched them. They got good nursing care, good physiotherapy and speech therapy, but from a medical point of view, there was nothing we could do to prevent the damage happening, let alone try to reverse it.”
Although alteplase became available in 1995, it wasn’t routinely used for nearly a decade. Auckland District Health Board gave it to all appropriate patients from 2001, but it wasn’t until 2005 that all DHBs used it routinely.
Brew says until 5-10 years ago, an acute stroke patient who was paralysed or couldn’t speak might have a CT scan or they might not. They’d be admitted to hospital “where they either died or languished”, and might be sent to rehab or see a neurologist weeks later.
Now, he says, he’s frustrated if a patient has to wait more than 15 minutes for a CT scan, and patients are whisked to the angiography suite within minutes – the record last year was a patient who was having the catheter inserted in his groin just eight minutes after the ambulance pulled up at the hospital.
In local and international clinical trials
that ended last year, about one in five patients had outcomes such as Blum’s, with no and very little residual disability. For every 2.6 patients treated, one improved an average of one point on the stroke outcome scale (see box, page 14). Brew says because doctors are getting better at it, and patients are getting treatment more quickly, about a third will now recover virtually unscathed, with another third showing clear improvement – “going from terrible to reasonable”. For a third it makes no difference, possibly because the artery can’t be cleared, or irreversible damage has already occurred.
The technique is constantly being reviewed and improved, he says. He now combines clot retrieval with aspiration, and says after initially punching through the clot with the stentreiver device, he then does nothing for a couple of minutes, allowing the brain to “have a drink” with the slightly improved blood supply.
“You only need a little flow to keep the brain alive. It may not immediately work normally, but if you deliver 10-15% of the normal cerebral blood flow, you extend the time when the brain remains viable from 300 seconds to hours. It resets the time you’ve got to get the artery open and the clot out.”
He says, on average, it takes two to four attempts, and leaving the stent inside the
Patients in whom the treatment works often have no idea how close they’ve come to death.
clot for that period tends to help the clot bind to the stent, improving the chances of it being successfully withdrawn.
Brew says Auckland City Hospital has five interventional neuroradiologists skilled at the procedure and at least two are involved in every case. But with one of them on leave at any one time, and another with other commitments, he can’t guarantee the procedure will be available to every suitable patient who needs it. “We have yet to fail, but it’s only a matter of time.”
He and Barber are heavily involved in planning how the service can be extended in other main centres where few of the procedures have been done. Brew says there’s a necessary trade-off in the number of staff involved, and the caseload required to maintain the skills to do the procedure. Dunedin, for example, doesn’t have the population density for a service, and they’re proposing rapid air transport from outlying areas to Wellington, Christchurch and Auckland in the short term and perhaps Waikato medium-term.
NO MESSING AROUND
Speedy treatment is critical for the best outcomes, with about 1.9 million neurons and 14 billion synapses lost every minute after a stroke.
The doctors know when they begin the procedure that there will be a portion of the area beyond the clot – the infarct – that is unsalvageable. However, a wider affected area, known as the penumbra, can regain normal function if blood flow is restored quickly enough.
Although future trials will look at whether the time frame for the procedure can be pushed out from the current six hours poststroke to seven, it can cause catastrophic bleeding if blood flow is restored to tissue that’s dying or already dead.
Brew remains intensely frustrated that every patient who qualifies doesn’t get the procedure, but acknowledges considerable advances have been made in a short time – by medicine’s standards at least. “In the end, hundreds of people a year will be treated this way in New Zealand, and of those, a reasonable number will be transformed from being disabled into being independent.”
The procedure can be used only in socalled ischaemic strokes, rather than those caused by a brain bleed, and not all patients will be suitable. Ischaemic strokes make up about 85% of all strokes.
About 14% of ischaemic stroke patients are given the clot-busting drug at Auckland City Hospital – the national rate is about 8%. It must be given within four and a half hours of the stroke, meaning it’s already too late for those who wake up having had a stroke in the night, or who delay coming to hospital.
Of that 14%, about half have a big clot that can be removed. There is no age limit. “When we started, and this was still considered an experimental treatment, we weren’t allowed to treat people older than 60,” says Barber, “but after a year, we moved this out to 70 and subsequent trials showed there’s no difference in terms of good outcomes
“There’s no difference in terms of good outcomes between people older or younger than 80.”
between people older or younger than 80. But you have to use common sense. There are old 60-year-olds and young 90-year-olds.”
The oldest person treated so far was in their mid-80s, but Barber says he wouldn’t hesitate to treat someone in their 90s, “if they were driving to golf or delivering meals on wheels”.
Auckland has performed only about 100 of the procedures in the past five years, with the early cases being either sporadic, or part of the clinical trial. In the early days, only a few were done each year, but Barber says since June, 26 people have been treated.
“If anyone deserved the procedure, she did, because she’s always looked after her health.”
did, because she’s always looked after her health. I said if they didn’t want to do the operation, just turn off the switch because Raewyn wouldn’t want to live like that. She’d said all her life she wouldn’t want to live like that. They did the op.”
Although she couldn’t talk after the procedure, three weeks later she was well enough to walk by herself across a busy Ponsonby Rd to Peter’s birthday dinner. Five years on, she regularly walks 2km and can go up and down Jacob’s Ladder, a stairway between Westhaven Drive and St Marys Bay. She’s never needed help with showering or personal care and still enjoys cooking. They’ve travelled to Turkey and New York without a problem.
She tried to resume driving, but her early attempts to get back behind the wheel ended with a crash through a brick wall at their home.
The lack of speech, and the struggle to identify objects, despite knowing what they are, is her biggest disability. “When she was talking to friends about me one day, she used the expression, ‘that man who belongs to me’. And she referred to our son as ‘the boy that we made’.”
Barber now uses the couple as a “double act” to explain the procedure to medical students in twice-yearly lectures.
“If you met Frank Blum and not Raewyn, you wouldn’t appreciate how nasty a stroke can be,” he says. “A person in their twenties can’t imagine being disabled. A lot of them would think being paralysed down one side is worse than being dead. They need to see how happy Raewyn is, and how happy she is to be alive and doing things. It’s a philosophical thing.”
Jacobs, who owns the marine engineering business Ovlov Marine, says without the procedure, not only would Raewyn have been bedridden if she’d survived, but he would have had to give up work to look after her.
He says although she’s not fully back to being the woman she was, “she’s pretty good. Life could be a lot worse, I tell you. It saved my life, and it saved Raewyn.”
Although she couldn’t talk after the procedure, three weeks later she was well enough to walk by herself across a busy Ponsonby Rd.