Hospitals in Illinois and across the country are changing the way they treat strokes after a battery of recent clinical trials found that swift surgical intervention improves the odds that patients will function normally again.
Instead of trying to break up the clots that cause strokes using only intravenous medicine, hospitals are increasingly offering a surgery along with the medicine while also speeding up treatment to reduce brain damage.
In the most recent of a half-dozen studies published in the past six months, 60 percent of patients who received both the surgery and the medicine regained the ability to walk, talk and live independently, while just 35 percent who received only the medicine recovered to the same degree, according to an article published last month in the New England Journal of Medicine.
The findings have resolved doubts that for years have surrounded treatment of the country’s leading cause of disability, experts said.
“Finally there is good, solid, randomized, controlled evidence that it helps patients,” said Dr. Victor Urrutia, medical director of the Johns Hopkins Hospital Comprehensive Stroke Center in Maryland, who was not involved in the recent studies.
In the procedure, known as a mechanical thrombectomy, a tube is inserted into the patient’s femoral artery near the groin and guided to clots near the brain. The doctor then pushes a device to the end of the tube, where a tiny cylindrical piece of mesh expands to extract the clot, restoring blood flow.
Thrombectomies have been performed since at least the early 2000s with mixed results, surgeons said. As recently as 2013, published trials showed no definitive benefit to performing thrombectomies in addition to administering clot-busting medicine.
What’s new is the added focus on starting the procedure quickly, advances in the medical devices used and better selection of patients who might benefit from the procedure, said Dr. Jeffrey Saver, a University of California at Los Angeles neurologist and one of the lead authors of the most recent study.
In the trial, which included 196 patients in 39 stroke centers in the U.S. and Europe, doctors achieved a median time from emergency room arrival to groin puncture of 90 minutes, 30 minutes faster than current international guidelines, Saver said. The trial included only patients who could be treated within six hours of the onset of acute stroke symptoms, and only those with clots in the largest arteries.
Most doctors used the mesh-net devices, called stent retrievers, which proved more effective than earlier devices that more closely resemble corkscrews and more often cause internal bleeding, Saver said.
The trial was ended earlier than planned, he said, because it would have been unethical not to offer the surgery to all patients after it had been shown to be so effective.
At University of Chicago Medicine’s stroke center, the trials have injected a new degree of certainty into doctors’ talks with patients and their families about whether to initiate a thrombectomy, said Dr. James Brorson, the center’s medical director.
“We would have begun the discussion somewhat earlier and couched it in uncertain terms prior to now,” Brorson said.
Still, the procedure doesn’t work for everyone, and results vary, he said. Sharp turns can make some patients’ arterial systems difficult to navigate, and some clots cannot be removed, he said.
The U. of C.’s stroke center is one of seven in Illinois that offer thrombectomies at all hours and meet other standards that qualify them as “comprehensive stroke centers,” said Kathleen O’Neill, the American Stroke Association’s regional vice president of quality and systems improvement. Rush University Medical Center, which participated in the most recent trial, is another.
The two academic centers are the only ones in Chicago with the certification, O’Neill said, although other hospitals offer thrombectomies.
The state of Illinois does not officially recognize the comprehensive designation, but the General Assembly passed a bill to do so last summer. Administrative rules that will help establish uniform treatment routines across Illinois, starting with the patients’ first contact with emergency medical providers, could be finalized as early as this fall, O’Neill said.
Some emergency responders have already begun changing protocols, said Jack Fleeharty, the Illinois Department of Public Health’s division chief for emergency medical services and highway safety.
“Time is quality of life,” Fleeharty said, likening the new stroke responses to recent changes in heart attack protocols to transport patients as quickly as possible to a hospital with the appropriate device to treat the kind of heart attack they are having.
About 87 percent of strokes are caused by clots, which the body forms to heal wounds. Clots also can occur in cases of abnormal blood flow and other blood vessel injuries, and sometimes they are dislodged and travel in the bloodstream, according to the American Stroke Association. Clot-caused strokes are known as ischemic strokes.
Only a CT scan can determine whether a stroke is ischemic, but emergency medical technicians can use facial expressions and limb function to assess the severity of a potential stroke, Fleeharty said. When the stroke appears to be severe, some EMTs have started considering whether to take the patient to the nearest comprehensive stroke center, even if that is not the nearest hospital, Fleeharty said.
Many hospitals that don’t offer thrombectomies are equipped to do a CT scan and start administering the clot-busting medicine. Some patients are then sent elsewhere for surgery, though such transfers consume precious time.
Rush University Medical Center’s stroke center receives stroke patients directly as well as transfers from other hospitals, said Dr. Demetrius Lopes, co-director of the stroke center. Working as part of a team of five to eight people, he has restored blood flow to some patients’ brains within 90 minutes of their arrival, he said.
Ideally, everyone would live within 20 minutes of a comprehensive stroke center, he said.
“If we do what we did in the study, we’re going to save people from being disabled,” he said. “There’s no doubt about that. Can we do that consistently and offer it to the whole population of Chicago? That is the challenge now.”
One patient who recovered nearly completely after a thrombectomy is Joseph DeVita, a 49-year-old Algonquin man who woke up one day in December and found he could not move to shut off an alarm clock.
“I couldn’t understand why it was happening” DeVita said. “I never in a million years thought I was having a stroke.”
His wife called an ambulance and he was transported to Advocate Sherman Hospital in Elgin. A CT scan there indicated he was having a stroke, and he was transported to Advocate Lutheran General Hospital in Park Ridge, where Dr. Thomas Grobelny performed a thrombectomy, DeVita said.
DeVita checked out of the hospital eight days later. The only physical reminder of the stroke is a dull ache in his right arm, he said.
Grobelny called DeVita’s recovery “completely remarkable” and said it should remind middle-aged people to learn the signs of stroke. Experts recommend using the acronym FAST: “face drooping, arm weakness, speech difficulty, time to call 911.”
Grobelny said he has been performing thrombectomies since 2001. He said the biggest factor behind the better outcomes for patients is the developments in the medical devices.
“We’re entering this new age of finally proving to everyone that stroke is a treatable disease,” Grobelny said.
Along with being the leading cause of disability, stroke is the fifth-leading cause of death in the country, according to the American Stroke Association. About 795,000 people have a stroke each year, and the number is expected to rise as baby boomers grow older. About 5,300 Illinoisans had a stroke in 2014, with 2,092 in Cook County, according to the Illinois Department of Public Health.
Common risk factors for stroke include high blood pressure, high cholesterol, heart disease, obesity, diabetes and cigarette smoking, along with age, heredity and past strokes or heart attacks. Women have more strokes than men each year, and African-Americans die of stroke at a higher rate than Caucasians.
There are about 75 comprehensive stroke centers in the country now, said Saver, the UCLA neurologist. He estimates that adequate access would require as many as about 400.
This story was produced in partnership with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.
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