“A new era has dawned for brain salvage,” says John Whapham, a neurosurgeon at Loyola University Hospital.
On a Saturday night earlier this year, Fidencio Nuñez, a 48-year-old cook at Shanahan’s in Forest Park, had just finished preparing a batch of seafood jambalaya. That’s when a coworker noticed that Nuñez was losing his balance and was unable to hold on to a chair with his left hand. A waitress called 911, and an ambulance soon whisked the married father of three to the closest hospital and then on to the Stroke Center at Loyola University Hospital in Maywood. A large clot was preventing blood and oxygen from getting to the right side of Nuñez’s brain, and it was so big that a drug called TPA (tissue plasminogen activator)—essentially Drano for clogged pipes in the cranium—could not dissolve it and restore blood flow.
Nuñez was experiencing a stroke. This affliction, the third-leading killer in the United States, occurs when blood vessels to the brain either burst (a hemorrhagic stroke) or are blocked by a clot (an ischemic stroke). Both events prevent the delivery of oxygen to the brain and, as a result, cause cells to die.
But fast work and a high-tech assistant helped avert disaster for Nuñez. After receiving a page, Sarkis Morales-Vidal, a neurologist at Loyola, used his home computer to examine Nuñez remotely via a robot at the hospital that was equipped with a stethoscope, a microphone, and a full-color high-definition camera. (The robot transmits test results and images, such as CT scans, to the doctor, who can see, hear, and talk to the patient, the patient’s family, and the medical team.) Morales-Vidal also notified the Loyola neurosurgeon John Whapham, who conducted his own examination of Nuñez from home. “We prepare proactively so we don’t lose time,” says Whapham, who can also remotely monitor patients traveling to a hospital by ambulance or helicopter.
After he got to Loyola, Whapham inserted a microcatheter the width of a pencil lead into Nuñez’s thigh; the microcatheter entered the femoral artery and from there traveled to Nuñez’s brain. Whapham then used a special tool to break up the clot and another device to suck the debris from the brain like a vacuum cleaner. “We create a road map with dye,” he says, “and then we steer, sort of like a video game, using these giant monitors.” With this procedure, instead of enduring a significant head wound, stroke patients, Whapham notes, “can go home with a Band-Aid on their leg.”
The quick, high-tech treatment is a game changer. “It can make the difference between the person who walks out and the person who’s dead,” says Whapham. “The next morning, [Nuñez] was watching football in his bed”—and he was back home within two days. “A new era has dawned for brain salvage,” Whapham declares.
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Each year, about 795,000 people in the United States experience a stroke—610,000 of them for the first time—and, according to the American Heart Association, between 15 and 30 percent are permanently disabled. But those numbers could go down: As of March 1st, with patients who have exhibited symptoms of stroke for less than six hours, ambulances bypass local emergency rooms and head straight for one of 19 stroke centers in the Chicago area. “Mortality is lower if you’re treated at stroke centers,” says Shyam Prabhakaran, the neurologist who directs the stroke program at Rush University Medical Center. (He is also a spokesman for the American Heart Association and chaired the committee that proposed the new stroke center policy.)
The holy grail of stroke research remains the discovery of a way to restore brain function months, or even years, after a stroke occurs. The secret may lie in blocking a protein called Nogo-A, which prevents the brain’s nerve fibers, called axons, from forming new connections. At Loyola University, Gwendolyn Kartje (who is also chief of neuroscience at the Edward Hines Jr. V.A. Hospital) is jump-starting the growth of nerve fibers in the brains of rats that have had strokes, which could reverse much of the damage. As Kartje reported in the journal Stroke in January, she induces strokes in aged rats to figure out how still-healthy parts of the brain can form new connections and take over for damaged areas. Kartje gives the rodents a drug made by Novartis that turns off Nogo-A so the brain regains a more youthful plasticity.
Illustration: Daniel Stolle
Thus far, doctors are conducting human trials of the medicine only on people with spinal cord injuries. But Kartje has demonstrated that the treatment also works for rodent stroke victims. With this new drug, she says, “the brain could totally rewire.” Meanwhile, someday—“really way off, 20 years, maybe more”—stem cells might be able to replace all the dead cells in the brain, even neurons, says Kartje.
Doctors are also working on some promising, if less lofty, ideas. For example, Richard Bernstein, an associate professor of neurology at Northwestern University’s Feinberg School of Medicine, is testing a way to determine which patients had strokes because of a fast, irregular heartbeat known as atrial fibrillation. Since the condition prevents the heart from pumping properly, blood can pool in the heart and clot, and in some instances those clots travel to the brain—which is why about 15 percent of people with atrial fibrillation who have had a stroke will suffer a second one.
To counter that negative effect, Bernstein implants a device the size of a flash drive in the chest of patients who have experienced a stroke of unknown causes. The device, manufactured by Medtronic, can detect atrial fibrillation; a regimen of blood thinners could then dramatically reduce the risk of another stroke. (To join the study at Northwestern, which has the largest enrollment of a dozen or so test sites in the United States, call 312-503-4394 within 90 days of a stroke of unknown cause.)
On another front, the FDA approved in April the use of the Pipeline Embolization Device, which reconstructs arteries in patients who suffer from hemorrhagic strokes. Locally, doctors at Rush have begun implanting the device in about three to five patients a week; the hospital is one of eight sites in the country—and the only one in Chicago—that is performing the procedure.
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With the growing use of new technologies and treatments and a greater reliance on stroke centers, the number of happy endings is increasing. Take Helene Czarnecki, 74, a type 2 diabetic who had her first heart attack at 64 and was part of Rush’s heart failure clinic for her atrial fibrillation. On February 2nd, the day after 20 inches of snow had fallen on Chicago, she was chatting on the phone with her daughter Charlene. “As we’re talking, in the middle of a sentence, she says, ‘Rrr, rrr,’ and drops the phone,” Charlene remembers. “I looked at my sister and said, ‘Call 911. Mom just had a stroke.’” (Helene was so weak that she couldn’t even reach the button on her Life Alert necklace.) The two sisters also called their mom’s brother, who lived upstairs from Helene. His incorrect diagnosis, as Charlene recalls it: “She’s fine. She just can’t talk.” Fortunately, the paramedics arrived quickly and shoveled their way to the front door.
When the sisters arrived at MetroSouth Medical Center in Blue Island, their mother was completely paralyzed on her right side and could not speak. “She would move her mouth, and nothing came out,” says Charlene. An ambulance hurried Helene to Rush—on the way, paramedics administered TPA, but to no effect—where the neurosurgeon Demetrius Lopes removed the clot. Later, a cardiologist told Charlene that the stroke was so big that her mother would have died without the intervention.
Today, Helene Czarnecki understands everything said to her. She can’t always spit out every word in response, but she often is incredibly articulate. For instance, says Charlene, instead of telling her physical therapists that she wants some water, Helene will announce, “I’m looking for some liquid refreshments”—a remark that speaks volumes.