Thursday, January 17, 2013

Upping the Odds of Stroke Recovery

Emergency room doctors face a quandary when a patient rolls in with a stroke: is it due to a clot blocking the brain’s blood supply (ischemic) or to a burst blood vessel (hemorrhagic)? The clot-busting drug tPA is lifesaving if it’s an ischemic stroke, but destructive if it’s a bleeding stroke. It also must be given within 4.5 hours of the stroke’s start, but only about 5 percent of people arrive in time.

Few hospitals in the nation can perform the delicate balancing act it takes to diagnose and start treatment as well as Massachusetts General Hospital. “We now treat 100 percent of those who are eligible for tPA, over 70 percent within an hour of arrival in our ER,” says Lee Schwamm, MD, director of the Mass General Acute Stroke Service and vice chairman of Neurology.

New Englanders who aren’t near Boston also benefit from Mass General’s top-tier stroke care through a telemedicine for stroke program the hospital pioneered 14 years ago. More than 30 hospitals around New England are signed up for the Telestroke Service, says Dr. Schwamm.

“Delays in therapy related to traveling long distances for care lead to poor outcomes,” he explains. The Telestroke Service provides round-the-clock consultations and remote treatment via teleconferencing. “It leverages our expertise to the broadest possible community, one of our highest priorities.”

In many ways, the history of advances in stroke and cerebrovascular disease (diseases affecting blood vessels supplying the brain) is the history of the Mass General Stroke Service, points out Dr. Schwamm. The famed Mass General neurologist C. Miller Fisher, MD, who died in April 2012, was the father of modern stroke neurology. His frameworks for diagnosing and managing stroke underpin many advances in the past 50 years. Mass General also led the way in using brain imaging, critical to the diagnosis and treatment of stroke, and was first in the nation to have a neurointensive care unit.

Despite much progress, every four minutes someone dies from a stroke and about half of those who survive a stroke are left with significant disabilities. One major area of research is to identify the genetic factors that predispose someone to stroke or that are associated with better or worse outcomes after one. For example, Natalia Rost, MD, MPH, associate director of Mass General’s Acute Stroke Service, and her group have identified abnormalities in the brain’s white matter that appear to have a role.

“It’s like a footprint of pre-existing damage related to diseased blood vessels in the brain,” says Dr. Rost. Using MRI scans, she has developed a way to calculate how much of this so-called white matter hyperintensity is present. They’ve discovered that the larger the burden of it in stroke patients, the greater the chance of a worse outcome after their stroke. That information, plus personal history (age, gender, smoking history, glucose, cholesterol and blood pressure levels, for example) as well as genetic make-up from collected blood samples are entered into a statistical model they’ve created. “It will give us the power to personalize stroke care in the future and will be vital for designing the next generation of therapies,” she says.

In the future, other advances may come from the synergy of heart and brain specialists working together to prevent and treat interrelated problems that affect both organs, such as blood clots. The Mass General Institute for Heart, Vascular and Stroke Care, which was launched in the fall, will help take advantage of these commonalities to accelerate discoveries that will benefit even more patients.

When Dr. Schwamm was an MGH neurology resident in 1992, there was no approved therapy for stroke. “Over the past two decades, we’ve seen a transformation in stroke care with a dramatic growth in our ability to help stroke patients.”

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By Ellen Barlow

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