As a new generation of treatments emerges for stroke, several Maryland hospitals are gearing up, creating teams and streamlining emergency room procedures to make sure stroke victims are handled as aggressively as trauma and heart patients.
In stroke, every minute now counts.
If someone gets to the emergency room within a crucial three-hour window of noticing stroke symptoms, a clot-dissolving drug, called t-PA, can reopen their blocked artery, restore blood flow and prevent fatal or disabling brain damage. The drug is expensive and risky. But its use -- and a new group of drugs and surgeries in the pipeline -- are revolutionizing the way organized medicine responds to stroke.
At the University of Maryland Medical Center, which has perhaps the most extensive effort, a new Brain Attack Team stands ready to give t-PA if a patient qualifies. When a stroke victim hits the entry door, several members of the "BAT" team buzz around the patient, drawing blood, asking questions, doing neurological exams. Lab work is returned within a half-hour. The patient is put in a designated bed, several feet from the CT scanner, so doctors can quickly see the brain's vascular system.
"Sometimes a little chill goes through me, that I was able to make some small change potentially in a patient's disability," said Dr. Marian LaMonte, the neurologist who heads Maryland's team. "We're right on the brink now of a whole new way."
In the past, there was little physicians could do. Some patients were given drugs to try to prevent a second stroke. But most people were simply put to bed and monitored for complications.
This year, the U.S. Food and Drug Administration approved t-PA, for tissue plasminogen activator, made by Genentech under the brand name Activase and already widely used in heart attacks. Compared with stroke victims given a placebo, patients given t-PA were at least 30 percent more likely to have minimal or no disability three months later, according to a published study.
Administered intravenously, at $2,200 a dose, t-PA is a genetically engineered copy of an enzyme that occurs naturally in the body.
"It's sensational. It's the first treatment for acute stroke that actually works -- in the whole history of medicine," exclaimed Dr. Robert Wityk, co-director of the division of neurology at Sinai Hospital. In January, he developed a protocol for using the drug and devised a structured exam that nurses administer to patients as a way to monitor any side effects.
The Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, St. Agnes Health Care and Carroll County General Hospital are among those where the drug is beginning to be used.
"Every day, we hear of a new hospital gearing up to do this, with special teams or other approaches. It's spreading like wildfire now," said Dr. Robert Bass, executive director of the Maryland Institute for Emergency Medical Services Systems.
Some hospitals, including Howard County General and the five in the Helix Health System, are not using t-PA for stroke.
Others, such as Anne Arundel Medical Center, are evaluating the possibility.
Bass said his agency doesn't yet plan to direct paramedics and ambulance personnel to send stroke patients to those hospitals that use the drug, because there isn't enough data to prove it's worth it.
"We're monitoring it very closely," said Bass, citing studies that showed several other clot-busting drugs had no benefit in stroke. He advised people who suspect they are having a stroke to immediately go to the nearest emergency room.
The National Institute of Neurological Disorders and Stroke is developing standards for the drug.
Dr. Richard T. Johnson, neurologist in chief at the Johns Hopkins Hospital, sees t-PA as only a small part of the stroke revolution. Researchers at Hopkins and the University of Maryland Medical Center are studying a variety of potential interventions, including applying surgical and radiological techniques used on the heart, such as angioplasty, to the brain. Drugs called "neuroprotectants," are being tested to see if they can slow the death of brain cells.
About 500,000 Americans suffer a stroke every year, leaving 150,000 dead. Nationally, it's the third-leading cause of death and a major cause of disability. About 80 percent of strokes are ischemic, meaning a blood clot has plugged an artery in the neck or brain. In the remaining 20 percent of strokes, called hemorrhagic, a blood vessel bursts, bleeding into the brain. In both cases, the brain cells, starved of oxygen, die.
Since t-PA can cause bleeding in the brain, it should be avoided in hemorrhagic strokes, and recipients must be monitored closely. Many factors may disqualify a patient, including head trauma, uncontrolled high blood pressure and taking blood-thinning medications. Of 25 people screened by Maryland's team, none has qualified.
The most important factor, though, is beating the three-hour deadline. The average stroke victim waits up to 12 hours before calling a doctor or going to an emergency room, physicians said.
"If grandfather is in the corner and grabs his chest in pain, people take him to the hospital," Johnson said. "But if his mouth drops to one side, people are more likely to put him in bed and check him in the morning."
Sudden weakness or numbness of the face, arm or leg on one side of the body.
Sudden dimness or loss of vision, particularly in one eye.
Confusion and loss of speech, or trouble talking or understanding speech.
Sudden severe, unexplained headaches.
Unexplained dizziness, unsteadiness or sudden falls, especially along with any of the other symptoms.