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Striking back at stroke

Stroke Center’s rapid response pays off when every minute counts

This past April, Wayne Stoner, 42, was lying on the love seat in his home outside Little Falls, Minnesota, when the first attack occurred.

His daughter was hosting a sleepover for her birthday, and she’d just told her dad that she was looking for a spare pillow. But when Stoner tried to answer, he discovered that he couldn’t move or speak clearly.

“That spell lasted about 30 seconds; then I came to and went out to get some air,” he recalls.

Two weeks later, he had a recurrence—this time when the alarm clock went off for work. Stoner lay unable to move for about a half a minute, then got up, glanced at himself in the mirror, and decided, “I look fine.”

He wasn’t worried. Even though he smoked a pack to a pack and a half of cigarettes a day—and had a family history of stroke and heart disease—he says, “I thought my health was wonderful.”

Stoner’s state of denial ended abruptly with yet another attack later that weekend, when he experienced slurred speech and severe dizziness while watching a movie at home with his wife, Brigette. The following Monday, his family doctor ordered an MRI of his head.

Just days later, Stoner met with Adnan I. Qureshi, M.D., executive director of the University of Minnesota’s Stroke Center, who told him he’d been experiencing TIAs, or transient ischemic attacks. Sometimes called “mini-strokes,” TIAs are a red flag for an impending major stroke caused by the occlusion, or blockage, of blood vessels. Stoner’s MRI images had revealed two small areas of damage due to arterial blockages in his brain.

He had, Qureshi informed him, a choice to make: Ignore the TIAs and go home, in which case he faced a high risk of being felled by a major stroke within the next few weeks. Or undergo neurointerventional surgery that would include an angioplasty (insertion of a balloon-like instrument or self-expanding stent that opens the blood vessel) and placement of a stent to keep the blood vessel open.

“I was scared, I’ll tell you that,” Stoner says. “I have a wife and three young kids. I didn’t really feel like I had a choice.”

He underwent the procedure on May 28.

“I was awake the whole time,” Stoner marvels. Today, besides the aspirin he takes daily as a blood-thinner and the 15 pounds he’s gained since he quit smoking, his life is back to normal. Stoner was lucky. Had he lived somewhere else, his story might have had a very different outcome—one that ended in death or long-term disability.

Stroke teams at the ready

Every year, some 10,000 Minnesotans are hospitalized for stroke. About 2,400 of them die. Stroke is the third-leading cause of death in the United States and the leading cause of disability.

Fortunately, Stoner ended up in the right place at the right time. Formed in 2006, the Stroke Center, which offers services at the University of Minnesota Medical Center, Fairview, and Hennepin County Medical Center, is one of only a handful of its type in the country—with a cross-disciplinary team of doctors, nurses, and other specialists trained in interventional neurology, neurosurgery, or neuroradiology to improve outcomes for stroke patients.

Although Stoner’s TIAs required urgent care, his symptoms were temporary. When the symptoms don’t clear rapidly on their own, a stroke is occurring, and the patient needs immediate treatment. Using clot-busting medications and other means, it is now possible to reverse some strokes if the patient is treated within three hours— and the sooner the better—of symptom onset.

The most common kind of stroke, called “ischemic” stroke, is caused by a blockage of blood flow to a region of the brain—the same condition that threatened Stoner’s health. Ischemic strokes account for 85 percent of all strokes suffered in the United States each year. The other 15 percent are called hemorrhagic strokes—those caused by bleeding that most often results when a weakened portion of a blood vessel, known as an aneurysm, bursts. Both types of strokes require rapid treatment for optimal outcome, but the goal is clearest for those with ischemic stroke: to open the vessel and restore blood flow as soon as possible.

At the Stroke Center, almost 20 percent of ischemic stroke patients receive acute neurological treatment to open the blocked vessel. That’s in line with research showing that 20 percent of stroke patients need that type of care. Nationally, however, only 2 percent of patients receive acute treatment.

What’s more, the elapsed time between when a patient arrives at one of the Stroke Center medical facilities until neurointervention is just 43 minutes. Nationally, the average is an hour. And those 17 minutes can be critical, especially for patients who are experiencing a major ischemic stroke.

In their earliest stages, ischemic strokes cause a core of brain cells to die as a result of loss of blood flow. Around them is a “penumbra” of cells that are in danger but still living. “Time is brain” has become a familiar refrain in neurology circles because the more quickly a stroke victim receives acute treatment that restores blood flow, the greater the likelihood that the penumbral cells will survive.

Even 17 minutes can mean the difference between a quick recovery with few, if any, long-term symptoms and permanent disability or death. In fact, up to 40 percent of ischemic stroke patients achieve complete recovery with acute clot-buster treatment administered within three hours of onset, as opposed to only 25 percent of patients who don’t receive treatment that quickly.

Combining research, education, and care

Adnan Qureshi, M.D., executive director of the University's Stroke Center. (Photo: Richard Anderson)

In addition to clinical care, the Stroke Center also offers education, training about six fellows a year, as well as research conducted through its investigational arm, the Zeenat Qureshi Stroke Research Center, to improve treatment methods already available, discover new therapies, and find ways to prevent strokes from occurring in the first place. The research center is off to a strong start, having published 85 research papers in scientific and medical journals in its first two years.

For Qureshi, the quest for new ways to treat and prevent stroke has roots in personal history. His mother, for whom the Zeenat Qureshi Stroke Research Center is named, died of a massive hemorrhagic stroke in his native Pakistan when she was only 39. The experience, he says, “was definitely a factor” in his decision to specialize in neurology. Meanwhile, the resources uniquely available at the University of Minnesota led to his decision to direct the Stroke Center.

“The University was the perfect venue because we don’t just provide clinical care,” he says. “We wanted a strong education and research component as well, which only the University can provide. We have one of the largest research and fellowship programs in the country right now.”

Treatment advances

Formation of the Stroke Center followed more than a decade of dramatic improvements in the treatment of both kinds of stroke.

For ischemic strokes, “thrombolytic therapies”—mechanical or, increasingly, pharmaceutical, methods of dissolving or removing blood clots—have become standard practice. This approach has been coupled with the development of increasingly sophisticated endovascular therapy—the delivery of clot-busting drugs directly to the site of the clot.

“Endovascular therapy decreases the dosage of the drugs we need to use while at the same time increasing their effectiveness,” says Mustapha Ezzeddine, M.D., director of neuro-critical care at the Stroke Center.

In fact, when this kind of therapy is used, the clot-busters are twice as effective in opening vessels as when they are administered intravenously—the standard approach until now.

Though hemorrhagic strokes are not as common as ischemic strokes, they are deadlier, with a mortality rate of 30 percent as compared with 10 percent for strokes caused by clots. Fortunately, new endovascular therapies have greatly improved survival and recovery rates for these types of strokes as well.

For example, “coiling” aneurysms has become a standard treatment for the half of hemorrhagic strokes in which an aneurysm has ruptured. In this therapy, a physician places a small coil of platinum inside the bulging blood vessel to provide structural support and prevent the vessel from rupturing again.

Meanwhile, aftercare for both ischemic and hemorrhagic strokes has also advanced. “Neurocritical care optimizes recovery and minimizes injury,” says Ezzeddine. “It also treats the medical complications that often follow a stroke.”

Says Qureshi, “The science of stroke is expanding quickly. We are seeing advancements in both rapid diagnosis and treatment.”

And for that, Wayne Stoner is grateful. “The treatment I received was wonderful,” he says. “I feel I was given a new lease on life.”

By Richard Broderick

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