Stroke : Risk Factors, Part 2

by Food and Drug Administration (FDA)

(Page 3 of 4)

It's a good idea to talk with your doctor about what hospital you should go to if you are at high risk for a stroke, Grotta says. "Consumers should demand good stroke care." The Joint Commission on Accreditation of Healthcare Organizations has recently moved to certify primary stroke centers by requiring them to meet certain criteria. One requirement is that doctors consider administering t-PA.

"It's also important that family members know about stroke symptoms because the stroke victim's thinking may not be clear and the person may not be able to call for help," Grotta says. Les Bissell, 40, who was treated with t-PA after having a stroke in January 2002, credits his girlfriend at the time for getting emergency help so quickly.

Following a vacation, Bissell got up to look at his mail in his Washington, D.C., apartment. Then he walked across the living room and collapsed, breaking a table on the way down. "My legs wouldn't work; they were like jelly," Bissell says.

He tried to get up and came crashing down again, this time taking the TV and stereo with him. His girlfriend had a friend who suffered a stroke a couple of years before and she recognized the signs. After asking him basic questions that he couldn't answer, like his name and where he was, she called 911. "I will always be thankful for her quick action," he says. "If I had been alone, I probably would have just stayed there on the floor and fallen asleep."

The morning after the stroke, a doctor jingled some keys in front of Bissell and asked him what they were. He had no idea. He was unable to walk or speak. "I could only cry out of fear and frustration," he says. "The alphabet was a complete mystery, although it did look vaguely familiar."

Slowly, Bissell recalled letters, words, and names. He got out of the hospital a few days later, and underwent months of speech therapy and physical therapy. He was treated for depression and attended support groups.

He has a slight speech impediment, gets exhausted easily, and has trouble with comprehension. He also has a whole new outlook. Now he lives on a 28-foot boat named HOPE and is sailing around the world to raise awareness about stroke. His voyage began in Annapolis, Md., in April 2004 and he expects to be sailing for three years.

He exchanges e-mails with other stroke survivors and spreads the word about prevention and treatment. "Don't let it beat you," Bissell says. "Seek help fast."

Expanding the Options

"The biggest impediment to designing therapy for acute stroke is that the brain is extremely vulnerable," Grotta says. "Brain tissue dies rapidly. The brain is also hard to access. The blood vessels are delicate and tiny, and it's hard to get to the brain with a catheter." One big area of research, he says, involves trying to improve on t-PA.

According to a study published in the Nov. 18, 2004, issue of The New England Journal of Medicine, patients who get a combination of t-PA and ultrasound may be able to leave the hospital with a greater chance of recovery. This preliminary study suggests that larger studies to assess the effects on the patient's functional abilities and stroke recovery are worth pursuing.

"Ultrasound causes vibrations that work with t-PA to break up clots," says Grotta, who was part of the international research team that conducted the study. The team was led by Andrei Alexandrov, M.D., at the University of Texas, Houston School of Medicine. Grotta says, "This may help the drug get to the clot and open up blood vessels faster."

Joseph Broderick, M.D., chairman of the neurology department at the University of Cincinnati, says, "We know that t-PA, while a great advance, doesn't really open up the clots fast enough in people with big strokes. We want to find out whether we can do better."

Broderick and his colleagues are studying an approach that combines t-PA with additional treatment through a catheter at the site of the brain clot. Broderick says, "Patients who have already received intravenous t-PA within three hours of onset are taken immediately for intra-arterial angiography, a procedure in which a catheter is inserted into the groin and threaded up to the arteries in the brain." Additional t-PA is put directly into the clot and the catheter is also used to help break up the clot.

"In another NINDS-funded study, we are also comparing t-PA with GP2B3A inhibitors, which are already approved for cardiac use, to see if this combination can open up arteries earlier," Broderick says. GP2B3A inhibitors are agents that prevent platelets in the blood from clumping together.

Researchers are also looking for novel approaches for treating acute ischemic stroke that could be used in addition to t-PA or instead of it. For example, neuroprotective agents protect the ischemic cells from damage or death until blood flow is restored. These agents hold promise, and many have worked in a lab, but none have proven effective in clinical trials.

Hypothermia is another neuroprotective approach under study. This involves cooling the body to lower body temperature and slow down brain damage due to stroke. Hypothermia can be achieved by inserting cold saline into the body intravenously to cool the body to a certain temperature. The more common method involves external cooling through the skin, such as with "cooling" blankets. "This has been effective in cardiac arrest patients with brain damage," Grotta says. "It's proof that neuroprotection could work."

Stroke experts say there is also great interest in treatment that could be started much earlier. Jeffrey Saver, M.D., is leading a study at the UCLA School of Medicine that involves treating stroke patients in the ambulance. Paramedics give the potentially neuroprotective agent magnesium sulfate in an attempt to increase blood flow to the brain and prevent buildup of damaging calcium in injured nerve cells. This experimental treatment is being studied in an NINDS-funded clinical trial.

About the Author

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