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New Tools for Stroke Treatment

Tampa Bay Times Article - July 9, 2015
 
New tool helps doctors win race to treat strokes
Clearing a clot in the brain is risky – and effective.
 
TAMPA — The thick clump of platelets blocking blood flow to Rosemary Marcario's brain wouldn't budge.
Doctors at Florida Hospital Tampa had tried dissolving it with a strong dose of blood thinners, but it was too large, too stubborn.
 
Now the team stood poised to try something more complicated: Dr. James Lefler would insert a small, web-like device through an artery in her groin, thread it all the way to her brain, and try to snag the clot. If all went according to plan, he would yank out the clump through the groin incision. Lefler had reason to be confident as he prepared to perform the procedure Friday. Four days earlier, the American Heart Association had added clot-retrieval devices to its list of recommended treatments for stroke patients, marking the first time in nearly two decades the group revised the guidelines.
 
Still, Lefler knew he had to act quickly. Each second the clot remained in place, 3,200 brain cells died. Another thing crossed the doctor's mind: "If I rupture that vessel she's dead on the table."
 
• • •
 
Before she fell on the kitchen floor Friday, setting into motion the chain of events that led to the neuroangio room at Florida Hospital Tampa, Rosemary Marcario was making a liverwurst sandwich for her husband, Larry, in their Tampa apartment. Larry, 85, had been opening the mail in the living room. "You know that terrible sound when someone falls on tile? That's what I heard," he later said. He darted into the kitchen to help his wife of 65 years.
 
Rosemary, 85, insisted she was fine. She hadn't hit her head and there was no blood. But Larry noticed a slight droop in the left side of her face and dialed 911. "My wife had a minor stroke," he told the operator. The stroke was anything but minor. When Rosemary arrived by ambulance at Florida Hospital Tampa around 1:40 p.m., she could hardly move the left side of her body. Her vision was blurred. She struggled to speak.
 
Rosemary remembers whipping through the emergency room on a gurney, and having her clothes cut off of her body. She can't recall anything else. Larry and the couple's daughter, Linda Wells, remember the afternoon in painstaking detail. Seven minutes after Rosemary's arrival, the doctors scanned her body for clots. Six minutes later, they gave her the intravenous blood thinner. Thirty minutes later, another scan.
 
"We knew it was serious," said Lori Derrico, a registered nurse and the neuroscience program coordinator. Lefler used 3-D images to pinpoint the location of Rosemary's clot: the middle cerebral artery behind her right eye. He quickly realized that much of her brain tissue was still alive, making her a good candidate for the clot-removal procedure. "Get her on the table," he urged his colleagues. "Let's go." 
 
Rosemary was put under anesthesia and rolled into the neuroangio suite, a room with futuristic white equipment and high-definition flat screens projecting images of her brain. Lefler began threading a wire tube through the artery in her groin at 3:56 p.m.
 
• • •
 
A clot-removal device works sort of like a Chinese finger trap. Once the wire tube is pushed through the clot, a catheter follows behind. The catheter deploys a wire mesh that expands into the clot and traps it.
 
When the catheter and mesh are removed, the clot comes out, too.
 
Doctors use the procedure, known as mechanical thrombectomy, only after they've tried dissolving the clot with intravenous blood thinners. The patient must have suffered an acute, severe stroke, but more than half of his or her brain must be intact.
 
It works best within six hours.
 
The procedure isn't exactly new. The Food and Drug Administration approved two so-called stent retrievers in 2012, including the Medtronic device known as the Solitaire that Lefler used on Rosemary Marcario.
 
The research, however, had been too thin to win over the American Heart Association.
 
"The previous recommendations were lukewarm," said Dr. William J. Powers, who chairs the Department of Neurology at the University of North Carolina at Chapel Hill and wrote the association's latest update. "We didn't really know if they worked or not."
 
That changed this year on the heels of several studies published in the New England Journal of Medicine.
 
"If you compare the people who (had the procedure) to those who didn't, it about doubles your chances of having a good outcome," Powers said.
 
Convinced the procedure worked, the American Heart Association updated its stroke treatment recommendations on June 29. Never before had a device made the list.
 
Powers said the new guidelines will "change the whole idea of how to deliver care for stroke around the country."
 
"We've got to figure out a way to get the people who need this (procedure) to a place where they can get it," he said. " That's not trivial. This requires people with specialized training and specialized facilities to take care of them."
 
• • •
 
Lefler was well-practiced at removing clots, having used the devices since their approval in 2012. But he didn't downplay the risk Friday.
 
"One small pass of the wire, the patient hemorrhages," he said.
 
To reach the blockage in Rosemary Marcario's brain, Lefler had to bypass an aneurysm in her abdomen. His first attempt to snag the clot was unsuccessful. Only after he threaded the wire through her body for a second time did he capture the clump, allowing the blood to once again flow through Rosemary's brain.
 
The entire procedure took about an hour — slightly longer than it usually takes the team at Florida Hospital Tampa.
 
By Monday, Rosemary was walking around her hospital room.
 
"I feel wonderful," she said Tuesday. "I feel blessed."
 
She praised the doctors and nurses who had cared for her, and her husband, whose quick thinking saved her life.
 
Larry choked up when he looked at his wife.
 
"So many images go through your mind, thinking what could have been," he said, his voice trailing off.
 
Their daughter, Linda, quickly chimed in.
 
"Remember we said we weren't going to talk about that?" she said. "We're going to focus on tomorrow and what's ahead of us."
 
Contact Kathleen McGrory at kmcgrory@tampabay.com or (727) 893-8330. Follow @kmcgrory.