By Shobana Muratee
Grey Matters, written on a poster with an image of a human brain is displayed on the glass door of the office of James C. Grotta, M.D., Neurologist, Hermann Medical Group, Director of Stroke Research, Clinical Institute for Research and Innovation, Memorial Hermann-TMC. Those words, became more impactful as we speak to him about what happens when a stroke occurs. “Stroke is most common condition that affects the brain,” Dr. Grotta said. “But people didn’t consider stroke as an interesting part of neurology until the 1970s when research suggested that strokes could be treated and prevented.” The American Stroke Association and the Centers for Disease Control report says nearly 800,000 Americans suffer a stroke each year – one every 40 seconds. About 87% of all strokes are ischemic strokes, in which blood flow to the brain is blocked.
Typically, when you develop stroke symptoms, you call 911. When the EMS arrives, the paramedics would have to figure out if it’s a stroke, then they take you to the emergency room which would take a minimum of 30-45 minutes. Once in the emergency room, you got to have a CT (computed tomography) scan and a few blood tests before the doctor can determine whether you are having a bleeding kind of a stroke or if it is a stroke due to a blocked artery, which is the most common kind. The medicine to dissolve the clot in case of a blocked artery actually increases the risk of bleeding, which is why it is important to know the type of stroke. Certain stroke types are more common in different ethnic groups. Bleeding in the brain, although occurs in everybody, is common in certain sub-groups particularly Asians and young black men because high blood pressure is more prevalent in these groups.
Timing is Crucial
It takes roughly an hour by the time patient is brought into the emergency room and CT scan and other tests are done. That hour could mean saving 120 million brain cells. Once the artery blocks off, cells die within minutes. You must act fast to open the artery. The only FDA-approved treatment for ischemic stroke is the clot-buster, tPA (tissue plasminogen activator) but it must be given within three hours of the first signs of stroke to be most effective, and the earlier the better within that three-hour time frame. This is a medication that is used only when someone already gets a stroke and not as a preventive. Considering a conservative figure of 600,000 ischemic strokes every year in the US (since 1/5 of the total number reported are due to bleeding), only 50,000 patients (<10% of stroke patients) are treated with tPA. If we expanded our ability to treat patients and got them treated faster, we could perhaps double that number.
What are the Signs and Symptoms?
It’s crucial to know the symptoms of a stroke. Think of the word ‘FAST’
F= Face. Once side of the face droops or can’t move, feels numb
A= Arm: The arm feels week and unable to lift
S= Speech: Patient can’t talk or speech is slur
T = Time: If any of ONE of those happens you must react right away.
The most important thing is the history, whether you’ve had those symptoms before. There isn’t a single test that says that you are going to have a stroke. Be alert of the symptoms and call 911 when they occur. People who are at risk for stroke are essentially the same people who are risk for heart attack. High blood pleasure, high cholesterol, smoking, lack of exercise, drug abuse all increase the risk of a stroke and heart attack.
What happens when you have a stroke?
Stroke is neurological when it happens in the brain- when an artery is blocked in the brain. And when artery is blocked in heart it causes heart attack. About 15% die from strokes, but the biggest problem in stroke is that it disables people. So, if you had a stroke the more likely thing is not that you would die, but that you would be left with paralysis, inability to speak or take care of yourself. It also takes a toll on you emotionally and financially if you need to go to a nursing home or hire people to take care of you at home. (Stroke costs the United States $38 billion a year as per the American Stroke Association and the Centers for Disease Control).
Who’s prone? Are genetic factors involved?
Everyone, but it mainly occurs in 50-80 years of age, but it’s also seen in young adults. If you stay healthy until 80, there’s a chance you can get a stroke at some point. When you get to be about 70, the chances are 1%-2% every year. There are genetic, racial differences but people shouldn’t think that they are safe because they are in a one gender or ethnic group. In the US, heart attacks are more common than strokes, but in China strokes are more common than heart attacks. It is a single biggest cause of death in China and many areas in Asia although it is not quite clear why. It could be a combination of factors. There is higher prevalence of bleeding type of strokes in the Asian subcontinent. In the United States, the risk of blocked artery causing a stroke is about five times greater than that caused from bleeding type of stroke. In every six stroke patients, five are going to be caused by a blocked artery and one of them caused by bleeding. In China, it’s more like two to one. Bleeding is much higher than blocked artery.
Mobile Stroke Unit
In March 2014, Dr. Grotta and his co-investigators initiated a three-year study with the launch of the country’s first mobile stroke unit, in partnership with Memorial Hermann-Texas Medical Center. John and Janice Griffin, owners, Frazer Ltd, Houston’s leading company that builds emergency vehicles offered their help in engineering the special ambulance equipped with a CT (computed tomography) scanner, the first of its kind in the nation. Also, generous support from H-E-B, Gallery Furniture and a few others who donated money up to $1.1 million, got the first unit on the road. Dr. Grotta, who is the Director, Mobile Stroke Unit Consortium, describes it is an emergency room on wheels. The mobile stroke unit would immediately do the diagnostic test on the spot and give tPA even before the patient is taken to the emergency room, saving a substantial amount of time.
Is it successful?
The mobile stroke unit has trained paramedics and/or nurses that recognize stroke. When someone calls 911 and the fire department ambulance in the city of Houston gets dispatched to pick up a possible stoke patient, mobile stroke unit is also dispatched. They arrive at the same time and evaluate the patient together. If it’s not a stroke the fire department continues to manage the patient. The mobile stroke unit operates in conjunction with the Emergency Medical Services of the Houston Fire Department, Bellaire Fire Department and West University Fire Department and covers Bellaire (inner Bellaire) within eight-mile radius of Texas Medical Center. We can currently fund only one shift every day, not a 24-hour service. We would like to have a second mobile stroke unit on the west side of town that services from out west of Southwest Memorial and Memorial City, an area prevalent for stoke and where a large population of Asians reside.
It is almost three years into the study that was started in 2014, to assess the outcome of patients that are treated on the mobile stroke unit and of patients treated by standard management. So far around 270 patients have been treated and about 800 patients transported to stroke centers including Memorial Hermann-TMC, Houston Methodist Hospital and St. Luke’s Medical Center. We know that it works and we can treat patients faster, but what we don’t know is that, if we speed up treatment, would it have a significant impact or outcome. It would take three more years of study and an additional 2-3 million dollars to find out if by treating patients faster, more patients recover.
Future plans include staring a mobile stroke unit in Denver and Memphis and next year, they would have an additional one in New York and Los Angeles that will be providing data.
But Dr. Grotta said he would like to have more data in Houston.Funds were also received from the Patient-Centered Outcomes Research Institute (PCORI) and American Heart Association (AHA) Dr. Grotta said.
Inside the mobile unit there is the CT scanner and cameras positioned in a way in which the doctor can get a view of the patient remotely. The paramedics and nurses can see the doctor on the computer screen and the microphone picks it up as they speak and that’s how the doctor adjusts the treatment. This is called telemedicine and it is part of the clinical trial that Dr. Grotta and his co-investigators are working on.
James C. Grotta, M.D., Neurologist, Hermann Medical Group, Director of Stroke Research, Clinical Institute for Research and Innovation, Memorial Hermann-Texas Medical Center, Director, Mobile Stroke Unit Consortium. In 1974 when Dr. Grotta was offered a job at UT Medical School that was just forming, he saw great potential in its busy emergency room to take care of acute stroke patients and to do his clinical research. He and his wife, a journalist who also got a job with the Houston Post finally moved to live in the Southwest. For over 40 years, Dr. Grotta’s research has focused on the development of new therapies for acute stroke patients. Dr. Grotta has played a leadership role in many clinical research studies of both thrombolytic drugs and cytoprotective agents after stroke. He spent two years in the U.S. public Health Service (Indian Health Service). He was a recipient of the Feinberg Award for Excellence in Clinical Stroke (1999, Physician of the Year (2006), and the Eugene Braunwald Academic Mentorship Award (2010), all from the national chapter of the American Heart Association (AHA).
International Stroke Conference 2017
The International Stroke Conference is the world’s largest meeting dedicated to the science and treatment of cerebrovascular disease.
This 2½-day conference features more than 1,500 presentations that emphasize basic, clinical and translational sciences as they evolve toward a more complete understanding of stroke pathophysiology with the overall goal of developing more effective prevention and treatment. Sessions in clinical categories will center on stroke community risk factors, emergency care, acute neuroimaging, endovascular and nonendovascular treatment, diagnosis, cerebrovascular occlusive disease, in-hospital treatment, and outcomes of stroke.
Basic Science Sessions focus on vascular biology in health and disease; basic and preclinical neuroscience of stroke recovery; and experimental mechanisms and models. Further specialized topics include pediatric stroke; intracerebral hemorrhage; nursing; preventive strategies; vascular cognitive impairment; aneurysms; subarachnoid hemorrhage; neurocritical care; vascular malformations; and ongoing clinical trials.
Presentations on these topics attract a wide range of healthcare professionals and investigators including adult and pediatric neurologists; neurosurgeons; neuroradiologists and interventional radiologists; physiatrists; emergency medicine specialists; primary care physicians; hospitalists; nurses and nurse practitioners; rehabilitation specialists; physical, occupational, and speech therapists; pharmacists; and basic researchers spanning the fields of cerebrovascular function and disease.