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Research Leads to Relief for a ‘Blow to the Brain’
Sometimes dramatic improvement can result from new stroke treatments
Driving home from work one day, John Kubala suddenly was in a daze. He felt as if he were dreaming.
When a police officer found Kubala leaning against his car unable to talk, the police officer at first thought Kubala was driving under the influence. Instead, he was having a stroke.
Visiting at the President’s Executive Luncheon are, from left: guest Thad
Gillian, James C. Grotta, M.D., director of the UT Medical School’s Stroke
Program, and patient John Kubala. Two patients attending the luncheon
represented all the patients who volunteer to take part in research trials.
“Without them we wouldn’t have anything to tell you,” Grotta said.
Photos by Ground Zero Photojournalism
Fortunately, the officer realized the stroke symptoms and rushed Kubala to Memorial Hermann Hospital, where he was treated by The University of Texas Medical School at Houston’s Stroke Team.
Six months later – recovered and back at work – Kubala was a special guest at the April 28 President’s Executive Luncheon, where the topic was “Clotbusting: How to Reverse a Stroke.”
“A stroke is a blow to your brain,” explained James C. Grotta, M.D., director of the UT Medical School’s Stroke Program and holder of the Roy M. and Phyllis Gough Huffington Distinguished Chair. “Most strokes are caused by a blocked artery in the brain; about 20 percent are caused by a hemorrhage or a ruptured artery in the brain. But one way or the other, part of the brain is robbed of blood flow and within minutes the cells of the brain die.”
Treatment for stroke has come a long way since the 1970s, Grotta said, when a standard textbook advised: “Supportive therapy in stroke patients is most important. The patient should be put to bed.”
The mainstay of stroke treatment today is tPA, or tissue plasminogen activator, a clot-busting drug. If given within three hours of the onset of a stroke, damage is prevented or reduced substantially.
John Kubala was treated with tPA and was put into an experimental protocol, in which a newer clot dissolving medication was added. As of the end of April, 14 patients had been treated with this combination, and in all except one, the result was really fast, Grotta said.
While investigation continues into other medications, Grotta said, “Probably our biggest success has been the use of what used to be a diagnostic technique that we now have found is a positive therapy.”
Using ultrasound to measure blood flow in the brain, the Stroke Team found that ultrasound also improves treatment.
Andrei Alexandrov, M.D., assistant professor of neurology and
radiology at the UT Medical School at Houston, and Anne
Wojner, Ph.D., center, assistant professor of neurology and
neuroscience critical care medicine, talk with patient Irma
Marshall. Marshall benefited from six months of rehabilitation
after she regained partial function from immediate treatment
of her stroke.
In one of the first patients in which the effect was observed, Andrei Alexandrov, M.D., related, “about 40 minutes into the infusion, we saw the opening of the vessel like somebody had broken open a bottle of champagne. Pop! In the next 45 minutes we saw a very dramatic recovery. The patient was completely normal in about an hour.”
Even with tPA, the team had never seen such a fast and dramatic recovery. How can this ultrasound, which is very gentle, help open these blood vessels, they wondered.
“Think about this as a cup of sweet tea,” said Alexandrov, who is an assistant professor of neurology and radiology and director of cerebrovascular ultrasound. “You take sugar, and you pour it into the cup. Most of it goes to the bottom, and it will sit there for the longest time.
“That’s what happens when you give tPA,” he said. “It goes in the bowl but the bowl is stagnant and doesn’t go anywhere. So the tPA, the clot-buster, cannot get where it’s supposed to.
“You take a spoon, and you stir the cup of the sweet tea to help the sugar dissolve,” Alexandrov said. “And that’s what ultrasound does in this particular situation. Ultrasound is like a noninvasive spoon, which stirs it a little bit and gets the tPA where it’s supposed to go.”
In a study funded by the National Institutes of Health, 38 percent of the patients on whom ultrasound was used sustained a complete clearance of their clots within two hours – compared to 12 percent of the patients receiving tPA alone. More than 70 percent experienced either a complete or a partial clearance of their clots.
The neurologists at the luncheon discussed other stroke treatments, as well. For instance, “We discovered in our laboratory,” Grotta said, “that the combination of low doses of caffeine and low doses of alcohol in very small quantities actually is neuroprotective and reduces damage in animal brains after stroke. In patients if we give them the equivalent of two cups of coffee and one stiff drink, they don’t object very much and they feel a lot better.”
Combining the “cocktail” with cooling the patient’s body temperature by a degree or two substantially reduces the damage, he said.
Besides finding the most effective treatments for stroke, another challenge is making those treatments available to larger numbers of patients.
“We are very fortunate in Houston to have a very effective paramedic system,” Grotta said. “We’ve worked with EMS for a number of years and trained paramedics. They know what stroke is, and they know to take you to one of the stroke centers in the city.”
Because there are no differences in symptoms between a stroke caused by a blood clot and one caused by a ruptured artery, a CT scan is required to make the diagnosis.
“That’s critically important,” Grotta said. “If the patient has a hemorrhage, you don’t want to give a clot busting drug and promote bleeding. Whereas some treatments can be delivered in an ambulance, this treatment requires that you get to a center where a CT scan can be given and interpreted. Ninety percent of the hospitals in the United States have the capability of doing a CT scan.”
If you call 911 in Houston, 60 percent of the stroke patients that the paramedics pick up will get to the emergency room within two hours from symptom onset, within time to receive treatment with tPA. Although nationally only 2 percent of patients with strokes are treated with tPA, in Houston stroke centers the rate is 20 percent – 10 times the national average.
Houston has five stroke centers – Memorial Hermann (where UT research assures that the latest treatments are available), St. Luke’s Episcopal Hospital, Memorial Hospital Southwest, Methodist Hospital and Memorial City Hospital. Beyond the reach of these stroke centers, the UT Stroke Team has federal grants to test telemedicine.
“We’re now hooked up to hospitals in Beaumont, and we’re able to extend our treatment out from Memorial Hermann to the other Memorial affiliated hospitals throughout Texas,” Grotta said. “With telemedicine, the patient and doctor are visible to one another in real time on the television screen. The physician can directly question and – through help from the nurse – examine the patient and advise on treatment.”
— Ina Fried, Public Affairs