New guidelines for treating stroke victims; Six-hour window for treatment can be safely extended in some cases

Ann Kelly lay awake on a table unable to move or talk as doctors pulled a clot out of a vessel in her brain using a catheter threaded from her groin. As blood flow returned during the emergency procedure, so did the feeling in her body.

"I was writing my own name right afterward," the 78-year-old Laurel woman said. "I was hungry. And ready to go home. I felt bad that I scared everyone."

Kelly suffered a major stroke - usually when a clot blocks blood flow to part of the brain - while eating lunch on the job one day last year and the right side of her body went numb, beginning with her fingers.

Her swift and complete recovery was possible because Kelly received quick care, within six hours of the first symptoms, according to national guidelines. But evidence has now given the medical community confidence that the clot-removing treatment called a manual thrombectomy can be performed much later - perhaps up to 24 hours after a stroke - preventing death and disability in more people.

Strokes are a major burden in the United States, striking nearly 800,000 people a year and killing about 133,000, according to the U.S. Centers for Disease Control and Prevention.

The new guidelines released by the American Heart Association and American Stroke Association earlier this year say that the clot-removing procedure could help people up to 18 to 24 hours after a stroke if the clot is located in a large blood vessel in the brain and the patient has brain function.

Such major strokes - accounting for 20 percent to 30 percent of all strokes - are among the most devastating, said Dr. Marcella Wozniak, medical director of the University of Maryland Medical Center'sNeurology Care Center.

After the guidelines changed, hospitals began considering how to treat more people, and some like the University of Maryland hospital are already assessing more patients for the surgery. The Maryland hospital has also helped lead a cooperative effort among hospitals and emergency responders in the state to get patients to the right places for treatment.

The goal is to restore the blood flow to a patient's brain before the damage becomes too extensive, said Wozniak, also an associate professor of neurology at the University of Maryland School of Medicine. "This increases the chance of survival and return to a normal or near normal life," she said

Minor strokes can resolve on their own or with clot-busting drugs if given in the first several hours. With major strokes, Wozniak said, it's not clear how many more people might be spared death or disability by widening the window of time.

Some people aren't in decent enough health to be able to recover, or their brain is too damaged by the stroke, she said. Others won't qualify because their clots are in vessels too small.

Picking candidates has been part art and part science, Wozniak said. Treating someone too late could cause more harm by increasing bleeding in the brain. Improved imaging and other assessments have helped doctors push the boundaries, she said.

The University of Maryland Medical Center treats about 600 to 700 stroke victims a year, mostly sent from other hospitals. It's on track to remove about 200 clots this year, up from about 100 last year and 30 to 40 in years past.

Ann Kelly said she feels lucky to have co-workers who got her prompt care and thankful for the medical professionals at St. Agnes who properly assessed her and others at Maryland who treated her.

She never thought she'd have a stroke. Kelly, who works as an office manager and receptionist at a Catonsville firm, had suffered a heart attack once and got a pacemaker, but her blood pressure was under control, she wasn't overweight and was active. She hopes people learn to recognize symptoms such as face drooping, arm weakness and speech difficulty and know it's time to call 911 - instructions known by the acronym FAST.

"I pray that they do have outcomes like mine," Kelly said. "Since this happened, I've heard so many stories about people's relatives and friends who are using walkers or wheelchairs or they didn't live."

The expanded window for treatment will help more people, though early treatment remains critical, said Dr. Gaurav Jindal, a neuroradiology specialist at the Universtiy of Maryland Medical Center. He said 24 hours still will be too long for most people, he said.

"Time is still very critical," said Jindal, also an associate professor of neuroradiology and neurosurgery at the Universtiy of Maryland School of Medicine. "Every 30 to 60 minutes' delay can decrease the chances of a good outcome by 10 percent."

"If you're having stroke symptoms, call 911," he added.

Maryland hospitals working out official details about assessing and transporting patients to and between hospitals, said Dr. Richard Alcorta, EMS medical director for the Maryland Institute for Emergency Medical Services, which coordinates the emergency procedures around the state.

He said there are about three dozen primary stroke centers in the state that can assess stroke patients and administer clot-busting drugs, and three comprehensive stroke centers that can extract clots. They include Maryland, Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, all in Baltimore.

Alcorta said Baltimore City is participating in a pilot study in which emergency responders use a tool in the ambulance to determine whether clots are in small or large vessels so they can take patients directly to centers where they could have them extracted, skipping assessment at another hospital. Results so far, he said, are encouraging.

The state, as part of a national effort, could also allow more hospitals to perform clot extractions.

There are still hurdles, such as how to quickly obtain high-resolution images of patients' brains and share them between hospitals. But Maryland's system of implementing new guidelines and other changes could put the state ahead of the pack in offering treatment, Alcorta said.

"There will be variability around the country," he said. "Not everyone has regionalization of care like we have in Maryland."

Certainly other hospitals nationwide are moving on their own or within their systems to assess more stroke patients for the procedure, said Dr. Mitchell Elkind, chair of the American Stroke Association.

Big cities will tend to move more quickly than rural areas where there are fewer centers able to offer the extractions, Elkind said. The rural centers will require even more coordination among emergency providers and hospitals. In some cases, centers will have to hire and train more people in the specialized procedure.

A few hospitals had already been treating patients just outside of the six-hour window, a threshold in place for about five years. But the guidelines give doctors confidence that they aren't likely to harm patients, said Elkind, professor of neurology at Columbia University College of Physicians and Surgeons and an attending neurologist on the stroke service at New York-Presbyterian Hospital.

"Many doctors tended to adhere to a strict cut-off at six hours," he said. "Now it will be more dependent on what images show. It will be a big change."

Still, Elkind said, people would be better off if they took preventive steps such as eating right, exercising, quitting smoking and controlling blood pressure and cholesterol.

"The treatment is great for those who have strokes," he said. "But it's better not to have a stroke in the first place."

meredith.cohn@baltsun.com

twitter.com/mercohn

Credit: By Meredith Cohn - The Baltimore Sun - meredith.cohn@baltsun.com;twitter.com/mercohn

Caption: Dr. Marcella Wozniak, right, medical director of the Comprehensive Stroke Center at the University of Maryland Medical Center, and Dr. Gaurav Jindal are part of the team at the center leading the effort to implement new guidelines on treatment of stroke victims.

Kenneth K. Lam/Baltimore Sun