TAG: "Stroke"

Police officer makes ‘miracle’ recovery after stroke surgery

‘Hearing that makes me feel really lucky.’

By Justin Petruccelli, UC Irvine

David Castañeda had grown used to the idea of dodging bullets in his 19 years as a policeman. But the disaster he dodged when he suffered a stroke in 2013 has even his stroke specialists at UC Irvine Health calling his recovery “a miracle.”

“Hearing that makes me feel really lucky,” Castañeda says.

The 44-year-old Riverside police officer had just finished serving a warrant with his department’s SWAT team when he suddenly collapsed. He was taken by ambulance to Riverside Community Hospital, where doctors administered clot-busting drugs and transferred him by helicopter to UC Irvine Medical Center.

After touching down at the medical center, Castañeda was rushed into surgery, where Dr. Shuichi Suzuki spent almost four hours removing two clots that had lodged in the right side of his brain. The neurovascular specialist with the UC Irvine Health Comprehensive Stroke and Cerebrovascular Center feared that Castañeda might lose all movement on his left side. But when Suzuki checked his patient a few hours later, Castañeda was awake — and moving his left thumb.

“They pretty much have said that for David to even make it through the night was a miracle,” says Castañeda’s wife, Denise.

Exceeding expectations

Castañeda’s recovery was just beginning. Told he might need to spend six months in a rehabilitation center, he stunned everyone by walking the next day. Soon nurses and staff members from all over the hospital were coming to see his progress. He was discharged less than a week after his surgery.

“He’s young, but I was still surprised by how quickly his symptoms resolved,” says Suzuki, noting that most stroke patients are older and need more recovery time.

Although Castañeda suffered no long-term effects to his cognitive or motor skills, he lives with constant headaches and fatigue, and he must take blood thinners and cholesterol medication to prevent further clotting problems. Foods he used to love no longer taste good. But he’s been able to make those adjustments with help from his UC Irvine Health team.

“Everyone’s been incredible,” Denise says. “I didn’t know what to expect, even when we came home. But the number they gave me went right to the nurse in the ICU. We have the best of the best doctors. He got the best care.”

First signs of trouble 

Castañeda’s doctors believe he made a small tear in his right carotid artery (known as a dissected artery) while lifting weights two days before his stroke. That would account for the nausea, headaches and fatigue he experienced before he collapsed. 

“If I had to do it over again, I’d have gone straight to the doctor on that first day,” he says.

Being aware of stroke symptoms and acting on them quickly is vital, says Dr. Lama Al-Khoury, Castañeda’s neurologist at the stroke center. Even relatively routine stoke treatments like clot-busting drugs are more effective the sooner they’re given. During a stroke, a patient can lose about 2 million brain cells every minute, so every second truly counts.

“The most important thing is alerting the patients and the community to call 911 right away if any sudden acute neurologic symptoms occur,” Al-Khoury says. “We have treatments of choice that work only early on. There is a window there, but it doesn’t mean you have a lot of time.”

Contributing factors

Castañeda’s case is unusual, not only because it involved a dissected artery (the cause of about 2 percent of ischemic strokes), but also because he was younger than most stroke patients and didn’t have any of the common factors that contribute to stroke — obesity, smoking and heavy alcohol consumption. Al-Khoury worries that she’s seeing strokes more frequently in younger people because they’re not controlling those risk factors.

“People don’t take good care of themselves,” she says.

Castañeda has retired from police work. Since his stroke, he has enough energy for about two hours of physical activity each day, so he makes them count. He spends time with his family and watches his three children play sports. It’s a different life, but one he credits to the care he received at UC Irvine Health.

“We were told that this is the place to go for stroke, and I’d say it lives up to that.”

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UC Davis Medical Center recognized for quality care for stroke patients

Receives Get With The Guidelines award.

By Karen Finney, UC Davis

UC Davis Medical Center has been recognized by the American Heart Association/American Stroke Association for using evidence-based guidelines that improve care and quality of life for stroke patients.

The medical center received the 2015 Get With The Guidelines-Stroke Gold-Plus Quality Achievement Award for consistently adhering to association-backed quality measures. UC Davis also made the Target: Stroke Honor Roll for timely use of a clot-busting drug known as tissue plasminogen activator, or tPA, which can reduce the effects of some strokes.

“The credit for this recognition truly goes to our expert team of emergency, neurology, vascular and rehabilitation specialists who are dedicated to the highest possible standards in stroke care for our patients,” said J. Douglas Kirk, chief medical officer at UC Davis Medical Center.

The medical center also meets guidelines of the Joint Commission as a Primary Stroke Center, a symbol of quality and high performance standards in stroke care.

“We are pleased to recognize UC Davis for their commitment to stroke care,” said Deepak L. Bhatt, national chair of the Get With The Guidelines steering committee and executive director of Interventional Cardiovascular Programs at Brigham and Women’s Hospital. “Studies have shown that hospitals that consistently follow Get With The Guidelines quality improvement measures can reduce length-of-stay and 30-day readmission rates, and reduce disparities in care.”

A stroke occurs when one of the blood vessels that carries oxygen and nutrients to the brain is either blocked by a clot (ischemic stroke) or bursts (hemorrhagic stroke), causing parts of the brain to die. A third type of cerebrovascular event — known as a transient ischemic attack, or TIA — is caused by a temporary blood clot and is often called a “warning stroke.” Each year, nearly 800,000 Americans suffer strokes, which are leading causes of death and serious, long-term disability in adults.

More information about the medical center and its Stroke Program is at medicalcenter.ucdavis.edu.

More information about Get With The Guidelines is at heart.org/quality.

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Long-term depression may double stroke risk for middle-aged adults

Study finds stroke risk remains elevated even after depressive symptoms improve.

By Laura Kurtzman, UC San Francisco

Adults over 50 who have persistent symptoms of depression may have twice the risk of stroke as those who do not, according to a new study led by researchers at Harvard T.H. Chan School of Public Health and UC San Francisco. Researchers found that stroke risk remains higher even after symptoms of depression go away, particularly for women.

The study was published online today (May 13) in the Journal of the American Heart Association.

“This is the first study evaluating how changes in depressive symptoms predict changes in stroke risk,” said first author Paola Gilsanz, ‎Yerby Postdoctoral Research Fellow at Harvard Chan School. “If replicated, these findings suggest that clinicians should seek to identify and treat depressive symptoms as close to onset as possible, before harmful effects on stroke risk start to accumulate.”

The study looked at health information from 16,178 men and women ages 50 and older participating in the Health and Retirement Study between 1998 and 2010. Participants were interviewed every two years about a variety of health measures, including depressive symptoms, history of stroke and stroke risk factors. There were 1,192 strokes among participants during the study period.

Compared to people with low depressive symptoms at two consecutive interviews, those with high depressive symptoms at two consecutive interviews were more than twice as likely to have a first stroke. Stroke risk remained elevated even among participants whose depressive symptoms went away between interviews, particularly for women. Those with depressive symptoms that began between interviews did not show signs of elevated stroke risk. Participants younger than 65 had greater stroke risk linked to their depressive symptoms than older participants with depressive symptoms.

The researchers suggest that depression may influence stroke risk through physiological changes involving accumulation of vascular damage over the long term. Damage may also be incurred indirectly through depression’s effect on health behaviors, including increased risk of smoking and physical inactivity.

“Because this is the first study to take this approach, we need replication of findings in independent samples, with people of different age groups, and exploring different reasons that depressive symptoms get better,” said senior author Maria Glymour, associate professor in the Department of Epidemiology and Biostatistics at UCSF, who worked on the research while at Harvard Chan School. “The surprising results make such replications even more urgent.”

The HRS (Health and Retirement Study) is supported by the National Institute on Aging (NIA U01AG009740) and is conducted by the University of Michigan. Funding for this study was provided by Eunice Kennedy Shriver National Institute for Child Health and Human Development at NIH (R24HD041023 to Capistrant); the National Institute of Neurological Disorders and Stroke at NIH (T32 NS048005 to J.R. Marden); the National Heart, Lung, and Blood Institute at NIH (1F31HL112613 to Gilsanz); the National Institute of Mental Health at NIH (1RC4 MH092707 to Walter, Kubzansky, and Glymour); the Initiative for Maximizing Student Development (5R25GM055353 to Gilsanz); the National Institute on Aging (R21 AG03438502); the American Heart Association (grant 10SDG2640243 to Glymour and Gilsanz and 09PRE2080078 to Capistrant) and National Institute of Allergy and Infectious Diseases at NIH (grants AI113251 and AI104459 to Tchetgen Tchetgen) and National Institute of Environmental Health Science (grant AI113251 to Tchetgen Tchetgen).

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Q&A: Wengui Yu, UC Irvine stroke center director

First hospital in Orange County designated as a Comprehensive Stroke Center.

Wengui Yu, UC Irvine

Wengui Yu, M.D., Ph.D., is a board-certified neurologist, neurointensivists and vascular neurologist who specializes in treating severe strokes and complex cerebrovascular disorders. As the new director of the UC Irvine Health Comprehensive Stroke and Cerebrovascular Center, his goal is to make it one of the best in the nation.

Before joining UC Irvine Medical Center and the UC Irvine School of Medicine, Yu directed neurocritical care programs at the University of Texas Southwestern Medical Center in Dallas and at Cedars-Sinai Medical Center in Los Angeles.

What is the significance of the designation as a Comprehensive Stroke Center?

UC Irvine Medical Center was the first hospital in Orange County to achieve this designation, which recognizes hospitals that have the state-of-the-art equipment, infrastructure, staff and training necessary to diagnose and treat patients with the most complex strokes. Provided through a partnership between the American Heart Association/American Stroke Association and The Joint Commission, Comprehensive Stroke Center status is the highest level of stroke certification available.

How does that benefit the community?

Stroke is the number one cause of disability and the number five leading cause of death in the United States. When treating a stroke, time is a huge factor, which means being able to respond quickly. A stroke can be devastating, but the proper treatment program can make a tremendous difference for patients. When a stroke happens, every minute counts. The faster you are diagnosed and treated for a stroke, the better the chances of recovery, which is why access to a Comprehensive Stroke Center is critical, where state-of-the art facilities and highly skilled specialists are available 24 hours a day, every day of the year.

The coordinated approach of the UC Irvine Health team of neurologists, neurosurgeons, neurointensivists, radiologists, nurses, pharmacists and therapists provides the highest level of treatment for stroke patients. As a leader in stroke care, we offer the most advanced technology and best practices. Our program makes a tremendous difference in the community by improving patient survival rates and minimizing disabilities.

Why is it important to have a team of specialists?

A stroke, or brain attack, occurs when a blood vessel in the brain is blocked by a blood clot, or when the blood clot bursts. That means we need to be able to respond quickly to open the vessel and restore oxygen and blood flow. The quicker treatment begins, the better chances patients have for survival and full recovery. Stroke patients need to be quickly evaluated in the emergency department by stroke neurologists.

Based on the type of stroke and degree of injury to the brain, the patient may be treated with a clot-busting drug, undergo endovascular clot removal, emergency brain surgery or resuscitation in the Neurointensive Care Unit. World-class care by highly trained experts increases survival and recovery from stroke.

What are the latest research findings in stroke care and rehabilitation?

I recently attended the International Stroke Conference in Nashville, where the results of four clinical studies were presented regarding the effectiveness of endovascular therapy using clot retrieval devices for treating an ischemic stroke. An ischemic stroke is triggered by a blood clot. For patients who experience an ischemic stroke, the clot retrieval device is threaded through an artery in the grown to the blocked artery in the brain. The clot is removed, quickly restoring blood flow to tissue being deprived of oxygen, but still viable. Brain cells that would have otherwise died are saved, reducing the rates of death and debilitation, and increasing the number of patients able to return to independent lives.

These devices can also be used in combination with the clot-busting drug tPA. Although tPA is very effective for dissolving small clots and has saved many lives, large clots, which are more devastating, do not respond as well. This is the top advance in the field of stroke care.

Any other comments or insights you’d like to share?

The UC Irvine Health Comprehensive Stroke Center has improved the lives of hundreds of stroke patients. These programs help establish standards of excellence and best practices that directly impact patients’ lives. As the only such certified center in Orange County, we are dedicated to providing the best possible care to stroke patients throughout the community.

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Clot removal device improves outcomes for those with acute ischemic stroke

Treatment used in UCLA-led study could help 60,000 patients every year.

By Kim Irwin, UCLA

A new device to remove obstructing blood clots can significantly improve outcomes for people who suffer a certain type of stroke, according to a study led by a UCLA investigator.

In patients with acute ischemic stroke — in which a clot blocks the blood supply to part of the brain — who received a clot-busting drug, removing the obstructing blood clot with a stent retriever device significantly reduced post-stroke disability and increased the percentage of patients who were independent in daily function after three months.

The findings represent the first new treatment for acute ischemic stroke in 20 years, since the development of the clot-busting drug tPA, said Dr. Jeffrey Saver, the study’s global principal investigator and director of the UCLA Stroke Center.

“These findings are a paradigm shift — a new era in stroke care — and we are ecstatic,” said Saver, who is also a professor of neurology at the David Geffen School of Medicine at UCLA. “We will be able to treat many more patients, who will have much better outcomes. This is a once-in-a-generation advance in acute stroke care.”

The findings appear today (April 17) in the New England Journal of Medicine.

The study, called Solitaire With the Intention For Thrombectomy as PRIMary Endovascular Treatment (SWIFT PRIME), was conducted at 39 hospitals in the United States, Canada and Europe. The study enrolled 196 people. It was originally slated to enroll 833, but was halted early because of early positive results in this and other stent retrieval studies, Saver said.

The study tested a second-generation stent clot-retrieval device called Solitaire. The first-generation devices tested previously had shown no benefit over medical therapy alone, which Saver said was disappointing.

The new study tested the Solitaire on patients within six hours of the onset of stroke symptoms. The 196 patients were randomly assigned to be treated with either tPA alone or tPA along with stent retrieval of the clot, with 98 people in each group. Saver said the study showed the clot-removal devices outperformed tPA alone. Three months after having a stroke, 60 percent of the people who received clot retrieval as well as tPA were functionally independent and free from disability, compared to 35 percent of those who received tPA only.

For patients with a large clot, tPA only reopens vessels 25 to 30 percent of the time, Saver said. In the study, the stent retriever device opened the artery 88 percent of the time, even when there was a large clot.

The preclinical research used to help develop the Solitaire device was performed at UCLA by Dr. Reza Jahan, a professor of radiology at the David Geffen School of Medicine at UCLA and a member of the UCLA Stroke Center.

“This device reopened arteries much more frequently with less injury to the vessel,” said Jahan, who also served as global neurointerventional adviser for the trial.

“The Solitaire also caused less bleeding and was able to more easily engage and entangle clots.”

About 1 in 10 ischemic stroke patients can be taken to a catheter lab in time to perform the clot retrieval. This means that about 60,000 stroke patients a year could benefit from the two-pronged treatment approach.

“While this won’t help all stroke patients, the ones it will help have the most disabling strokes,” said Dr. Sidney Starkman, the UCLA study site principal investigator and co-director of the UCLA Stroke Center

“Right now, they get tPA and it helps a third of them, but the other two-thirds end up dependent on others for help or they die,” said Starkman, who is also professor of emergency medicine and neurology at the David Geffen School of Medicine at UCLA.

UCLA has a long history developing and testing stent retrieval devices, Saver said. The first clot retrieval stent device, a coil retriever, was invented at UCLA, and several major clinical trials of clot retrieval devices have been led by UCLA Stroke Center doctors.

“We are very happy to see this decade-long research program result in an important advance for stroke patients,” said Saver.

The study was one of three positive stent retrieval studies presented in February at the International Stroke Conference.

Stroke is the fifth leading cause of death in the United States and is a major cause of adult disability. About 800,000 people in the United States have a stroke each year. One American dies from a stroke every four minutes, on average.

The SWIFT PRIME trial was funded by Medtronic, which manufactures the Solitaire device.

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Artificial blood vessel lets researchers better assess clot removal devices

Novel technology could improve device design, improve post-stroke recovery.

By Scott LaFee, UC San Diego

Researchers at the UC San Diego School of Medicine have created an in vitro, live-cell artificial vessel that can be used to study both the application and effects of devices used to extract life-threatening blood clots in the brain. The artificial vessel could have significant implications for future development of endovascular technologies, including reducing the need for animal models to test new devices or approaches.

The findings are published in the current online issue of the journal Stroke.

Cerebrovascular disease covers a group of dysfunctions related to blood vessels supplying the brain. Risk factors include hypertension, diabetes, smoking and ischemic heart disease. More than 6 million American adults are affected, with the number steadily growing.

When blood supply to the brain is significantly diminished or blocked, an acute stroke may result, requiring quick medical intervention to avoid permanent brain damage or death. More than 795,000 Americans experience a stroke each year; 130,000 die.

“Timely restoration of normal blood flow is absolutely critical,” said Alexander Khalessi, M.D., director of endovascular neurosurgery and surgical director of neurocritical care at UC San Diego Health System. “Clot-dissolving drugs like tPA (tissue plasminogen activator) help, but might not work sufficiently fast or fully in some situations. In those cases, doctors must perform endovascular thrombectomies where they mechanically remove the emboli or clots.”

The rate of endovascular thrombectomies is rising, but the approach, which typically involves running a catheter to the site of the blockage and using one of several marketed devices to remove the clot, can be improved, said Khalessi. For example, some patients experience negative consequences caused by either the mechanical removal of the emboli or by the restoration of blood flow, called reperfusion, specifically to the endothelial cells (ECs) that form the lining of blood vessels.

Current pre-clinical analyses of new therapeutic approaches or devices is limited to either in vitro glass or plastic tubing testing intended to mimic biological counterparts or by using animal models, such as pigs.

“Both of these have significant drawbacks. Although transparent and thus easier to study, glass and plastic tubing does not recapitulate blood vessel biology,” said Khalessi. “In vivo animal models are more realistic, but we cannot directly observe the interaction between devices and ECs. Plus animals are not perfect models of humans and they are expensive to use.”

Khalessi, along with co-author Shu Chien, M.D., Ph.D., director of UC San Diego’s Institute of Engineering in Medicine, and colleagues developed a novel in vitro live-cell platform that allows direct visual characterization of effects and injury patterns to ECs. Bovine artery ECs were perfused into optically clear, biocompatible tubular silicone with a thickness of 0.25 millimeters and inner diameters of 2.5, 3.5 and 4.5 millimeters.

The researchers then introduced porcine blood clots into the platform, allowing the clots to integrate, tested various clot-retrieval devices and examined the post-removal effects.

“We found that the in vitro platform permitted high-resolution quantification and characterization of the pattern and timing of EC injury with various thrombectomy devices and vessel diameters. The devices each displayed different effects.”

The researchers subsequently validated their in vitro findings with in vivo testing.

“This work offers significant promise going forward,” said Khalessi. “The live-cell artificial vessel enabled us to conduct detailed studies of the endothelium after thrombectomy, which may contribute to future device design. Animal studies confirmed the relevance of the platform, which suggests the artificial model could represent a practical, scalable and physiological alternative to existing technologies.”

Co-authors include Dayu Teng, Jieying Li, and Yi-Shuan Li, UCSD Department of Bioengineering and Institute of Engineering in Medicine; and Jeffrey Scott Pannell, Robert C. Rennert, and Victor W. Wong, UCSD Division of Neurosurgery.

Funding for this research came, in part, from competitive grants from Covidien Ltd. and Penumbra Inc.

Disclosure: Alexander Khalessi holds consulting arrangements for physician training with Stryker Neurovascular, Covidien and Penumbra.

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1 in 4 atrial fibrillation patients receives unnecessary blood thinners

Researchers believe cardiology specialists may be unaware of risk.

An electrocardiogram reading traces irregular, rapid and chaotic atrial activity, seen in lead V1 (the top squiggly line).

By Heather Buschman, UC San Diego

About one quarter of all atrial fibrillation patients at the lowest risk for stroke receive unnecessary blood thinners from cardiology specialists, according to a new study by researchers at the UC San Diego School of Medicine and UC San Francisco, and these health care providers must be made aware of the resulting potential health risks. The findings are published online today (April 13) by JAMA Internal Medicine.

“Clinicians who prescribe blood thinners need to be diligent about weighing the risks and benefits of these medications,” said lead author Jonathan C. Hsu, M.D., cardiologist and assistant clinical professor of medicine at UC San Diego. “In those who have no risk factors for stroke, the risk of bleeding likely outweighs the benefit of stroke reduction. The fact that blood thinners were prescribed to so many patients with no risk factors for stroke is a wakeup call that we need to do better for our patients.”

In atrial fibrillation, electrical impulses are triggered from many areas in and around the upper chambers of the heart instead of just one area. This activity is chaotic, and the atrial walls quiver rather than contract normally in moving blood to the lower chambers.

For atrial fibrillation patients at risk for blood clots, anticoagulation therapies such as warfarin or other drugs reduce the risk of illness and death. But because their use carries a bleeding risk, they are not recommended for atrial fibrillation patients at a particularly low risk for stroke.

In fact, current guidelines do not recommend oral anticoagulation in patients under age 60 without heart disease or other known risk factors for blood clots or in atrial fibrillation patients without any established risk factor for stroke. What’s more, the previous guidelines, which were in place at the time the data for this study were collected, contained a very strong recommendation specifically to avoid anticoagulants in that population.

To examine the prevalence of inappropriate anticoagulant prescriptions in young and healthy patients at the lowest risk for blood clots, Hsu and team used a large national registry of cardiovascular patients. From this, they reviewed nearly 11,000 patients age 60 and under and found that roughly 25 percent were prescribed oral anticoagulant therapy contrary to contemporary guideline recommendations. Further, they found that males with atrial fibrillation at the lowest risk of stroke were more likely to be prescribed oral anticoagulation than females, as were older patients and overweight patients without stroke risk factors.

“The irony is that there is a general push to get providers to prescribe these drugs, and they are also generally under-prescribed among many atrial fibrillation patients who actually need them,” said senior author Gregory Marcus, M.D., director of clinical research at UC San Francisco. “Our study suggests people are trying to do the right thing but, due to a lack of understanding of some of the critical nuances, go too far in that direction in low-risk patients.”

Co-authors of this study also include Paul S. Chan, Fengming Tang, St. Luke’s Mid America Heart Institute and the University of Missouri, Kansas City; and Thomas M. Maddox, Veterans Affairs Eastern Colorado Health Care System/University of Colorado School of Medicine.

This research was funded, in part, by the National Heart, Lung and Blood Institute, part of the National Institutes of Health, (grant K23HL102224), U.S. Department of Veterans Affairs, Medtronic and SentreHeart Inc.

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UCSF: Some atrial fibrillation patients receive unnecessary blood thinners

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Heart pouch may explain potentially important cause of strokes

UC Irvine findings could lead to new therapeutic strategies for preventing stroke.

By Tom Vasich, UC Irvine

A pouchlike structure inside the heart’s left atrial chamber in some people may explain strokes that otherwise lack an identifiable cause, according to UC Irvine School of Medicine researchers.

Dr. Mark Fisher, a professor of neurology and pathology & laboratory medicine, and colleagues evaluated 75 stroke patients at UC Irvine Medical Center to learn whether this left atrial septal pouch could be a potent source of stroke-causing blood clots.

Of the 23 patients who had experienced a stroke of undetermined origin (a “cryptogenic” stroke), 30 percent possessed the left atrial septal pouch. It was present in only 10 percent of the 52 patients who’d had a stroke with an identifiable trigger.

Stroke is the leading cause of long-term severe disability and the fourth-most-common cause of death in the U.S. About 80 percent of the 700,000-plus strokes that occur annually in this country are due to blood clots blocking a brain artery. In up to a third of these cases, the clots’ origin cannot be determined.

UC Irvine cardiologists first discovered this pouchlike structure inside the heart’s left atrial chamber in a 2010 study.

“The cul-de-sac nature of this heart pouch may promote stagnation of the blood, forming clots that can travel into the brain and cause a stroke,” Fisher said.

“This finding points to a potentially important cause of strokes,” he added. “The presence of this pouch could change how neurologists treat these patients and lead to new therapeutic strategies for preventing strokes.”

Fisher said that large-scale studies are necessary to verify the results of this study, which appears online in Frontiers in Neurology at http://journal.frontiersin.org/article/10.3389/fneur.2015.00057/abstract.

The research was conducted at UC Irvine Medical Center by members of the Department of Neurology (Fisher and Dr. Annlia Paganini-Hill), the Division of Cardiology (Drs. Dawn Lombardo, Nathan Wong, Ailin Barseghian, Jashdeep Dhoot, Harkawal Hundal and Jonathan Salcedo) and the UCI School of Medicine (Dr. Jonathan Wong, who is now with the California Pacific Medical Center). It was supported by the American Heart Association.

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Brain’s iconic seat of speech goes silent when we actually talk

UC Berkeley discovery has implications for diagnoses, treatments of stroke, epilepsy.

New findings will better help map out the brain’s speech regions (Photo courtesy of Adeen Flinker)

By Yasmin Anwar, UC Berkeley

For 150 years, the iconic Broca’s area of the brain has been recognized as the command center for human speech, including vocalization. Now, scientists at UC Berkeley and Johns Hopkins University in Maryland are challenging this long-held assumption with new evidence that Broca’s area actually switches off when we talk out loud.

The findings, reported today (Feb. 16) in the Proceedings of the National Academy of Sciences journal, provide a more complex picture than previously thought of the frontal brain regions involved in speech production. The discovery has major implications for the diagnoses and treatments of stroke, epilepsy and brain injuries that result in language impairments.

“Every year millions of people suffer from stroke, some of which can lead to severe impairments in perceiving and producing language when critical brain areas are damaged,” said study lead author Adeen Flinker, a postdoctoral researcher at New York University who conducted the study as a UC Berkeley Ph.D. student. “Our results could help us advance language mapping during neurosurgery as well as the assessment of language impairments.”

Flinker said that neuroscientists traditionally organized the brain’s language center into two main regions: one for perceiving speech and one for producing speech.

“That belief drives how we map out language during neurosurgery and classify language impairments,” he said. “This new finding helps us move towards a less dichotomous view where Broca’s area is not a center for speech production, but rather a critical area for integrating and coordinating information across other brain regions.”

In the 1860s, French physician Pierre Paul Broca pinpointed this prefrontal brain region as the seat of speech. Broca’s area has since ranked among the brain’s most closely examined language regions in cognitive psychology. People with Broca’s aphasia are characterized as having suffered damage to the brain’s frontal lobe and tend to speak in short, stilted phrases that often omit short connecting words such as “the” and “and.”

Specifically, Flinker and fellow researchers have found that Broca’s area — which is located in the frontal cortex above and behind the left eye — engages with the brain’s temporal cortex, which organizes sensory input, and later the motor cortex, as we process language and plan which sounds and movements of the mouth to use, and in what order. However, the study found, it disengages when we actually start to utter word sequences.

“Broca’s area shuts down during the actual delivery of speech, but it may remain active during conversation as part of planning future words and full sentences,” Flinker said.

The study tracked electrical signals emitted from the brains of seven hospitalized epilepsy patients as they repeated spoken and written words aloud. Researchers followed that brain activity – using event-related causality technology – from the auditory cortex, where the patients processed the words they heard, to Broca’s area, where they prepared to articulate the words to repeat, to the motor cortex, where they finally spoke the words out loud.

In addition to Flinker, other co-authors and researchers on the study are Robert Knight and Avgusta Shestyuk at the Helen Wills Neuroscience Institute at UC Berkeley, Nina Dronkers at the Center for Aphasia and Related Disorders at the Veterans Affairs Northern California Health Care System, and Anna Korzeniewska, Piotr Franaszczuk and Nathan Crone at Johns Hopkins School of Medicine.

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Paramedics may be best first lineof defense in treating stroke patients

First-of-its-kind study, led by UCLA, offers hope for faster, more effective care.

By Kim Irwin, UCLA

A consortium led by UCLA physicians has found that paramedics can safely start providing people with medication in the first minutes after the onset of a stroke instead of waiting for them to receive treatment at a hospital.

Although the drug tested, magnesium sulfate, did not improve patient outcomes, the research points to a new method for treating stroke patients quickly.

For people who have suffered a stroke, immediate treatment is key — the more time that passes before the restoration of blood flow, the higher the likelihood that stroke victims will suffer irreversible brain damage.

The study findings indicate that paramedics can give intravenous medications to stroke patients within the “golden hour,” the window during which treatments are most likely to help patients survive and avoid debilitating, long-term neurological damage. That finding is a game-changer, said Dr. Jeffrey Saver, the study’s co-principal investigator and director of the UCLA Stroke Center.

“The trial succeeded in its goal of devising a means to deliver promising drugs to stroke patients in the first minutes, when there’s the greatest amount of brain to save. We have opened a new therapeutic window that is now being used to test other compounds and deliver clot-busting drugs to patients in the field,” said Saver, who also is a professor of neurology at the David Geffen School of Medicine at UCLA. “Stroke is a true emergency condition. Time lost is brain lost — for every minute that goes by without restoration of blood flow, 2 million nerve cells are lost.”

The study appears in today’s (Feb. 5) issue of the New England Journal of Medicine.

The phase 3 Field Administration of Stroke Therapy–Magnesium (FAST–MAG) clinical trial involved collaboration among 315 ambulances, 40 emergency medical service agencies, 60 receiving hospitals, 715 emergency physicians, 210 neurologists, 26 neurosurgeons and 2,988 paramedics in Los Angeles and Orange counties. In the study, half of the 1,700 patients had the study drug administered within 45 minutes, while 74 percent were treated within the golden hour.

“This study involved an unprecedented cooperative effort of paramedics in the field and emergency physicians serving as investigators,” said Dr. Sidney Starkman, co-principal investigator and co-director of the UCLA Stroke Center.

“Through this study we were able to instill permanently in everyone’s mind the idea that ‘time is brain.’ We believe this represents a paradigm shift in the treatment of stroke and potentially numerous other neurological conditions,” said Starkman, who also is professor of emergency medicine and neurology at the Geffen School. “We demonstrated that paramedics not only are eager to provide the best possible patient care, but also are capable of being invaluable partners in an intense, time-dependent clinical trial.”

Today, the only ways to treat strokes caused by blocked blood vessels are to reopen the arteries with tissue plasminogen activator, a clot-busting drug, or to use catheters to remove the clot. But, in general, neither can be done until the patient arrives at the hospital and undergoes a CT scan to rule out bleeding in the brain. Additional treatments can only be offered after that, by which time substantial brain injury may already have occurred.

The FAST–MAG trial used magnesium because in animal studies it dilated blood vessels and increased blood flow in the brain. Magnesium also countered the damaging calcium buildup that occurs when cells are deprived of oxygen. It had been already approved for use in humans, it had a good safety profile and paramedics were familiar with it.

“Now we are tasked with finding a different agent or combination of agents that can improve stroke outcomes within that golden hour,” Saver said. “The ambulance treatment platform can be used around the world to test promising agents.”

Dr. Bill Koenig, medical director of the Los Angeles County Emergency Medical Service Agency, worked closely with Saver and Starkman on the FAST-MAG study.

“To assist paramedic recognition of stroke victims, the nationally recognized Los Angeles Pre-hospital Stroke Screen was developed,” Koenig said. “FAST-MAG also served as an impetus to create the Los Angeles County System of Stroke Hospitals, which every year treats over 10,000 stroke victims. When the day comes that a medication can successfully treat stroke in its early stages, this novel system in Los Angeles will be well positioned to immediately apply the treatment to our patients. I am confident that with the dedicated investigators, along with a finely tuned EMS system, that discovery will be sooner rather than later.”

Dr. Walter Koroshetz, acting director of the National Institute of Neurological Disorders and Stroke, said this study shows that it is possible to get treatments to stroke patients even before they arrive at a hospital.

“Because a blocked blood vessel causes brain damage over minutes to hours, this pre-hospital approach to treatment is sure to be adopted and refined in clinical research studies,” Koroshetz said. “Ultra-early brain salvage in stroke patients will someday surely reduce the tremendous burden of disability and death due to stroke.”

Saver said clinical trials currently being conducted in the U.S., Canada and England are testing new compounds using the early treatment infrastructure created by the FAST–MAG study.

Stroke is the fifth leading cause of death in the U.S. and is a major cause of adult disability. About 800,000 people in the U.S. have strokes each year, and one person dies from a stroke every four minutes, on average.

The study was funded by the National Institute of Neurological Disorders and Stroke at the National Institutes of Health.

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UC San Diego to host region’s first camp for stroke survivors, caregivers

Therapeutic retreat offers support, education and a bit of fun.

Alexander Khalessi, UC San Diego

By Jackie Carr, UC San Diego

On Jan. 23-25, more than 15 stroke survivors and their caregivers will go on a mini-vacation in La Jolla as part of a therapeutic retreat for those whose lives have been affected – sometimes turned upside down – by stroke. The 50s-themed stroke camp is being co-hosted by UC San Diego Health System, which has one of the nation’s first certified Comprehensive Stroke Centers.

“Stroke camp is part of UC San Diego’s larger commitment to the care of neurovascular patients and their families,” said Alexander Khalessi, M.D., director of endovascular neurosurgery and surgical director of neurocritical care at UC San Diego Health System. “Beyond receiving the best possible neurological care or developing new therapies, we support patients through their recovery and get them back to their lives.”

The camp will be the first Refresh & Retreat Stroke Camp in California, with the flare of an American Bandstand theme, complete with an invitation to bring “your letter sweaters, poodle skirts and dancing shoes.” The event is sponsored with Covidien, a global health care leader.

Stroke care has advanced rapidly in recent years, but strokes still involve some permanent loss of healthy brain tissue due to either a lack of blood flow or bleeding within the brain itself. As a result, many stroke survivors require significant time to recover and rehabilitate. During this healing process, it is the caregivers – often a spouse or family member – who may suddenly find themselves overwhelmed and socially isolated by their new responsibilities.

“Stroke camp is about pampering the caregivers and recognizing the toll strokes take on them,” said Julie Jurf, R.N., stroke care coordinator, UC San Diego Health System. “The camp’s aim is to bring fun, respite and renewal to stroke survivors, their families and caregivers.”

Jurf will volunteer at the retreat to assist caregivers.

“I will be pushing a wheelchair, standing in line for food, or doing whatever needs to be done so that my caregiver can go for a swim or relax,” she said. “Even just a two-day break can go a long way to bring renewal to people’s life.”

Khalessi added that stroke camp provides patients with support and encouragement, offers a welcome rest for their caregivers, and provides an opportunity to bond with other stroke survivors.

Over three days, attendees will be invited to participate in a variety of camp-like activities, including drum circles, craft-time and 50’s bingo, as well as survivor and caregiver break-out discussion sessions that allow attendees to vent, share and console as needed.

In addition, Khalessi, a national expert in catheter-based and open cranial neurosurgeries for stroke, aneurysms and other blood vessel disorders of the brain, will lead a tour of the Center for the Future of Surgery at the UC San Diego School of Medicine. This facility is a national destination for developing and refining new life-saving stroke treatments, now transforming the standard of care for stroke patients.

“Stroke is a disease that had no solutions 30 years ago. It is now a treatable medical and neurosurgical emergency. Even five years ago, stroke care involved a single drug and supporting patients through their new disabilities,” Khalessi said. “We now have catheter-based procedures and devices that allow for rapid and safe restoration of blood flow in the most severe forms of stroke, involving large vessels of the brain,” a procedure known as stent thrombectomy that in a recent study published in the New England Journal of Medicine greatly improved stroke patients’ prognoses.

“We have phenomenal new treatments for hemorrhagic stroke, or bleeds within the brain, due to cerebral aneurysms or high blood pressure, using minimally invasive surgical or catheter-based techniques,” he said. “These strokes are no less devastating and were a death sentence a decade ago.”

The designation of a Comprehensive Stroke Center at UC San Diego Health System is formal recognition of its ability to receive and treat the most complex stroke cases around the clock, every day of the year, with a multidisciplinary team of neurologists, neurosurgeons, cardiologists and rehabilitation specialists.

Approximately 680,000 American’s each year survive a stroke, making stroke the nation’s leading cause of disability. A patient’s ability to benefit from the latest in stroke-care technologies hinges upon a third party recognizing stroke and ensuring that the patient is brought to a hospital where comprehensive stroke care can be provided.

About Retreat & Refresh Stroke Camp
Retreat & Refresh Stroke Camp is a nonprofit based in Peoria, Illinois. It has sponsored 105 stroke camps nationwide since 2004. The nonprofit’s founder and executive director, Marylee Nunley, is caregiver to her husband John, who had a stroke in 2001. For more information, visit http://strokecamp.org.

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UCLA honored for stroke care

Receives Get With The Guidelines award for implementing quality improvement measures.

The UCLA Comprehensive Stroke Center at Ronald Reagan UCLA Medical Center has received a Get With The Guidelines – Stroke award for implementing specific quality improvement measures outlined by the American Heart Association/American Stroke Association for the treatment of stroke patients.

Get With The Guidelines – Stroke helps hospital teams provide the most up-to-date, research-based guidelines with the goal of speeding recovery and reducing death and disability for stroke patients. UCLA earned the Gold-Plus Quality Achievement Award award for measures that include aggressive use of medications and risk-reduction therapies aimed at reducing death and disability and improving the lives of stroke patients.

UCLA also received the association’s Target: Stroke Honor Roll for meeting stroke quality measures that reduce the time between hospital arrival and treatment with the clot-buster tPA, the only drug approved by the U.S. Food and Drug Administration to treat ischemic stroke. People who suffer a stroke who receive the drug within three hours of the onset of symptoms may recover quicker and are less likely to suffer severe disability.

“At the UCLA Comprehensive Stroke Center, we are dedicated to improving the quality of stroke care, and The American Heart Association/American Stroke Association’s Get With The Guidelines–Stroke helps us achieve that goal,” said Dr. Jeffrey Saver, director of the UCLA Stroke Center and professor of neurology at the David Geffen School of Medicine at UCLA. “With this award, our hospital demonstrates our commitment to ensure that our patients receive care based on internationally-respected clinical guidelines.”

“We are pleased to recognize UCLA for their commitment and dedication to stroke care,” said Dr. Deepak L. Bhatt, national chairman of the Get With The Guidelines steering committee and executive director of Interventional Cardiovascular Programs at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School. “Studies have shown that hospitals that consistently follow Get With The Guidelines quality improvement measures can reduce patients’ length of stays and 30-day readmission rates and reduce disparity gaps in care.”

Get With The Guidelines–Stroke also helps UCLA’s staff implement prevention measures, which include educating stroke patients to manage their risk factors and to be aware of warning signs for stroke, and ensuring they take their medications properly. Hospitals can make customized patient education materials available upon discharge, based on the patients’ individual risk profiles. The take-away materials are written in an easy-to-understand format in either English or Spanish.

According to the American Heart Association/American Stroke Association, stroke is the number four cause of death and a leading cause of adult disability in the United States. On average, someone suffers a stroke every 40 seconds; someone dies of a stroke every four minutes; and 795,000 people suffer a new or recurrent stroke each year.

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