At first, it’s like waking up in a strange land. Some can’t speak or understand the language. Many are disoriented and confused. Later, after the violent attack has retreated, many are left severely disabled. Others have not survived.
Stroke, the third-leading cause of death in the United States behind heart disease and cancer, affects each of its victims differently. Until recently, the fate of those patients was nearly out of their doctors’ hands.
Stroke has worked its way up on the emergency room priority list. Experimental drugs, one approved by the Food and Drug Administration in June, have given victims more hope and created an urgency in how the disorder is treated.
“It is similar to people who are drowning,” said Dr. Richard Hughes, an assistant neurology professor at the University of Colorado Health Sciences Center in Denver. “If they get pulled from the lake quickly, they have a better chance of survival. The window of opportunity to reduce the severity of a stroke after it has occurred lasts only for a few hours.”
For rTPA, the recently approved anti-clotting drug, that window is only three hours. Patients who fail to reach a hospital within that time cannot receive the drug, which has proved beneficial in many victims. Other medical factors also can exclude a patient from being an rTPA candidate.
Clots cause about 80 percent of strokes. The rest are the result of a ruptured vessel in the brain. The clot can form in the brain or clog an artery that supplies brain cells. In all cases, the result is decreased blood flow to the cells, hindering their function. “But they (the cells) are not dead yet,” said Hughes, explaining that rTPA dislodges the clot and halts the cell starvation. When successful, the drug saves cells, thus decreasing brain damage and disability.
That is quite a breakthrough for stroke treatment, according to Karen Putney Iannella, vice president of the National Stroke Association. “Stroke patients have come in and historically sat in the back of the emergency room. They’ve sat there for hours and hours.” There was little a doctor could do but wait for the stroke to take its course.
Now, Iannella said, rTPA can really make a difference in people’s lives. “We’ve seen drastic improvement in patients.”
But for stroke victims, getting to an emergency room is not always easy.
John McFetridge of Boulder, Colo., had a stroke–or brain attack, as the NSA is starting to call it to emphasize the urgency–four years ago. His wife of nearly 30 years had gone skiing with some friends. He had just taken a shower and was trying to put on his glasses.
“I kept picking them up and dropping them, picking them up and dropping them. Then, my whole right side went out, and I just fell to the floor.”
McFetridge, then 53 and a company president, said he was unconscious for about three hours. He was awakened by the phone. He dragged himself to it, but he was too late. He said he just lay there and waited. Finally, it rang again. It was his wife. “I went to say hello, and I couldn’t talk. I didn’t realize until that moment that I couldn’t talk.”
McFetridge, a health-care consultant, said it wasn’t until the end of that nine-day stay in intensive care that he began to realize he had suffered a stroke.
“I never ever thought that I had had a stroke,” said McFetridge, who lost all speech ability and movement on the right side of his body. As he lay helpless on the floor, he said he was oblivious. “I was just clueless about what was going on. Remember, stroke wipes out a portion of your brain,” he said, noting that his wife had immediately thought stroke.
Hard work and a strong desire to return to his state before his stroke helped McFetridge walk and talk again. He works half time, and people who do not know him might not suspect he has had a stroke.
Faced with the reality that many people do not know the signs of stroke or understand the need for urgent care–a 1996 NSA/Gallup poll showed that two-thirds of people were unaware of the short time for care and 91 percent were unaware that sudden blurred vision could be a sign of stroke–more drugs with longer windows of opportunity are continually being studied.
“Two years ago, there were about 50 compounds being studied,” Iannella said. “Now, there are over 200.”
One of those drugs under scrutiny is part of a Boulder clinical trial directed by the Alpine Clinical Research Center. “A lot of patients are not eligible to receive rTPA,” said Peg Sharp, a registered nurse and owner of the Alpine center. `It has a fairly significant risk profile.”
If the drug is administered inappropriately, it is ineffective and increases the risk of “devastating hemorrhage,” Hughes said. The risk of causing bleeding in major organs is present even when the drug is administered on time.
Another class of drugs called neuroprotectives is gaining significant research attention. The recommended time frame for giving these drugs is within six hours of symptom onset, and if a patient were given a neuroprotective outside of that window, it is not likely it would hurt them, Sharp said.
Alpine is one of about 50 other centers in the country taking part in a blind study of Cerestat, meant to minimize the effects of an ischemic cascade, a chain reaction of complex chemical and electrical processes initiated by a stroke’s damaged brain cell zone. This cascade leads to the release of free radicals and, eventually, more cell death. It lasts about 24 hours.
“The hope is, in the future, we will be able to do a combination therapy with the two types of drugs,” said Susan Nichamoff, manager of the NSA clinical trials acceleration program.
Neuroprotectives alone and in conjunction with anti-clotting drugs also are being studied at the Health Sciences Center, said Hughes, who is associated with a number of stroke organizations and emphasizes the need for research.
“As a neurologist, stroke is perhaps the most common devastating illness you care for, and I do research in the hope that this research will eventually lead to fewer strokes and less severe strokes,” Hughes said.
