THE QUIET DISEASE

Physicians race against time in order to minimize and prevent the damage caused when this silent killer strikes.

 

By Christopher Tedeschi

George Teitelbaum stares at the monitor above the operating table, looking at an artery that became blocked by a blood clot about four hours ago when his patient began to feel numbness and tingling in one side of his body-the early warning signs of a stroke.

Scrutinizing the monitor's image of the four-and-a-half-foot-long catheter, which he has guided up the patient's carotid artery from the groin to the brain, Teitelbaum wiggles the wire a bit and takes aim.

As the catheter's tip abuts the clot, Teitelbaum begins sending a drug through the tube. He is shooting the clot with urokinase-a powerful "clot busting" medication that could free the patient's artery from a potentially fatal blockage in less than an hour.

On the monitor, the blood slowly begins to flow past the clogged area, signaling that the urokinase is dissolving the blood clot and the patient's brain can receive the vital oxygen that it needs to stay alive.

Brain Attack

Teitelbaum is an interventional radiologist and associate professor in USC's Department of Neurological Surgery. His endovascular techniques-the art of snaking tiny hollow tubes through long stretches of artery to the point of a potential stroke-have changed the way stroke is treated at USC. The techniques have introduced the possibility of treatments that do not involve surgery, but rather the use of the long catheters to open clogged arteries and stabilize weak blood vessels.

Since he moved to USC from the University of California at San Francisco two years ago, Teitelbaum has been working with neurosurgeon Steven Giannotta, M.D., USC professor of neurological surgery, whose specialty is vascular surgery of the brain. The partnership led to the creation of USC's Center for Stroke and Cerebrovascular Disorders. The Center offers screening and counseling for patients in danger of having a stroke, as well as a variety of medical and surgical treatments to help reduce the risk.

"The updated term is brain attack," Teitelbaum says, noting the similarities between stroke and heart attack.

"Teitelbaum's arrival at USC allows us to practice with a multi-treatment approach, when beforehand, all of our treatments revolved around invasive surgery," Giannotta says, noting that with a greater number of treatments available at the Center, physicians can offer the best therapy to each particular patient. With the help of vascular surgeons from the Department of Surgery, the Stroke Center offers a range of therapies, from vascular surgery to endovascular treatments, matched at only a handful of other hospitals in the Western United States.

Stroke is the third leading cause of death in the U.S., trailing close behind heart attack and cancer. In addition, stroke is the nation's leading cause of adult disability. Some of the most common risk factors for stroke include high blood pressure, atherosclerosis, smoking, age, and a sporadically rapid and irregular heartbeat called atrial fibrillation.

In the past, people tended to accept the frustrating idea that little could be done once a stroke had occurred. But now stroke has become a treatable disease. Giannotta hopes to see the signs of stroke become widely recognized, in order to increase the number of stroke patients who are able to receive immediate care. "We all know the signs of heart attack," he says. "We need to do the same thing with stroke, because the technologies for treating stroke are evolving so rapidly. We're not nearly as nihilistic about prevention and treatment as we used to be."

Common stroke symptoms include an inability to speak or move part of the body, or numbness or heavy feeling in an arm or leg. Other possible symptoms include headache, blurred or double vision, confusion, and dizziness. These symptoms indicate that an artery that supplies blood to part of the brain may have become blocked by fatty deposits or blood clots.

Prevention has also evolved. New drugs can help to prevent stroke long before it happens. A group of medications called anticoagulants, for instance, help prevent the formation of dangerous blood clots which could travel to the brain and ultimately cause a stroke.

To check for partially blocked arteries and screen for stroke risk, the Stroke Center recently began offering noninvasive ultrasound screenings of the neck's carotid artery at a fraction of their normal cost. If partial blockage is detected, patients will have at their disposal the expertise of some of the nation's most experienced neurosurgeons and vascular surgeons.

"The test gives us valuable information about a quiet disease," says Darwin Eton, M.D., USC associate professor of surgery. Eton stresses the ease and power of the ultrasound screening procedure that can detect serious aneurysms or arterial blockage before a stroke occurs. "Anyone with any stroke risk factor should be screened," he adds.

When a stroke does occur, brain cells start to die. Racing against time, physicians have to determine the best way to reopen narrowing vessels, in order to maintain a continuous flow of oxygen-rich blood to the brain. Depending on the stroke's cause, a variety of techniques are available to minimize the damage and prevent further trouble.

Arteries and Aneurysms

With the addition of Teitelbaum's endovascular procedures, patients at USC have more choices regarding stroke treatment than anywhere else. "Together, we offer different perspectives," says Eton. He performs a carotid endartectomy-an operation in which surgeons physically remove fatty, fibrous and calcific deposits from blocked blood vessels. The surgery may be done after a patient has complained of symptoms of stroke, or even before symptoms occur.

For patients with clogged arteries who may not be satisfactory candidates for surgery, Teitelbaum uses an approach called carotid angioplasty. Using the catheter, he inflates a small balloon to expand obstructed blood vessels, pushing debris aside and restoring a healthy blood supply to the brain.

The widened blood vessel is kept open by a stainless steel stent-a tiny cylindrical device that permanently lines the inside of the damaged artery and prevents the channel from collapsing on itself and reverting to its obstructed state.

The balloon method offers an alternative to conventional vascular surgery, although it neither replaces nor necessarily outperforms the endartectomy procedure. Angioplasty can be preferable in patients for whom surgery is too risky, or for people whose arterial blockage is in a difficult place to reach.

Teitelbaum's catheters have other uses as well, once again complementing already available surgical techniques. A procedure recently approved by the federal government makes use of the long tubes to deliver structural support to weak-walled sections of artery called cerebral aneurysms.

Aneurysms look something like small balloons extending from the wall of a blood vessel, not unlike a bubble that might appear on the side of an automobile tire. If the small blood-filled sacs burst, a jet of blood can surge into the brain, destroying brain tissue and possibly depriving the brain of essential oxygen.

Using a thin catheter, surgeons insert a small platinum coil-a miniature "slinky" between one and 10 inches long-into the sac created by the aneurysm. The coil restricts blood flow to the outpocketed area, ultimately causing the aneurysm to clot-off. The method offers an attractive alternative to major surgery, previously the only other available treatment for cerebral aneurysm.

Urgent Action

Physicians need to realize that when a patient complains of stroke symptoms, urgent action may be in order. Says Giannotta, "Greater numbers of patients experiencing stroke symptoms will benefit from immediate and uninterrupted care. The Stroke Center instituted a toll-free number so physicians can maintain a continuum of care by reaching medical staff at USC University Hospital around-the-clock."

"There's an enormous job to be done in the way of public education," Teitelbaum says, "and there is the potential to dramatically reduce the number of lives damaged or lost."

 

You can reach the Center for Stroke and Cerebrovascular Disorders at 1-800-USC-CARE.

 

 

Risk Factors For Stroke

 

 

Warning Signs of Stroke