Stent Retrievers Revolutionize Treatment of Some Strokes

April 26--Around 4 p.m. on Nov. 30, Josie Jupina asked her husband, Ted, to help her make the annual Christmas wreath.

She went upstairs for supplies. He headed for the garage.

When she came back, she found him on the floor, unable to move his left arm and leg. His speech was slurred. He knew something was wrong but he wasn't afraid. "My wife was right there," he said. "My guardian angel. She took care of me."

Indeed she did. Josie Jupina instantly suspected her husband of 51 years was having a stroke. She was afraid. "I thought I would have an invalid," she said.

She called 911. The ambulance took Ted from their home in Lansdale to Abington Memorial Hospital. The medical team there discovered his right middle cerebral artery was totally blocked by a clot. The entire right side of his brain was at risk.

Hana Choe, the interventional neurologist on call, knew Jupina faced death or paralysis in a nursing home. She decided to try a treatment technique that is revolutionizing care for large strokes like his.

She threaded a catheter through his leg into his brain, and, using a device called a stent retriever, snagged the half-inch-long clot and pulled it out. Then she removed a clot in a smaller vessel nearby.

When she was done, Jupina could move his arm and leg again. He has some weakness in his left leg now, but he's walking well with a cane. In January, he celebrated his 91st birthday.

Josie Jupina uses the word miracle.

Area doctors use it, too, along with game changer and huge advance.

"The first time I saw it, my jaw fell to the floor," Choe said of the procedure. "It's as if they had been sleeping and then they wake up."

The last major advance in stroke care was in 1996 when the clot-busting drug tPA was approved. It tends to work gradually. When stent retrievers work, blood rushes to starving brain cells. If it gets there fast enough, as it did for Jupina, symptoms disappear on the cath lab table.

Stent retrievers -- the FDA approved two in 2012 -- got a big boost in February, when three new studies released at an American Stroke Association conference added to evidence from an earlier paper that the devices lower the risk of disability and death.

In the latest three studies, researchers compared the percentage of patients free of major disability after treatment. Each study yielded different numbers, with the percentage of stent retriever patients who had good outcomes ranging from 53 percent to 70 percent. The corresponding numbers for tPA patients were 29 percent to 40 percent.

Three 2013 studies found stent retrievers did not help, but experts said the newer trials were better designed.

The devices won't work for every stroke, and, like tPA, they have to be used within hours of the onset of stroke symptoms. Despite massive publicity, many people still do not do what Josie Jupina did: call 911 the minute they notice symptoms.

Plus, only a handful of local hospitals are using stent retrievers. It's a complex procedure usually done in big facilities with well-prepped teams. Stroke experts are now beginning to discuss a politically charged topic -- how to ensure that patients get quick access both to tPA, which can be given in many hospitals, and to stent retrievers.

"This is the time when we get to redesign as a society how we want to care for this disease," said Guillermo Linares, director of neuro-interventional services at Temple University Hospital.

The Joint Commission accredits hospitals as comprehensive -- the highest level -- or primary stroke centers. Philadelphia and the Pennsylvania suburbs have three comprehensive centers: the Hospital of the University of Pennsylvania, Thomas Jefferson University Hospital, and Abington. Temple is working toward the distinction.

In South Jersey, the state has designated Kennedy University Hospital -- Washington Township as a comprehensive stroke center.

All of those hospitals use stent retrievers.

Cooper University Hospital, Albert Einstein Medical Center, Bryn Mawr Hospital, Hahnemann University Hospital, and St. Mary Medical Center also use the devices, they reported in response to an Inquirer query.

Area stroke experts said they thought patients with suspected symptoms ideally should go to centers that can give tPA first and then, if necessary, be transferred to a bigger center that can use a stent retriever. Whether that's happening as often as it should is unclear.

Scott Kasner, director of Penn's stroke center, said some hospitals administer tPA and figure they've done their duty. "That happens all too often, and that's a real shame," he said.

Robert Rosenwasser, chair of neurological surgery at Jefferson, agreed. He is exploring adding tele-medicine to ambulances to speed the triage and transfer process.

About 800,000 Americans have strokes each year. Most -- 680,000 -- are caused by clots that block blood vessels that feed the brain, said Lee Schwamm, director of acute stroke services and tele-stroke at Massachusetts General Hospital. A third to half of those occur in large vessels -- the ones where stent retrievers work -- but experts predict the number of patients who will get stent retrievers will be far lower. Their estimates vary widely.

Like tPA, stent retrievers must be used quickly. For the drug, patients need to get to the hospital within 41/2 hours of symptom onset. Most don't. Other factors can also make them ineligible. Overall, only 8 percent to 10 percent of stroke patients get tPA, Schwamm said. At high-performing hospitals, 15 percent to 25 percent get it. It is less effective against big clots.

Fewer than 2 percent of patients with strokes caused by clots receive endovascular treatments -- those delivered through blood vessels -- like stent retrievers, Schwamm said.

Stryker and Medtronic, which make the two types of approved stent retrievers, see huge potential. Stryker said 10,000 U.S. stroke patients had clots removed last year. That number could grow five to 10 times if patients recognize symptoms quickly and go to hospitals that can give the treatment.

Medtronic foresees a worldwide market worth $500 million a year in the next few years.

Though some studies have used stent retrievers in patients up to 12 hours after symptoms started, experts said benefits were more likely within six to eight hours. The faster patients are treated, the better.

"Time is very important," Rosenwasser said. "As every hour goes by, it reduces the chance of a good outcome by 7 percent."

Sophisticated medical imaging is changing the equation. Doctors can now see how well the smaller vessels around a stroke feed tissue in the damage zone.

The amount of time those smaller vessels can keep brain cells alive varies. Four hours might be too much for some people, Linares said. Others might be OK 10 hours after a stroke starts.

"In the future," he said, "we're not going to use time as much as we use physiology."

Need Help? Don't Delay

After a heart attack or stroke, every moment is valuable. If you notice any of these symptoms, call 911 immediately; don't wait for symptoms to pass.

Signs of stroke

Sudden numbness or weakness of a leg, arm, or the face.

Face drooping.

Sudden confusion or difficulty speaking.

Sudden trouble seeing with one or both eyes.

Sudden trouble walking or dizziness.

Sudden severe headache with no known cause.

SOURCE: American Stroke Association

Signs of heart attack

Discomfort in the center of the chest that lasts more than a few minutes -- or goes away and comes back. It can feel like pressure, squeezing, fullness, or pain.

Discomfort in one or both arms, the back, neck, jaw, or stomach.

Shortness of breath.

Other signs include a cold sweat, nausea, or lightheadedness.

SOURCE: American Heart Association

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