Mending the mind

One crumb of comfort from the PM's crisis is a heightened awareness of medicine's revolutionary progress.

By HILARY LEILA KRIEGER
January 12, 2006 10:30
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The first attack came on the road. As Prime Minister Ariel Sharon was traveling from Jerusalem to Tel Aviv on December 18, he complained to his son Gilad that he didn't feel well. Sharon's driver turned the car around and brought the PM to Hadassah University Medical Center in Ein Kerem, where it was determined that he had suffered a mild stroke caused by a blood clot in his brain. He was released two days later. The examination revealed the source of the clot was likely to be a small hole in his heart, which he was scheduled to have sealed. But 10 days later came the second attack. As Sharon was resting at his ranch the night before the operation, he again began to feel ill. He was again rushed to Hadassah Ein Kerem, this time by ambulance, and treated for a massive brain hemorrhage, another kind of stroke. Doctors then performed three operations over the course of three days to stop the bleeding and suction out the accumulated blood that was pressing on other parts of the brain. Though the prime minister's condition remained serious during and after the operations, his chances of survival were helped by the flourishing of technology to treat strokes when once there had been no therapeutic options. Had he been felled by two such strokes a mere decade ago, he wouldn't have had access to some of the advanced imaging technologies that rapidly suggested the cause of the first episode, the technique that found the small hole in his heart and an improved blood-clotting medicine available to help stop his hemorrhage. In the past 10 years, a veritable revolution in stroke diagnosis, treatment and rehabilitation has occurred. What has prevented the greater impact of all this progress is, at least partly, a lack of awareness among ordinary people of how it could benefit them. A modicum of comfort in the Sharon case, therefore, is that the medical revolution is now emphatically visible. "In the past when a subject developed a stroke, there was nothing to do about it," Prof. Natan Bornstein, chairman of the neurology department and stroke unit at Tel Aviv Sourasky Medical Center, says matter-of-factly. "He was put aside in one of the internal medicine [rooms] and that was it." Indeed, although strokes have been a known disease for centuries, it is only in the last decade or so that hospitals have become anything more than a place of refuge for victims. Strokes occur when the normal flow of blood to the brain is disrupted, causing the death of neurons in the brain. By far the most common - comprising some 80 to 85 percent of cases - are ischemic strokes, in which blood clots temporarily or permanently cut off the supply of oxygen to the brain. The other kind is hemorrhagic strokes, in which blood bursts into brain tissue following a leaky or exploded blood vessel. (Sharon has suffered both types of stroke.) Depending on the amount of brain tissue destroyed, severe disability and even death can result. The latter is twice as likely among those suffering hemorrhagic strokes because they appear so suddenly and it takes time for the patient to reach a neurosurgeon and for the operation to staunch the flow of blood. But new technology, medicine and expert teams have made significant inroads in treating ischemic and hemorrhagic strokes. Bornstein recalls that assessing and treating neurology patients was once "a slow-motion process" of examinations, tests and consultation. But once changes in the field allowed for intervention as opposed to observation, "We became critical care emergency physicians." The transformation found its feet 30 years ago with the invention of the CT (computerized tomography) scan, which uses X-ray technology to construct 3-D images of the brain and changes inside it. But it only took off and became widely used much more recently, once the CT scan and the computers it depends on to compile data had been refined sufficiently to provide this information - which reveals whether a stroke is a blood clot or a hemorrhage, a precondition for any treatment - fast enough to allow for intervention. Only now, a US-based company is bringing a portable CT scan onto the market that can be used in any emergency room for efficient processing of patients. Without such advanced technology, patients need to be transferred to a separate room to undergo the scan, taking time and exposing the patient to risk while being moved. More sophisticated brain imaging, which gives more detailed information about brain functioning and the locations of clots or hemorrhages, came from the ongoing development of magnetic resonance imaging (MRI). It has the advantage of using magnetic fields rather than radiation to scan the brain, but it also takes longer to work, which is a major disadvantage in treating strokes. More recently, a new type of MRI, called an MRA, has provided not only mapping of the brain, but of the actual blood vessels that ruptured, leaked or were blocked during a stroke. The "A" stands for angiography, a process that graphically represents blood vessels. A further MRI modification, the DWI (diffusion weight imaging) gives additional insight into the causes of strokes and the extent of their damage. It can even detect viable tissue that can still be salvaged. An additional technology called echocardiography, which goes through the esophagus, enabled doctors to spot the small opening between the atria of Sharon's heart. Doppler ultrasound provides information on the condition of arteries and on tracking the flow of medication to alleviate strokes and finding out whether it has been effective. "We can see what we're treating. We're not blinded to what we treat," summarizes Dr. David Tanne, head of the stroke center at Sheba Medical Center at Tel Hashomer. "The more information you have in the early stages, the more you can tailor your treatment." And now there is effective treatment available. Most significant was the approval of tPA (tissue plasminogen activator) by the US Food and Drug Administration in 1996 to dissolve blood clots that cause stroke. Until then, the drug had been used to restore the flow of blood following heart attacks. The "clot-buster" medication was registered for strokes by the Israeli government only in 2005, but it has been used in hospitals here under special arrangements for a few years. "This is a major, major breakthrough in stroke treatment," according to Tanne. "We didn't have a treatment that could save part of the brain" from being destroyed. tPA is administered intravenously. The imaging allows doctors to know exactly where to send the drug. And the new drug NovoSeven - currently used to halt hemorrhages from hemophilia - has already shown preliminary success in keeping a bleed inside the brain from growing if administered soon after a stroke, according to Bornstein, who indicated it probably was used to treat Sharon. Bornstein also refers to another drug in development as a possible "light at the end of the tunnel" when it comes to protecting the grey matter around the area affected by a stroke from further damage. Israel is currently participating in international trials on this neuroprotectant. An additional "breakthrough" medicine functions "like a cork screw" to extract clots, in the words of Bornstein. It can be applied when intravenous tPA might not be effective, though its use has not yet been widespread. The delicacy of these treatments demonstrates that an essential component of all of these advances is a special medical team trained in stroke care. It is a growing neurosurgery sub-specialty for which doctors undergo special training, and counts among its leaders Dr. Jos Cohen, the surgeon who has led the operations on Sharon. The teams are particularly necessary because treatment can be deadly if administered on the wrong type of stroke patient. The tPA, which dissolves clots, would only exacerbate bleeding if used on a patient who is hemorrhaging. But it can work wonders if used under the right circumstances on appropriate patients, as Rahel, a 47-year-old mother of six from Jerusalem, found out last year. She was attending a party in Mevaseret Zion and suddenly felt a terrible, piercing headache. "I was told to sit down and relax, but I felt a pain in my neck and couldn't move it from side to side. I felt nauseous," she recalls. "I decided to go to the emergency room at Shaare Zedek Medical Center because the day center where I work is there." There, emergency room doctors performed a CT scan and realized she was having a stroke. Since the hospital doesn't have a neurosurgery department, they rushed her to Hadassah in Ein Kerem, which had just inaugurated a $3 million brain angiography room. "I was vomiting and felt terrible. I just wanted to sleep. I don't remember anything after that," she relates. Alerted by the emergency room, Cohen, who had been at home, arrived quickly. Tests showed that Rahel had suffered an acute ischemic stroke that required delivery of the new clot-busting therapy via angiography to a vital artery in her brain. Subsequently she also underwent surgery. "I feel like new. I am absolutely normal, with no disability," Rahel says in amazement. "I thank God, and Dr. Cohen, who was His emissary! He is an angel." Rahel has a message for those who find themselves in a similar situation: "Don't take an aspirin and go to sleep. That's what a woman in the ward next to me did, and she is now seriously paralyzed." In fact, time is most definitely of the essence. The tPA treatment is effective only within the first three hours of the stroke; within six hours, the effects of a stroke become irreversible. And time is dependent on awareness - otherwise you don't know what the symptoms are, or that you need to race to the emergency room, as Rahel's fellow patient found out the hard way. Moshe Berlin, another of Cohen's charges, was luckier. The former Brooklynite, who immigrated to Israel in 1971, was at his desk in his Jerusalem apartment jotting notes when he looked down and discovered that his sheet of paper was blank and his pen was lying on the ground. He leaned over to retrieve the pen and fell out of his chair. He couldn't move. He called for help to a repairman who happened to be at his home. But - not knowing he'd had a stroke or that time mattered - Berlin didn't seek medical help until his wife came home and insisted he visit a hospital. "I have a tendency not to share my problems with anybody, which was one of the stupidest things I ever did, because now I understand the longer you wait [after a stroke], the harder it is to reverse the effects," explains Berlin. Now Berlin is so sensitive to the importance of time, he subscribes to a private service that brings emergency health workers to his home at his call. "People should be aware of the symptoms and go immediately to the hospital, as with a heart attack," says Bornstein. "Everyone knows that if you have pains in your chest, you need to go immediately to the hospital. It's the same with a brain attack." Considering their prevalence and morbidity, "not enough attention has been given to strokes," charges Tanne. Israel sees some 15,000 new cases of stroke per annum, of which around 2,500-3,000 die within the year, making it the third leading cause of death and the leading cause of severe disability. Now the clot-buster treatment has the potential to decrease the risk of permanent disability following a stroke by 65%. While 33% of those suffering an ischemic stroke will still be disabled, out of 100 stroke victims, 15 to 20 more than those who don't receive the treatment will go home without any lasting damage. Of course the ideal way to beat strokes is prevention, and this effort has also made major strides. "The best way is to avoid the disease, rather than cure it," says Amos Korczyn, chair of the neurology department at Tel Aviv University. "If we do things properly, we can eliminate a lot of strokes." Regular exercise, proper nutrition and stress management are key, as are eliminating major risk factors such as smoking, obesity and, especially, treating hypertension to bring blood pressure down to normal. The requirements apply to young and old, as strokes are not just a disease of the elderly. According to Cohen, the mean age of a stroke victim is around 50, and even children with congenital defects can be among those stricken. Berlin, for one, shed more than 50 kilograms and went from being obese to weighing a healthy 80 kg. after his stroke. The 68-year-old also walks long distances regularly - something he can now do with ease, rather than huffing and puffing as he did before. And he knows what symptoms to look out for: sudden numbness or weakness in the face, an arm or leg; sudden confusion in the form of difficulty in speaking or understanding; difficulty in expressing or comprehending words; slurring; sudden trouble seeing through one or both eyes or double vision; unexpected trouble walking, dizziness, loss of balance or coordination; an abrupt, severe headache with no known cause; or a sudden decline in consciousness. It's especially important that Berlin keep an eye out for such warnings, as those who have suffered strokes already are at much higher risk to have additional attacks. While 10% of victims of ischemic strokes die immediately, 25% die within the first year after a stroke because of complications - including infections and disease that can result from being bedridden - and because of repeat attacks. But Tanne says by being proactive, "It's not inevitable that you'll go through a second stroke." Part of the public inattention to strokes in Israel, though, has been that - unlike a heart attack - once it happens, nothing could be done about it. The discipline had to wait for the technology to be invented and refined before it could significantly reduce mortality and disability. And even so, most Israeli hospitals still haven't established the facilities necessary to offer the most effective treatment. American and European governments have long been pushing the issue. Several US states, for example, have imposed rules like that of the Massachusetts Department of Public Health, which mandates that ambulance staff only take patients suffering from stroke symptoms to hospitals offering stroke centers. Whereas in Europe, 50% of patients get taken to such special stroke units - and the "golden standard" of 70 to 80% has been reached in Scandinavia - less than 5% of Israeli patients do. While Europe has spent the last decade working out how to get patients to appropriate facilities, Israel has started planning its stroke care network only much more recently. A council on stroke care in the past year recommended to the Health Ministry how and where to build stroke centers. The council is waiting for the ministry to complete the plan it has prepared, but Tanne adds that it's not only a matter of the Health Ministry's will, but of treasury-supplied budgets. "Stroke units help to save lives and reduce disability, but most people in Israel don't have access to them," notes Tanne. "Sharon is in a highly equipped intensive care unit... but most patients don't have such a system." About two weeks before Sharon was hit with his first stroke, a group of stroke victim advocates gathered outside the Knesset to protest the lack of attention and funding for the health problem. They also set up a booth where legislators could check their blood pressure and other stroke risk factors. No more than two MKs even bothered to stop by, according to Sandra Levy, whose stroke victims organization Ne'eman helped with the demonstration. "Stroke is not a sexy disease," Levy says of the lack of appeal. "After a stroke, people often don't leave the house because they don't want people to see how they walk, how their faces are crumpled." She relates that many in her own community of academics avoided her and her husband after a stroke left him "totally incapacitated." "They can't deal with it," she says. And those forced to live with disability is something she sees more and more of, now that it is possible to pull certain stroke victims back from the brink of death - and because the number of stroke victims has been rising. Levy has mixed feelings about developments in the field of strokes. "The change is that people are surviving and living longer as severely handicapped, which makes me cry," she says. There have been improvements in rehabilitation that have coincided with the advances in treating strokes, allowing people to regain more capabilities than ever before. Tanne, for example, points to new MRI technology, which explores what parts of the brain can recover capacities damaged in strokes. There are even studies now looking at how areas of the brain neighboring on damaged tissue can actually compensate for what's been lost. But Bornstein acknowledges that in the short term, "it means you get more people with disabilities." He also notes that while the death rate of stroke patients diminished by around 5% per year between the 1960s and 1990s, the improvement slowed to a snail's pace of only 1 or 2% just as the major advances began to be introduced, while incidence of stroke increases. "We don't understand it," he concedes. "Theoretically, we can treat quite a lot," says Korczyn. "But a lot of it is implementation." So the actual changes have been significantly more modest, partly due to the lack of awareness by individuals and partly because so few hospitals have the proper staff and facilities in place to provide the urgent care needed. Levy hopes both will change soon, though she says that will happen only if there is sufficient political will and economic backing. A month ago, she says, "I wasn't optimistic because I didn't think the resources would be forthcoming and we would have a long, slow battle." Today, she continues, because of the Sharon case, "there's a better chance." Shortly after the prime minister's first stroke, she and others from Ne'eman were invited to the Health Ministry to discuss the rehabilitation needs of the population affected by strokes and strategies for prevention. "We've still got a long way to go," says Levy. "[But] it's obvious that things are going to be quite different now, that there will be more awareness." As Bornstein puts it, "Now, unfortunately, one prime minister made a change, at least in awareness." Judy Siegel-Itzkovich contributed to this report.

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