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Latest Advances in Stroke Care
Dr. Ilana Ruff Treiber discusses the F.A.S.T warning signs of a stroke, the importance of receiving treatment after suffering a stroke and the different treatment options available.
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Learn more about Ilana Ruff Treiber, MD
Ilana Ruff Treiber, MD
In my clinic I see patients with transient ischemic attacks, ischemic strokes, hemorrhagic strokes, and cerebral venous sinus thrombosis. I evaluate patients as a second opinion to establish what may have caused their stroke and determine the best treatment to prevent future stroke. I also see patients with carotid and vertebral artery stenosis, moyamoya disease, vascular malformations (aneuryms/AVMs), and cerebral amyloid angiopathy.Learn more about Ilana Ruff Treiber, MD
Transcription:
Latest Advances in Stroke Care
Melanie Cole (Host): Welcome. Today we’re talking from breakthroughs to bedside, how long is the time window for stroke treatment today. My guest is Dr. Ilana Ruff. She’s the Director of Stroke Quality and Vascular Neurologist and Stroke Specialist for Northwestern Medicine. Dr. Ruff, I’m so glad to have you with us. As I told you off the air, I am going through this right now. So, this is such a timely topic. Tell us a little bit about stroke treatments and how they’ve advanced over the years. What’s different now than 20 years ago?
Ilana Ruff Treiber, MD (Guest): Well, I think it’s actually just interesting to think about the background of stroke care and that it was just a little over 20 years ago that we learned about TPA being something that’s effective for stroke care and it took us a little while to figure that out actually also. But in 1996, TPA which is the clot busting medication was something that was shown to be beneficial for patients. And that really changed everything about stroke care. All of the sudden, if you got to the hospital quickly enough, we could give you a treatment that could improve your disability and potentially make people completely functional which was great.
Over the past five years, I think stroke care has really changed so much. It’s actually really exciting. Now we have thrombectomy which is actually when the clot occurs, we can actually go in and take the clot out. But it took us a little while to figure that out also. In 2013, the trials were all negative and that was because so much has evolved since then and so, in 2013, the trials did not show a benefit and that was because the clot extraction devices were – they used older clot extraction devices in those trials, they weren’t doing the most modern imaging and our times were just not as good. We weren’t getting patients through the process more quickly.
And more recently, we found in 2015 and 2016, that we can do these thrombectomies and that they are beneficial for patients. So, a lot has changed in just the past 20 years, very rapidly.
Host: So, I’m glad that you mentioned thrombectomy and we’ll talk just a little bit more about that, but we’ve heard over the years, time is brain. Why is time so important and is it as important as it was?
Dr. Ruff: So, that’s a great question. Time is brain basically comes from the idea that in order to get a stroke treatment, it’s important for you to get to the hospital very quickly and I still would say that’s absolutely the case. As you can imagine, the longer a blood clot sits in a blood vessel, the less blood flow is getting to the brain tissue and the more likely it is that the brain tissue will die and then we can’t do anything.
But actually the new saying in stroke is tissue is brain. And the reason for that is because with modern imaging, what we can find is that actually sometimes when there’s a clot in the brain, other blood vessels kind of help out. Those are called collaterals and so actually it turns out that we can do – with modern imaging, we can actually see that sometimes the brain is actually preserved longer than we would have expected in the past and so, while time is still important, now with these modern imaging techniques we can actually – we actually are now saying tissue is brain so we can actually look at the blood tissue when patients come in.
Host: Isn’t that fascinating? Really with the imaging, it’s what makes it so advanced and we can see so much more now than we could. So, along those lines then, tell us about the DAWN Study and the DEFUSE-3 Study. What were those studies and what did they show us?
Dr. Ruff: So, I have to say I actually will never forget the moment I woke up in the morning and opened up my email and there were slides from the European Stroke Conference saying that DAWN was positive, and this is revolutionary in stroke care. So, one of the things that’s been very frustrating for patients and physicians alike is that the times were so important. Patients had to be in the hospital and get to the hospital quickly and have their imaging and make a decision very quickly within six hours of their stroke.
And one of the things that’s been frustrating for us is patients who wake up with strokes. So, when we make these decisions, it’s when they were last known well. So, if you went to bed at 11 p.m. and you were fine, and you woke up with your symptoms; we have no idea if your stroke occurred at 5 a.m. when you woke up or at 11 p.m. when you went to bed, but we were timing it from 11 p.m. and so that’s so frustrating for patients who come in.
The DAWN and DEFUSE studies are really exciting because what they is do is they use the imaging techniques that we have now available to us to show that if a patient has a very small core infarct, so the stroke itself and a large area that’s at risk of becoming completely dead and having a stroke; those patients can actually benefit from these clot extraction devices with thrombectomies and they do very, very, very well. Actually, in these studies, for every two to three patients that we treat, one patient is actually functional baseline, walking, talking, functioning in society. And that’s really, really exciting because it allows us to offer stroke treatment to many more patients.
Host: Wow, that’s exactly what happened to my dad Dr. Ruff. He woke up with a stroke and we did not know when it occurred so it’s amazing to me that you just said that. Tell us how has Northwestern Medicine been involved in either of these studies.
Dr. Ruff: So, Northwestern Medicine was involved in the DEFUSE-3 Study and so that was very exciting for us and in fact, the fact that we’ve been able to use a study that we were involved in and then actually apply it to our patients now, as soon as we found out that these studies were positive, we immediately changed our protocols to include patients within that 24-hour window and actually what’s really exciting also is these studies are also impacting the greater Chicagoland area so, for patients who call 9-1-1 and get into an emergency vehicle, the way that the emergency vehicles decide which hospitals to go to are based on these criteria as well. So, EMS will take you to the nearest hospital that can take care of a patient with a large stroke, which is great.
Host: So, how else then along those same lines, has this been applied now to the real world population in terms of like patient selection criteria and that representability of the 24-hour time window?
Dr. Ruff: So, it’s a real challenge because trying to figure out which patients would apply for these studies is important and so not all patients have a clot in one of the large vessels of the brain and so therefore you might be having a stroke, but you might not be eligible for clot extraction. And so trying to figure out which patients should be taken to a center where there’s clot extraction versus patients who might go to a center where they could just get TPA versus just going to a center where you can get stroke care can be very challenging. And that’s actually something we are studying in Chicago and so there’s actually a study going on as we are triaging the patients using certain evaluation techniques to determine whether the patient might have what we call large vessel occlusion or an occlusion of one of the large arteries currently.
Host: Are there some limitations that still frustrate you Dr. Ruff? Is there something – because I want you to tell us about what’s new on the horizon and where you see stroke care going from here. Are there still some things that you wish would happen a little bit faster?
Dr. Ruff: Well so, I think what’s frustrating still is that there are still patients who come into the hospital that have stroke symptoms, that are not eligible for TPA and are not eligible for thrombectomy. So, their clot might have dissolved and gone into other little blood vessels and therefore we can’t go and take them out. And so, there’s still patients who are going to have strokes that we want to be able to treat and I think kind of the next era is really going to be what we call neuroprotection and so, how can we potentially protect patients’ brains that aren’t eligible for these types of therapies and help them with recovery. And is there any sort of therapy that we can give them to protect their brains while they are ischemic or still having tissue damage or is there any way that we can promote growth of the brain tissue back. And so I think those are kind of the new – that will be the next horizon of stroke care.
Host: So, wrap it up for us with your best advice and your takeaways from this really exciting time in stroke care and prevention advice, if you’d like to give us that and so, are we still looking at FAST as our symptoms and signs so that we know? What do you feel are some of the most important things you would like listeners to know?
Dr. Ruff: I think it’s still very, very important that as soon as you recognize stroke symptoms to call 9-1-1 and come to the hospital. Because time is still quite important and the stroke symptoms that I always tell my patients about are things like facial weakness, so you mentioned FAST, facial weakness, arm, speech and T is time. But other things to think about are anything that comes on suddenly like dizziness, double vision, difficulty walking, weakness on one side of the body, numbness on one side of the body. Those are reasons to come straight to the hospital. Strokes don’t hurt, so it’s not like a heart attack where you have chest pain so a lot of times people don’t realize that and so I think it’s important to realize that as well. And calling 9-1-1 is very important because the EMS will take you to the nearest hospital that can take care of a stroke patient.
I think the other thing that’s important is to remember that stroke is a blood clot in one of the blood vessels going to the brain, but sometimes you can have a bleeding stroke as well and so I always tell my patients not to take anything before you come so don’t take an aspirin, it’s not like a heart attack because if you have a bleeding stroke, we certainly don’t want you to take a medication that can cause worsening of the bleeding.
Host: That’s really good advice Dr. Ruff. Something that people really need to take note about. So, what a great point and thank you so much for coming on and sharing your expertise about all of the exciting advancements going on in stroke care today.
That wraps up this episode of Northwestern Medicine PodTalk. Head on over to our website at www.nm.org/stroke for more information on the latest advances in stroke medicine and to get connected with one of our providers. If you found this podcast as cool as I did, please share on your social media, share with your friends and family and be sure to check out all the other fascinating podcasts in our library. I’m Melanie Cole.
Latest Advances in Stroke Care
Melanie Cole (Host): Welcome. Today we’re talking from breakthroughs to bedside, how long is the time window for stroke treatment today. My guest is Dr. Ilana Ruff. She’s the Director of Stroke Quality and Vascular Neurologist and Stroke Specialist for Northwestern Medicine. Dr. Ruff, I’m so glad to have you with us. As I told you off the air, I am going through this right now. So, this is such a timely topic. Tell us a little bit about stroke treatments and how they’ve advanced over the years. What’s different now than 20 years ago?
Ilana Ruff Treiber, MD (Guest): Well, I think it’s actually just interesting to think about the background of stroke care and that it was just a little over 20 years ago that we learned about TPA being something that’s effective for stroke care and it took us a little while to figure that out actually also. But in 1996, TPA which is the clot busting medication was something that was shown to be beneficial for patients. And that really changed everything about stroke care. All of the sudden, if you got to the hospital quickly enough, we could give you a treatment that could improve your disability and potentially make people completely functional which was great.
Over the past five years, I think stroke care has really changed so much. It’s actually really exciting. Now we have thrombectomy which is actually when the clot occurs, we can actually go in and take the clot out. But it took us a little while to figure that out also. In 2013, the trials were all negative and that was because so much has evolved since then and so, in 2013, the trials did not show a benefit and that was because the clot extraction devices were – they used older clot extraction devices in those trials, they weren’t doing the most modern imaging and our times were just not as good. We weren’t getting patients through the process more quickly.
And more recently, we found in 2015 and 2016, that we can do these thrombectomies and that they are beneficial for patients. So, a lot has changed in just the past 20 years, very rapidly.
Host: So, I’m glad that you mentioned thrombectomy and we’ll talk just a little bit more about that, but we’ve heard over the years, time is brain. Why is time so important and is it as important as it was?
Dr. Ruff: So, that’s a great question. Time is brain basically comes from the idea that in order to get a stroke treatment, it’s important for you to get to the hospital very quickly and I still would say that’s absolutely the case. As you can imagine, the longer a blood clot sits in a blood vessel, the less blood flow is getting to the brain tissue and the more likely it is that the brain tissue will die and then we can’t do anything.
But actually the new saying in stroke is tissue is brain. And the reason for that is because with modern imaging, what we can find is that actually sometimes when there’s a clot in the brain, other blood vessels kind of help out. Those are called collaterals and so actually it turns out that we can do – with modern imaging, we can actually see that sometimes the brain is actually preserved longer than we would have expected in the past and so, while time is still important, now with these modern imaging techniques we can actually – we actually are now saying tissue is brain so we can actually look at the blood tissue when patients come in.
Host: Isn’t that fascinating? Really with the imaging, it’s what makes it so advanced and we can see so much more now than we could. So, along those lines then, tell us about the DAWN Study and the DEFUSE-3 Study. What were those studies and what did they show us?
Dr. Ruff: So, I have to say I actually will never forget the moment I woke up in the morning and opened up my email and there were slides from the European Stroke Conference saying that DAWN was positive, and this is revolutionary in stroke care. So, one of the things that’s been very frustrating for patients and physicians alike is that the times were so important. Patients had to be in the hospital and get to the hospital quickly and have their imaging and make a decision very quickly within six hours of their stroke.
And one of the things that’s been frustrating for us is patients who wake up with strokes. So, when we make these decisions, it’s when they were last known well. So, if you went to bed at 11 p.m. and you were fine, and you woke up with your symptoms; we have no idea if your stroke occurred at 5 a.m. when you woke up or at 11 p.m. when you went to bed, but we were timing it from 11 p.m. and so that’s so frustrating for patients who come in.
The DAWN and DEFUSE studies are really exciting because what they is do is they use the imaging techniques that we have now available to us to show that if a patient has a very small core infarct, so the stroke itself and a large area that’s at risk of becoming completely dead and having a stroke; those patients can actually benefit from these clot extraction devices with thrombectomies and they do very, very, very well. Actually, in these studies, for every two to three patients that we treat, one patient is actually functional baseline, walking, talking, functioning in society. And that’s really, really exciting because it allows us to offer stroke treatment to many more patients.
Host: Wow, that’s exactly what happened to my dad Dr. Ruff. He woke up with a stroke and we did not know when it occurred so it’s amazing to me that you just said that. Tell us how has Northwestern Medicine been involved in either of these studies.
Dr. Ruff: So, Northwestern Medicine was involved in the DEFUSE-3 Study and so that was very exciting for us and in fact, the fact that we’ve been able to use a study that we were involved in and then actually apply it to our patients now, as soon as we found out that these studies were positive, we immediately changed our protocols to include patients within that 24-hour window and actually what’s really exciting also is these studies are also impacting the greater Chicagoland area so, for patients who call 9-1-1 and get into an emergency vehicle, the way that the emergency vehicles decide which hospitals to go to are based on these criteria as well. So, EMS will take you to the nearest hospital that can take care of a patient with a large stroke, which is great.
Host: So, how else then along those same lines, has this been applied now to the real world population in terms of like patient selection criteria and that representability of the 24-hour time window?
Dr. Ruff: So, it’s a real challenge because trying to figure out which patients would apply for these studies is important and so not all patients have a clot in one of the large vessels of the brain and so therefore you might be having a stroke, but you might not be eligible for clot extraction. And so trying to figure out which patients should be taken to a center where there’s clot extraction versus patients who might go to a center where they could just get TPA versus just going to a center where you can get stroke care can be very challenging. And that’s actually something we are studying in Chicago and so there’s actually a study going on as we are triaging the patients using certain evaluation techniques to determine whether the patient might have what we call large vessel occlusion or an occlusion of one of the large arteries currently.
Host: Are there some limitations that still frustrate you Dr. Ruff? Is there something – because I want you to tell us about what’s new on the horizon and where you see stroke care going from here. Are there still some things that you wish would happen a little bit faster?
Dr. Ruff: Well so, I think what’s frustrating still is that there are still patients who come into the hospital that have stroke symptoms, that are not eligible for TPA and are not eligible for thrombectomy. So, their clot might have dissolved and gone into other little blood vessels and therefore we can’t go and take them out. And so, there’s still patients who are going to have strokes that we want to be able to treat and I think kind of the next era is really going to be what we call neuroprotection and so, how can we potentially protect patients’ brains that aren’t eligible for these types of therapies and help them with recovery. And is there any sort of therapy that we can give them to protect their brains while they are ischemic or still having tissue damage or is there any way that we can promote growth of the brain tissue back. And so I think those are kind of the new – that will be the next horizon of stroke care.
Host: So, wrap it up for us with your best advice and your takeaways from this really exciting time in stroke care and prevention advice, if you’d like to give us that and so, are we still looking at FAST as our symptoms and signs so that we know? What do you feel are some of the most important things you would like listeners to know?
Dr. Ruff: I think it’s still very, very important that as soon as you recognize stroke symptoms to call 9-1-1 and come to the hospital. Because time is still quite important and the stroke symptoms that I always tell my patients about are things like facial weakness, so you mentioned FAST, facial weakness, arm, speech and T is time. But other things to think about are anything that comes on suddenly like dizziness, double vision, difficulty walking, weakness on one side of the body, numbness on one side of the body. Those are reasons to come straight to the hospital. Strokes don’t hurt, so it’s not like a heart attack where you have chest pain so a lot of times people don’t realize that and so I think it’s important to realize that as well. And calling 9-1-1 is very important because the EMS will take you to the nearest hospital that can take care of a stroke patient.
I think the other thing that’s important is to remember that stroke is a blood clot in one of the blood vessels going to the brain, but sometimes you can have a bleeding stroke as well and so I always tell my patients not to take anything before you come so don’t take an aspirin, it’s not like a heart attack because if you have a bleeding stroke, we certainly don’t want you to take a medication that can cause worsening of the bleeding.
Host: That’s really good advice Dr. Ruff. Something that people really need to take note about. So, what a great point and thank you so much for coming on and sharing your expertise about all of the exciting advancements going on in stroke care today.
That wraps up this episode of Northwestern Medicine PodTalk. Head on over to our website at www.nm.org/stroke for more information on the latest advances in stroke medicine and to get connected with one of our providers. If you found this podcast as cool as I did, please share on your social media, share with your friends and family and be sure to check out all the other fascinating podcasts in our library. I’m Melanie Cole.