LOS ANGELES, Cali. (Ivanhoe Newswire) -- Stroke is the leading cause of long-term disability in the U.S. A stroke caused by a brain hemorrhage is the most devastating. In fact, 75 percent of patients with this type of stroke die. Now, there’s a new way to treat the problem and it’s saving lives.
Jon Galvan is lucky to be alive and moving so well. Five years ago, he suffered a stroke while he was at work.
“I felt a pop in my head,” Jon Galvan told Ivanhoe.
Jon had a hemorrhage inside his brain. The traditional way to remove it was a craniotomy—where doctors made a large incision in the scalp, bone, and brain.
“Open craniotomy may do so much harm, that it negates the benefit of getting the blood clot out,” Neil Martin, MD, Chairman, Department of Neurosurgery, UCLA, told Ivanhoe.
UCLA Surgeon Neil Martin is performing a much less invasive procedure.
First, he makes a tiny incision through the eyebrow. An endoscope with a light and camera on the tip helps him navigate with GPS-like precision to the clot. CT scans guide him to the hemorrhage, which he suctions out.
“This operation offers the ability to remove the blood clot without imposing additional insult or damage to the brain,” Dr. Martin said.
Jon had the minimally-invasive approach. He’s still working on his mobility, but he has come a long way.
“I just look at it as another series of, not problems, but obstacles that I have to overcome,” Jon said.
Dr. Martin and his colleagues have been working on this procedure for more than 10 years. The phase two clinical trial was performed at seven major medical centers around the U.S. and included 24 patients.
Neil Martin, MD, Chairman, Department of Neurosurgery at UCLA, talks about a new procedure for brain hemorrhages.
What is a brain hemorrhage?
Dr. Martin: A brain hemorrhage is one type of stroke. Brain hemorrhages can occur from a ruptured brain aneurysm, but really the most common cause of a hemorrhage in the brain is hypertension. Hypertension, high blood pressure causes weakening of the small blood vessels in the brain and when they rupture they cause intracerebral hemorrhage.
What happens to the patient?
Dr. Martin: When that occurs, typically a patient experiences a headache, then they have a neurological deficit that may be impairment in speech or paralysis of an arm and leg. In severe hemorrhages, they may lapse in to a coma.
So you as a surgeon you have to go in and fix that problem, what traditionally would you have to do?
Dr. Martin: For these patients when they hit the emergency department, they look like a stroke patient. We have to get a brain scan immediately and that shows the hemorrhage, a CT scan will show the hemorrhage. As a surgeon, I have to decide do they have a large hemorrhage that’s life threatening that has to be removed in order to prevent pressure from building up and impairing brain function and causing progressive deterioration, or do they have a small hemorrhage that can be managed conservatively, medically and allow them to recover spontaneously.
Now for these patients do they suffer the same type of symptoms like stroke people, do they become paralyzed on one side? Does all that extra blood on the brain basically have that affect?
Dr. Martin: In the case of an intracerebral hemorrhage, bleeding in the brain, the symptoms are stroke like. But they often involve a little more slowly than they do with traditional strokes. In an ischemic stroke where a small clot blocks a key brain blood vessel, the same kind of process happens in a heart with a heart attack, there’s a neurologic deficit that occurs almost immediately. They’re paralyzed right away, they can’t speak, and they may be unable to walk. In an intracerebral hemorrhage, often the bleeding progresses over minutes, fifteen minutes, a half an hour, hours sometimes. And that increase in bleeding causes progressive slowly developing neurological deficit. They may have a headache initially then they may develop impaired speech, then paralysis of an arm and a leg. That evolution is something that we see more often in an intracerebral hemorrhage.
With this type of hemorrhage are the affects reversible?
Dr. Martin: So the key thing that happens with an intracerebral hemorrhage that can be corrected surgically is that the pressure builds up and that can impair the function of the brain. Once the blood leaks out of blood vessels, it releases toxins in to the brain tissue. Probably relate it to the iron in hemoglobin, which causes progressive swelling in the brain. There are two things going on, there’s the immediate pressure effect and then there’s this toxic effect that builds up over hours and even days and that really is what we can impact. Now, we can’t do anything about the disruption or tearing of nerve fibers or damage to brain cells that occurs mechanically at the time that the hemorrhage develops. We can certainly relieve the pressure by removing the blood clot and we can remove all of that blood that is gradually acting as a toxin in the brain.
Until now it’s been a pretty invasive surgery to get rid of this hemorrhage, the blood?
Dr. Martin: Right. In the past we did a craniotomy, that involves a large incision on the scalp, opening a window in the bone, taking a bone plate out, making an incision through the brain and then visibly usually with the aide of the operating microscope removing, sucking out the blood that is in the brain. So, you’re doing good by getting the clot out and relieving the pressure, but you’re potentially doing harm by retracting on the brain, incising the brain. Many of the studies that have been carried out in neurosurgery have suggested that the invasiveness of a craniotomy, large open surgery may negate the benefits of getting the clot out.
Seventy five percent is the mortality rate?
Dr. Martin: Intracerebral hemorrhage really is the last unsolved problem in acute stroke. We just don’t have a proven therapy for it and it’s the most devastating kind of stroke, the stroke with the highest mortality rate. We’re looking for more effective, less invasive ways of evacuating, removing the blood clot, relieving the pressure, getting the toxins out, and that really is what this new procedure is about.
When that hemorrhage happens is it more of the hemorrhage that causes the death or the invasive part of the surgery after such a traumatic event that causes it?
Dr. Martin: We have suspected that invasive open craniotomy may cause so much harm that it negates the benefit of getting the blood clot out. In some cases, it may impose an additional stress on the patient that can cause further complications. The death rate from intracerebral hemorrhage is tremendously high, and this is something we want to affect with a procedure like this. The key is not just to have the patients survive, but survive in a severely disabled or vegetative state. The key is to have the survivors recover and have a quality of life.
Is this new surgery helping to do that?
Dr. Martin: Our view is that this operation offers the ability to remove the blood clot without imposing additional insult or damage to the brain.
What is this new procedure called?
Dr. Martin: The new procedure that we’ve developed is a stereotactic endoscopic minimally invasive approach to removing brain hemorrhage. Basically, it involves using a GPS like system to steer an endoscope that could be used as a suction port to remove the blood clot without making a large incision in the brain. We’re putting an eight millimeter sheath, or catheter, or tube directed in to the blood clot, and we’re steering it to the center of the blood clot using a computerized image guided system that works off the CT scan or the MRI scan that’s been obtained as the patient is being evaluated.
Where do you go through so there’s no opening of the skull?
Dr. Martin: The opening we make is what we call a burr hole but it’s a small opening in the bone that’s about the size of a nickel. It allows the introduction of this catheter or sheath into the hematoma and the incision is about an inch long. We put the incision in a location that’s going to give us the most benign, the least harmful trajectory and pathway in to the blood clot and yet still give us good access to the blood clot.
How long would the traditional surgery take compared to this one, and what about recovery that one compared to this one?
Dr. Martin: An open craniotomy typically takes two and a half to four hours to open the bone, go in evacuate the clot and then close everything up. This procedure takes under an hour and it involves a very short incision and within fifteen minutes of starting, the procedure the blood has already been evacuated.
Is there a time frame that you have to get the blood out for the best results?
Dr. Martin: This procedure usually is not done as an emergency. In the first few hours there’s ongoing bleeding and the situation is rather unstable. We try to stabilize the patient by lowering their blood pressure and allowing the bleeding to stop. This minimally invasive procedure makes it difficult to actually get to a bleeding blood vessel and stop it. We wait until the bleeding stops and the situation stabilizes. It’s that first twenty four to thirty six hours that are critical. Beyond that much of the damage is done the pressure has taken its affect the toxic byproducts of blood have been released in to the brain so we try to get in that first thirty six hours to get the blood out before these delayed effects have a chance to take hold.
What’s the difference in recovery?
Dr. Martin: There’s not a dramatic difference in shortening the stay in the hospital because the stay in the intensive care unit is designed to treat the damage done from the initial effects of the hemorrhage. What we do find however is that the patients are in the intensive care unit for a shorter period of time. They generally move from the acute care hospital into a rehabilitation program earlier and that has significant benefits in getting them back to the road to recovery. We’re working with Johns Hopkins and I’m working with another doctor here. The study of a new surgical procedure is very complex. It requires collecting a lot of data, evaluating a substantial number of patients and intensive care is a critical part of the recovery. I’m working on this project with an investigative team from Johns Hopkins led by Dan Hanley and I’m working with the intensive care director here at UCLA Paul Vespa. That team is critical to bring a new procedure in to the standard clinical realm.
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