Transcription:

Melanie Cole (Host): Did you know that every 40 seconds someone in the United States has a stroke? That’s an unbelievable number. The good news is that there is a new treatment that’s proving to be very effective at removing large clots. In conjunction with tPA, it can lead to better outcomes for stroke patients. My guest today, is Dr. Kyle Pfeifer. He’s an interventional radiologist with Advanced Radiology. Dr. Pfeifer, what typically happens when someone has a stroke? What’s the first line of defense? What do you do for them?

Dr. Kyle Pfeifer (Guest): Typically, the patients are brought into the emergency department where they are evaluated by the Emergency Department physician. They often consult the neurology service, and the neurologist typically will evaluate the patient and decide if the patient is a candidate for tPA. That’s usually the first step. If the patient can’t receive tPA or if the patient is not improving on tPA, then they will often call upon us for the potential for a mechanical thrombectomy.

Melanie: Tell us first what tPA is intended to do. What is it?

Dr. Pfeifer: tPA is a medication that’s meant to break up clot essentially. People call it a clot-busting medication. It’s injected into the patients’ vascular system, and the medication finds its way – and it can break up clot anywhere in the body, including clots that are forming in the brain.

Melanie: So then, what would be the next step? If you determined that the tPA isn’t quite doing as much as you need it to do – if that’s the first line of defense – then you mentioned mechanical thrombectomy. How can that help someone who has had a stroke, and is it used in conjunction with tPA?

Dr. Pfeifer: Yeah. Mechanical thrombectomy is the mechanical removal of the clot that’s causing the problem. It can be used in patients that have received tPA that isn’t improving, or there are many patients that cannot receive tPA, and then they would be a candidate for a mechanical thrombectomy.

Melanie: So, who can receive tPA? Speak about the candidates for this first for tPA, and then segue into mechanical thrombectomy and why if someone is not a candidate – or if they are why that would be the next step?

Dr. Pfeifer: Most patients would be a candidate for tPA unless they’ve had some type of recent surgery or if they’ve got some type of malignancy with metastases throughout the body. Many times, patients do improve on tPA. It all depends on how much clot there is that’s blocking the vessel. For patients that can’t receive tPA or the patients that aren’t improving or getting worse with the tPA, that’s when we bring them to our interventional suite, and we perform the procedure called the mechanical thrombectomy.

Melanie: Tell us about the procedure. What does it do, and how does it work?

Dr. Pfeifer: Mechanical thrombectomy involves placing a catheter from the groin access sight all the way up through the neck and into the large blood vessels that supply the brain. A lot of people are familiar with a heart catheterization. This is a very similar technique, except instead of going to the heart, we go all the way up to the blood vessels that supply the brain. We take very detailed pictures. That’s called a cerebral angiogram. It helps us define exactly where the clot is and what kind of perfusion the patient is having to the brain at that time. We have a couple of different tools that fall under the category of mechanical thrombectomy, which is meant to physically go up to or into the clot and physically remove it from the blood vessel – so, not waiting for medication to slowly break it down or dissolve the clot, literally just pulling out the clot from the blood vessel that’s causing the occlusion.

Melanie: That’s so cool. So, really tell us a little bit about the benefits of this treatment versus other treatments – or what you had done in the past if you had a clot that was too large for tPA to work on really – what had you done, and what are the benefits of this now?

Dr. Pfeifer: People have been – in addition to giving IV tPA, some doctors have been placing catheters inside the brain right at where the clot is and slowly dripping in that tPA directly onto the clot. That’s very time-consuming; it does not always work. The benefit of the mechanical thrombectomy is mainly the speed at which it can be performed. We’re able to go directly up and engage the clot. We have two separate devices, one that works somewhat like a vacuum cleaner if you will where it applies suction to the clot and pulls it out, and the other device is what’s called a stent retriever. It’s like a mechanical cage that expands inside the stent, and it captures the clot, and then we’re able to pull that back. The main benefit is the speed at which we can perform the procedure.  

Melanie: And then what happens after that? If you are able to remove that clot, then is that patient now at a lower risk? Do they stay on the tPA? Do they go on blood thinners? What happens next?

Dr. Pfeifer: Typically, after we are done with our mechanical thrombectomy, the patients are transferred to the ICU for very close observation as far as their neurologic status. We don’t always know what it means when we pull the clot out. We’ve obviously given them the best chance at making a recovery. Some patients, when you reperfuse the brain, by the next morning they are breathing on their own, and some of them are even making 100 percent recovery even by the next day. Some people will go on to have a certain degree of stroke.

It all depends on the timeline. If someone gets to us kind of late and we’re able to pull the clot, it’s possible that they may still have a smaller-scale stroke – much smaller than what they would have had if we had not performed the mechanical thrombectomy. Some patients even when you’re successfully pulling the clot out – some patients have already sustained so much damage to the brain that it doesn’t ultimately change their outcome. For a lot of our patients, they go from having very severe stroke symptoms to completely normal the next day.

Melanie: Since this is relatively new and pretty ground-breaking, Dr. Pfeifer, is there a learning curve? Is it difficult to do this procedure?

Dr. Pfeifer: It’s not an easy procedure, but it’s based on a lot of the same skillsets that we use all over the body. It’s something that with the proper training, it can be performed in anywhere from 20-30 minutes from the time you start the procedure to when the brain is reperfused.

Melanie: Really in this last decade – I don’t know if you agree with me, but you’ve witnessed a really rapid and really significant advancement in the treatment of acute ischemic stroke, so where do you see this going? Do you see this continually improving? Give us a little blueprint for what you see happening in the next bunch of years.

Dr. Pfeifer: I think the next step would be better defining the patients that we can help and getting patients to treatment earlier. Timing is absolutely critical with the brain. Every minute is lost brain function. Streamlining the process, getting patients to us as quickly as possible, but also with the advances in certain technologies allow us to image the brain and to understand how much brain has already sustained an injury that is not recoverable versus how much of the brain is compromised – how much brain could potentially be salvaged. I think the tools are slowly improving, but I think the main thing for patient outcomes will be getting patients sooner and better defining which patients we’re actually able to help.

Melanie: Wrap it up for us with your best advice about stroke, and time is the brain, and let the listeners know what you want them to know about recognizing those signs very quickly so that they can get in and get tPA or mechanical thrombectomy if that’s indicated.

Dr. Pfeifer: Right, and you said it, timing is absolutely everything. We encourage patients and patients’ families that anytime someone is having symptoms or anything that doesn’t seem right – stroke symptoms can vary depending on which blood vessel is blocked and exactly what’s going on. Families can look for things like facial droop or difficulty understanding language or speaking. Anything like that seems out of the ordinary; we encourage patients’ families not to hesitate to call EMS and get the patients in as soon as possible for proper evaluation.

Melanie: It’s very important you mentioned EMS – trying not to drive themselves to the hospital. It’s very important that they call EMS because they have the ability to call ahead and let the Emergency Room know what’s going on?

Dr. Pfeifer: Yes. Sometimes people are concerned about the cost of calling an ambulance, but we recommend trying not to be concerned about those things and being focused only on the safety of the family members. We do encourage patients not to try to drive themselves or to drive a family member in. We encourage them to call EMS, so EMS can try to recognize what’s going on and as you mentioned, get the next step moving so that we’re prepared, and we can be as efficient as possible.

Melanie: Thank you so much, Dr. Pfeifer, for being on with us today, and this fascinating topic, and this exciting, new procedure of mechanical thrombectomy. It’s very important for listeners to learn about. A special “thank you,” to our podcast partner, Cornhusker Bank. For more information on today’s topic, please visit bryanhealth.org/stroke, that’s bryanhealth.org/stroke. This is Bryan Health Podcast. I’m Melanie Cole.