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Physicians Update

Fall 2008

New Stroke Treatments Extend Window of Opportunity

New Approaches to Stroke

UCLA Health Physicians Update - Fall 2008 Neurology/Neurosurgery issue: New Approches to StrokeSeeking emergency help immediately following a stroke can set in motion a series of life-saving events. Up until recently, three hours was thought to be the window of opportunity to initiate treatments to save brain cells from dying following an ischemic stroke. The UCLA Stroke Team is pushing that time limit by as much as five hours. The team’s advances extend to other types of stroke as well. The unique team of emergency neurologists, vascular neurosurgeons, stroke neurologists, interventional neuroradiologists and neuro- rehabilitation specialists continues to lead the field in stroke treatment and is helping to develop, test and teach new devices and protocols to treat the third-leading cause of death and leading cause of disability in the United States.

Only a small percentage of acute stroke patients present within the three-hour time window for effective treatment with tissue plasminogen activator (tPA), the FDA-approved clot-dissolving drug for ischemic stroke. But several new devices and research protocols have increased the arsenal for neurologists and neurosurgeons in the treatment of stroke, even for patients not seen within the three-hour time period.

New techniques

“We now have a number of techniques we can use to reopen blocked blood vessels in the brain, as well as trials ongoing for acute stroke treatment,” says Gary Duckwiler, M.D., interventional neuro- radiologist at the UCLA Stroke Center. “Beyond three hours, there are patients for whom we can go in the artery with X-ray guidance and infuse tPA intra-arterially at the site of the blood clot.  We also have devices that grab the blood clot and pull it out, and others that aspirate the blood clot. We have balloons and stents that can open up narrowed and blocked cerebral blood vessels. And we have various ongoing trials looking at techniques and agents to support blood flow to the brain.”

UCLA directs county-wide training

UCLA Health Physicians Update - Fall 2008 Neurology/Neurosurgery issue: New stroke treatments extend window of opportunityAs the only comprehensive stroke-treatment and stroke-research facility in Los Angeles County, the UCLA Stroke Center is directing the Los Angeles site of the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) study, a Phase 3 National Institutes of Health (NIH) trial involving all of the county’s 2,000 paramedics and 55 other hospitals. Patients who activate the 9-1-1 system within the first two hours of a stroke and consent to the study are randomized to receive either magnesium or a placebo from the paramedics en route to the hospital, as a test of magnesium’s potential as a brain-protective drug when given early after stroke onset. The Los Angeles-based part of the study is headed by Jeffrey Saver, M.D., director of the UCLA Stroke Center.

More stroke-busting devices

The number of mechanical devices that reopen blocked arteries in the acute-ischemic-stroke patient is also increasing. The first such recanalization device, the MERCI Retrieval system, was invented at UCLA and approved by the FDA in 2004. Earlier this year a second device, the Penumbra Stroke System for aspirating clots, received approval. “These devices can be used up to eight hours after symptom onset — or five hours longer than standard intravenous tPA,” Dr. Saver notes. The UCLA Stroke Center is participating in NIH trials to test the ability of both devices to improve outcomes for stroke patients.

The increased application of balloon angioplasty and stenting for neck and brain arteries is yet another important new development that is being studied at UCLA and elsewhere as part of the NIH’s Carotid Revascularization Endarterectomy vs. Stent Trial (CREST). The UCLA Stroke Center is also set to launch the first randomized trial weighing the long-term stroke-prevention benefits of stenting in the hard-to-reach intracranial arteries. UCLA neurosurgeons are taking part in the Carotid Occlusion Surgery Study (COSS), a national clinical trial evaluating the effectiveness of brain bypass surgery to prevent stroke in patients whose carotid artery is blocked. “Brain bypass surgery offers a promising therapy to provide a new source of circulation to the brain, and thus prevent stroke, for patients with otherwise inoperable complete carotid artery occlusion. UCLA is the only center in Southern California offering bypass surgery for stroke prevention in the COSS clinical trial,” says Neil Martin, M.D., FAANS, chair of the UCLA Department of Neurosurgery.

Pioneering minimally invasive surgery

Antonio De Salles, MD, PhD, - UCLA Department of NeurosurgeryUCLA interventional neuroradiologists developed the leading device used to treat brain aneurysms, the Guglielmi detachable coil embolization technique, as well as the more-recent MERCI Retrieval system for treating ischemic stroke, and now UCLA’s Department of Neurosurgery is pioneering minimally invasive surgery to treat brain hemorrhage. Rather than treating this most- devastating form of stroke by standard craniotomy, UCLA neurosurgeons are going through an opening in the skull the size of a nickel and using endoscopic techniques to remove the blood clot that results from the hemorrhage. Dr. Martin says the first patients treated with this approach have shown promising results.

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