Brain Coffee Video Podcast Episode 18 – The Latest in Stroke Treatment and Recovery

Welcome to the Brain Coffee Podcast, where Drs. Eric Leuthardt and Albert Kim
unlock life’s little mysteries about health, wellness, entertainment, technology, and how the brain makes sense of it all. Sit back, relax, and open up your mind. – Well first off, Josh, thank you very much for joining us for some coffee at Brain Coffee today. – Maybe it’s fitting; we were just finishing our bacon kolaches so maybe the topic that Josh is going to talk about… – It’s quite appropriate. – is very appropriate. – So maybe just a brief introduction. So Josh, obviously, is a rising star in the
field of neurosurgery and stroke. So, I think having the opportunity to talk
about stroke and kind of, you know, what’s going on with it. Uh, it’s great to have you here. – Yeah. – Everyone’s interested in it. – Yeah. – So maybe before we even really get started,
why don’t you tell us, because obviously I think we all know, – We talk about it. – we talk about it, but what – How do we define what exactly a stroke is? – Yeah. So a stroke is really just
any sudden onset, acute insult to the brain. I mean, in its simplest definition. It can come
from a couple of different sources. The most common thing we think of is that
a vessel somewhere in the brain just suddenly gets blocked by either a blood clot or a piece
of material that breaks off a blood vessel wall coming from another place. And, that part of the brain is being starved
for blood supply. And so whatever it does, it just stops working
and the patient will have an issue because part of the brain’s not working suddenly. And then it can also happen because a
blood vessel just burst in the brain and you have bleeding in the brain and it just happens suddenly in the same way. So, you know, people came up with the idea
of stroke because they originally thought that it was the gods punishing them for something. And it was Zeus throwing a bolt of lightning
from the sky and striking them down suddenly for breaking his rules and his laws. And so it was sort of a, you know, a stroke
of lightning from the gods originally, is where it came from. – Could still be true. – Yeah. – Right, right. – I think that that element – it’s sudden, right, you know… – And there are two different kinds. – Yeah, it’s sudden and there are two different kinds; that’s right. Either, really in some senses – either too little blood and not enough oxygen, or too much, meaning the blood, kind of essentially, is like a
little bomb going off in part of the brain. – OK. So maybe we can talk about them separately. – Yeah. – Why don’t we talk about the block first. So not enough blood, and we all know
time is brain, right. So, once it’s blocked… – So maybe explain that, unpack that. Why his time brain? – So, you know, what I’ve heard, and correct
me if I’m wrong, is that if your blood vessels in your brain are blocked off,
you have something on the order of five minutes for that blood to come back to that brain
so that brain can live. So a part of the brain starved of
blood for five minutes, will die. – Well, we used to think that,
but that’s not necessarily true. – Ah ha! – Rising star, tell us. – Yeah, exactly. So, we found that everybody has a completely different profile of their brain, how they
get blood supply, how long they can go without oxygen. And so, people are kind of divided into fast
progressors and slow progressors. And unfortunately I have no way of telling
you, you know, a random person walking down the street, if their brain is starved
of oxygen, is going to be a fast progressor and they’re going to die in five minutes, as
you just suggested. Or they can go for 24, 36 hours before it dies. And that’s, I think one of the big hot things
in stroke right now is they’re trying to figure out who are the fast progressors, who
are the slow progressors, because we found that we can actually help these slow progressors
for a very long time and we haven’t lost a window in treating them. – I see. – So it’s almost like, for instance, people can hold their breath for different lengths of time, you know what I mean? So your brain is the same, in the
sense, that I guess some people – whether it’s because of their
genetics, their metabolism, their blood flow – they can, their brain can “hold its breath”
because it’s blocked for a period of time, whereas some people are really wimpy. – I see. But the stopwatch is still going. – Oh yeah. – The stopwatch is always going. – The length of time is different. – You assume time is brain. You assume everybody is going to progress,
but we found that it’s not the same time for everybody and that everybody has worth a look,
a little bit deeper. – Well, what’s cool about that, is that that
really does give more hope to the situation, right? Because I think, you know, again, I think
that the “time is brain” – five minutes you’re gone, it’s done it. But now, we’re expanding that window of hope
on a multitude of levels. – Yeah. So how about can we do about it? – Well, there’s a lot of things you can do about it. It all depends on how severe the symptoms
are and, you know, what the time window is. So, you know, one of the biggest revolutions
in the stroke came in the late nineties, which was a clot buster called tPA. And we found that if we give tPA within
three hours of the onset of symptoms, the majority of patients – about 30 out of
100 – would get better from their stroke after a few days. – So that busts the clot inside the vessel. So then the blood flow resumes,
is that the idea? – Exactly. – Okay. Gotcha. – So tPA was really the first just big game
changing stroke treatment. We’ve been using it for
almost 30 years now — I guess 20-25 — and it’s really been
our mainstay of stroke and what’s been exciting about tPA is that as the last 20 years have progressed we found that the window
wasn’t just three hours, we found that in certain patients,
we extended up to four and half hours and now we’re even looking at
extending it out to nine hours and even looking at
extending out to 24 hours in certain patients, based
on getting the right images to prove that their brain is
actually still hanging on and they’re worth still trying to bust up the clot with medicine. – tPA is not for everyone
isn’t that right? – tPA is not for everyone, it is a very powerful
blood clot buster, can definitely induce
bleeding anywhere in the body. It’s probably the most
powerful blood thinner in medicine that we have. So, certainly if you’ve had recent surgery, if you’re already taking
another blood thinner, or you have certain bad medical problems, tPA is actually dangerous for you and the chance of it causing a hemorrhage somewhere in your body, whether it’s your gut or your brain it’s just too great and
it’s really not worth what it might do for your stroke cause it’s gonna cause
another devastating event. – But if you’re one of these people
that’s eligible for it then it’s not five minutes anymore, you got, maybe — I mean fast
as possible is still better but you still have several hours. – Three hours for anybody out of the box as long as you haven’t
had a recent surgery or one of these other things that keep you from getting tPA, and then certain patients go
out to four and half hours and now out to nine and we’re even starting to do
research on out to 24 hours. – And I think one of the take homes for me when I think about this,
actually there’s two of them. One is, if you have a sudden event or something’s changed with you, that means you need to see a doctor. You’re going to an
emergency room, right now. – That’s a really important point because if you look at statistics that the CDC gathers
on stroke and whatnot, they actually found that in
a big survey a few years ago that out of all the people
who came who had a stroke, only 38% of people actually knew something was bad enough wrong with them that they should actually
seek medical attention. So there’s a huge opportunity
for people understand that you have a sudden event and arms not working, I can’t talk, my speech is slurred, I’ve
suddenly gone blind.. – Don’t sleep it off. – Don’t sleep it off, you need to go immediately to the hospital and get evaluated — it’s probably a stroke, and there’s probably
something we can do about it. – Right, and I think the second point
that I was thinking about is that, and I think this is gonna get to talking
about some of the other stuff, is that tPA is for some
people, not for others, but there’s a number of different things that are emerging that can really have an impact. I mean, obviously, you do a lot of that. – Yeah so you know, aside from medicine the most exciting thing
I think that’s happened in cerebral vascular disease in the last, really, hundred
years is thrombectomy for stroke. – OK, so, what does that mean exactly? – So that means rather than assuming a medicine is
gonna bust up this clot and get the vessel
flowing with blood again, we’re not going
to rely on the medicine, we’re actually gonna go up
through the arteries of the body, we usually use the the leg artery, which is a big artery you feel in your groin crease, and we can actually take tools inside the artery all
the way through the body up into the brain and we actually have devices
that grab onto that clot, and remove it from the blood vessel instead of relying on a
medicine to break it up. – So it’s really a
roto-rooter, yeah exactly. – Okay, and it’s minimally invasive, the way you’re describing it? – Yeah, so just through a small needle poked into a blood vessel. – It’s amazing. – And so I guess and
that’s more recent right? People have been working on it for years, but I think it’s really come into its own in, really I guess, how many years? – So well, I mean honestly, if you look at the medical literature, the first time people have this concept was as early as 1958. – Oh! Well maybe not so recent, right? – But for it to be actually practical and have stuff to work, I would say the first devices really came to market around 2006-2007. We didn’t have great success mainly cause patient
selection was was not right and the devices weren’t as good. And then there’s a lot of hope from 2010, 2012, 2013 that the next generation of devices is really gonna be the game changer and we still found that
those weren’t working as well as we thought. But all of us who are
doing stroke treatments knew that we always had these patients who were having a severe stroke, we got a clot out and
they were instantly better as soon as the clot was out. And so we knew that this was going to work we just had to get the devices
right and the patients right and everything was sort
of – came back to the table. And in 2015 there were five just large landmark studies that showed that this treatment
was just revolutionary and that without a doubt it worked and that it made patients
with severe strokes better, for the most part pretty instantaneously. – So what I think is really cool about this… – Four years ago, wow. – is the persistence – you know, for instance – it really gets all about
fighting the good fight, in the sense that, really, you know.. – Doggedness. – Doggedness. You failed once,
it didn’t go so well, you didn’t get it quite right, even the second round of
technologies didn’t quite make it, it didn’t achieve but there was this persistence in vision to say; hey look, we can get this to work. – 60 years later. I mean,
that’s what you said. – I think that speaks well of our system and our scientific endeavor for kind of really
getting past the hard problems. Stroke is obviously a hard problem. – Obviously yeah, so tell me more about when you have to
do this thrombectomy. You know, is it like… – So I mean, again, time is brain. Time is brain, so you want
to do it as soon as possible. I think it’s important to know that there’s a huge variety of strokes. Some people have very minor strokes, some people have really severe strokes, so this is really for the more
moderate to severe strokes – Bigger ones, OK. – And we’re looking for some
of the larger blood vessels in the brain so we call it a large vessel occlusion. But these are the strokes
that if they’re left untreated are gonna be much more
devastating to the patient and are also the ones that the medicine, the tPA, is not nearly as effective for. – So it’s really complementary. – So it’s probably out of all
the strokes, it’s probably somewhere between 20 and 30%
of all comers with strokes are eligible for this treatment. – That’s a lot. – But these are also the ones that are gonna have the really bad stroke, so these are the ones we had
the most to benefit from. – So people paralyzed on one side
of the body or something like that.. – So we found that you if we put everybody
sort of in the same pool that anybody who’s within
six hours of their symptoms is worth treating and they’re
probably gonna get better probably at least two out
of every three patients are gonna get significantly
better with the treatment if we treat them within six hours. So and that doesn’t matter who you are if you’re a fast progresser
or a slow progresser we don’t even discriminate, we just assume that
everybody under six hours has a really good chance
of getting better. After six hours we’ve got
to do some special imaging called perfusion imaging and we look at how much of the stroke has already taken hold of the brain and we found a lot of patients they don’t have good perfusion
but the brain isn’t dead yet. – I see. – So basically perfusion means
the brain’s not working but the blood’s still flowing. – It’s still getting there and
through alternative pathways but those little alternative pathways they’re just not strong enough to make the brain hold on forever. – It’s like hanging on
a cliff, by the fingers. – Literally, fingers on the edge of a cliff, that’s right. – So our goal is to get to the patient before they fall off the cliff. And so we found that
with this special imaging that we can we can
intervene up to 24 hours now. – Oh wow, that’s a long time. – Right, pulling you over the edge. That’s cool. – Well that’s great. So that’s the
artery-blocked side of things, right? So, I know you mentioned the other side, if the artery busts open like a bomb, so what kind of things cause that. – Well there’s a lot of things. So, some people have
this high blood pressure and that the pressure in the blood vessels overwhelms the vessels and literally a vessel
just explodes and ruptures and that will cause bleeding in the brain and sort of literally a blood
clot will form in the brain. Some people have blood vessel
problems like an aneurysm. That’s when you have sort of a weakening of the blood vessel wall and
it sort of forms a blister and if you can imagine just
on a blister on your skin, eventually that blister can pop and that can cause bleeding on the undersurface of the brain. We call that subarachnoid hemorrhage,
is the technical term for it, and that’s when an aneurysm bleeds –
that’s a form of a stroke. – Just as a very crude analogy here, like, I remember my basement flooded and actually it flooded twice for
two very different reasons. One, basically it was
a really bad rain once and basically the sewage system backed up – that’s the equivalent
of hypertension, right? Like the pressure is too high and then blood you know
went into my basement. And another time, basically, a pipe burst and… – It was a weak pipe. – It was a weak pipe,
right, exactly like an aneurysm. – Yeah, that’s a great analogy. So then we have we
have high blood pressure, we have aneurysms, which are this balloon
thing you’re talking about. Anything else that can cause that? – Sure, there can be all
sorts of blood vessel problems something called an
arteriovenous malformation which is sort of almost like having a birthmark on your
brain that you’re born with, those are prone to bleed, you can have, you know, various forms of just these deposits in your brain that we call amyloid angiopathy and that’s sort of related
on Alzheimer’s disease, – Yeah was about to say that. – Yeah so I see, so people of
all sorts can also have these… – They get these plaques
that develop in their brain and that weakens the blood vessels and can cause you to just spontaneously have a brain hemorrhage. – Wow, I see. So can we do anything about these? – Sure, so there’s a whole slew
of treatments for aneurysms and we can do anything
from operate on them and we place little metal clips across the base of the aneurysm and pinch him shut. We’ve been doing that since the 1950s and still do it a lot today
and then more excitingly are the inside the blood vessel treatments, the minimally invasive treatments, with all sorts of little metal coils that block off the aneurysm. Sometimes we put stents
in that divert blood flow. – Let’s talk a little bit more about that because I think that’s
it’s almost hard to imagine. – Yeah no, you’re right. – Okay so we’ve got this blister, right? – Let’s say these are vessels and you got this blister in the middle – Like the blister right? – Yeah. – Great. And so basically one is
you can put clip across it, and literally going on the
outside pinching it off. Pinching the blister off. But talk a little bit more about how you go inside the vessel. How do you fix the
inside of a vessel wall? – So just like the strokes where we snake our way up through all
the blood vessels of the body, we do that for aneurysms. And instead of taking out a blood clot, here the idea is to actually
induce the blood clot in the aneurysm only and so we kind of park
a tiny little catheter which is just this thin tube – it’s about the size of a
piece of angel hair pasta – and we can actually guide that
all the way through the body up into the brain and put it just right at the entry part of the this little blister. – That’s a long piece of pasta. – Yeah, right. – Yeah, I mean, these are this long, so… and then through that we just deploy these little metal coils which are these strands of platinum and we pack enough of them in the aneurysm that it blocks it off. – So like basically the inside
of aneurysms clotted off. – That’s right. So where’s it clots – I mean it’s actually kind
of a very interesting thing. There’s times that you do not
want a clot in the blood vessel, because that’s gonna cause the stroke that causes loss of blood flow. But there’s times again
when the pipes burst, because you’ve got a blister,
you actually want a very specific – essentially, a well controlled clot to form on the inside of this vessel, so that it basically
doesn’t burst anymore. That’s really neat. – So when do you do the outside method versus the inside-out method? – Well, aneurysms come in all
sorts of shapes and sizes and no two are alike, and there are times when we obviously like to use the
minimally invasive method because the patient
doesn’t get a big surgery, but sometimes that’s not
the safest thing to do because we can’t be precise enough with it. And when we’re doing the open
brain surgery and the clipping, we really have the the
maximum amount of versatility and we can precisely place these clips so that it just really
takes care of the aneurysm and doesn’t occlude a normal blood vessel, because you don’t want to
pinch off a normal blood vessel with the clip and you
don’t wanna block off a normal blood vessel with the coils because that will obviously cause a stroke. So, you know, the clips provide
the maximal versatility but they also provide the
maximum amount of invasiveness and the biggest procedure
for the patient… – You have to cut, make an incision
in the scalp, a hole in the skull, and really go into the folds of the brain. – So, it comes at a price, whereas the the minimally
invasive treatment from the inside of the blood vessel, you know, with the technology today we can probably treat
90% of aneurysms that way – I see. Not all of them, though. – But not all of them. And so
we try to do it when we can. You know, certainly if an aneurysm
has bled and it’s ruptured and the brain’s in sort of a swollen state because of the bleeding, we found that patients don’t like to have their heads
opened up in that state. – Right, right. Don’t touch the angry brain. – Well it’s kind of like if you had, a bruise on your arm or if you really injured yourself anytime you have to
touch or manipulate it more, it hurts, it’s more susceptible to injury. – That’s true. But you know it’s interesting, so it
depends on the person and the aneurysm then, if you use the coils
from inside the vessel or the clips from outside the vessel, I see. No, it’s interesting because in a lot of
other things that we do, maximally safe is not
necessarily minimally invasive. Sometimes maximally safe
is maximally invasive. It’s just what you need. – It’s this careful balance and this is where I think, again, computers won’t replace us just yet because we really need
to create this fine judgment of, you know, what is the optimal strategy for a given individual for a
given problem that they have? – Interesting, interesting. – But, you know, every couple of years the devices progress further and there’s more aneurysm shapes that we can fix from the inside and, you know, the technology is exciting as it’s always evolving. – Any robots or things like that they use
for any of these things? – Well things are actually in development for robotic, inside-the-blood-vessel techniques, and it’s actually made a lot of progress in interventional cardiology
for heart procedures and in India, there’s
actually a robotic company that’s found that a doctor 30
miles away from the patient can control all the devices that go in the patient with a robot and do heart stents and open up people who are having acute heart attacks. – It seems like that type of technology really expands the scale of which you can, you know, essentially touch people. Meaning that like, again,
there’s people in communities – we were talking about “time is brain” – that if you’re, you know, 100
miles out, 200 miles out, small town… – Rural Missouri – you don’t have Dr. Osbun there. – Right, exactly. – How do they get to you? – Time is brain, and if you
look at all the metrics in the United States, in terms of how many people are within an hour of getting to a hospital
that can treat a stroke, it’s really almost 75 – 80% of the population,
but the distribution is terrible because a lot of our population of the U.S. is along the coast, on the
west coast and the east coast and the south coast. And so, that all has just
this plethora of centers that can take care of this, but if you look at the
the middle of the country where there’s a lot
more vast areas of land and travel to a big
center that can do this we’ve got a really bad
distribution of hospitals and a lot of patients just
really don’t have access to that kind of care. So anything that can extend the doctors that have expertise in this, like a robot that’s
well-positioned somewhere that somebody else can control. I think the future is really bright for, you know, having more
patients in our country have access to this kind of treatment. – Although I think a take-home
point for the here and now is that not all hospitals are created equal. So you’ve really got to
go to the right place. – Even forgetting about robots. You’re not gonna have the things *you*
can do everywhere, right? – So you have to be a little bit judicious to think that not all hospitals
are the same in treating stroke, and say you had to go to
the right place, right away. And all the really amazing
emerging technologies when people come in with a stroke – how are they doing? – So a lot of patients within minutes or a few hours after us
finishing our procedures will get instantly better and reverse all their symptoms and it’s really amazing and miraculous. Unfortunately that’s not everybody. We found that on the whole, within about three months – ninety days or so – after one of these procedures that the majority of patients will get back to living independently and be able to take
care of all their needs and be fairly mobile and walking around and able to run all their own errands and hopefully return to work. But then there’s still
definitely some patients, probably about a third of them, that end up having some sort of disability after a major stroke like this and they can get a lot
better over many months by doing intensive rehabilitation, but it takes a lot of work and some of them are left
with really permanent deficits that really affect their lives every day. – So you think that about, what, in about
a year it’s settled out and get sort of what
they can get out of rehab. – Yeah, 18 months we think they’re kind of their maximum benefit from rehab and they’re really as good
as they’re gonna get. – But people like yourself that – are you working on
things beyond that year? – There’s still reason for hope. and I think that’s the cool thing is that there’s still a
continuum of hope here because – certainly in my laboratory we’re working with technology to see if we can rewire
and recover the brain long after the injury has settled down. And it’s this idea of what we
call brain computer interface, this idea where you basically
take signals from the brain, essentially capture the patient’s thoughts, and allow them to control something and see if in the process of doing that you can rewire the brain. – So they use the Force or something? – Well, not quite the Force! So, just as I think we’ve seen really, kind of, an amazing progression of technology and technical capability in
the treatment of acute stroke through these investments in technologies, but we’re also seeing a real renaissance of how we can use computers to decode signals from the brain. And this idea of – as an example, if you have a stroke patient even in the chronic stage, and they can’t move
their hand for instance, – So now we’re a year out from
Dr. Osbun doing everything he can. – That’s right. – Things are settled out, they
still have a disability. – That’s right. Now one of the most
common persistent deficits after a stroke is that
they have a paralyzed hand. – Oh yeah. – And now they may not be
able to move their hand but they can still
imagine moving their hand. They can still think
about moving their hand, they can still try, but that
you can’t actually do it. And so where are those
thoughts coming from? So we’re starting to really explore and understand the ideas of where those thoughts are coming from. Part of it are coming
from one side of the brain that controls that paralyzed
limb which is damaged but there’s actually
signals and physiology associated with thoughts to
control that paralyzed hand on the uninjured side of the brain. – Oh! that’s different from
what we learned in med school. – Exactly. That’s right. And now we can tap into that. And, again, we don’t have to put – you know, it doesn’t require a surgery but you can put electrodes on the scalp, record brain signals
and again with computers and essentially new computer algorithms, you can pick up those signals and decode that a person wants to
control their paralyzed hand with their uninjured side of the brain. And the reason that’s important now… – That’s cool. – It is cool because now what we can do is,
we can allow them to control things, and we’re starting to use systems where basically, people
are wearing a headset they’re wearing an external robotic and and they’re controlling
their paralyzed hand with this wearable robotic. And in the process, when they
continue to do that over time it’s almost like a new form of
rehabilitation for chronic stroke. They’re gaining function back and that’s one of things we
published a couple of years ago. – Do they have to keep wearing the thing? – So, they wear it for a few months and then after a few months
after continued usage, then they actually gain that
function back themselves – essentially the uninjured
side of the brain is taking over control over the paralyzed hand. – I see. Without the robotic. – Without the robot. – That’s cool, so that
probably would apply to any one of your patients, for instance, in the long term with chronic problems. Whether it’s the loss
of blood flow to brain and you have some injury… – Yeah, when you talk about this, I always think of one
of my favorite movies when I was growing up,
which is the Star Wars series – and how Luke gets his prosthetic
hand, after he loses it, back. – We’re just a little shy of that, but that’s a first step. – We may see it in our
lifetime we never know. – I think that’s right and I
think this is, really – these are the first emerging technologies of how we can tap into
the power of the brain to essentially, kind of change our brains and our bodies for the better. And I think we’re gonna
see a lot more this stuff come down the pike. – You, Eric, you’re talking about all your brain computer
interface where you search. I know you’re very excited about it and it’s been not just a
scientific outlet for you, but also a creative outlet for you. Aren’t you sort of designing a play around all this right now? – Not just me, it’s Albert and myself. In addition to our filmed
communal coffee conversations, we wrote our first play back in 2016, is that right? – 2014. – Okay so you’re right, so
you’re absolutely right. So in in addition to
brain computer interfaces that have been a long inspiration, whether it be – I’ve actually written a couple of novels – but Albert and I have
been working on plays actually for many years now. – Couple of years, yeah. – Our first play was in
2014; that was BrainWorks. And now we have another installment of BrainWorks coming out. – It’s coming out this summer July 2019. – That’s right, again it’s a
three-year work in progress. – And we do talk about brain interfaces and stroke, like you’ve
been talking about. – And it really is a
multitude of clinical stories where I think one of the things
that’s so important is that when we do talk about technology, in addition to the kind of conversations
that we’re having now, I think people need to engage with them and we do have a story that has really
been inspired by one of our patients about how he recovered using
a brain computer interface after stroke. – That’s amazing. – Should be fun. – It’ll be fun, yeah. – It’s deeply uncomfortable
getting ready for it, of course. – That’s right, we talked
about the cognitive marathon like where it is quite literally
easier to do neurosurgery than to prepare for a play. – Like memorizing lines and all that stuff. – And knowing your position,
but it’s a whole lot of fun. – So funny. I always laugh when people say that things
are not brain surgery because I think there’s
a lot of things in life that are way harder than brain surgery. – Absolutely, absolutely. – It’s a hidden secret. – I know, we’ll delete that out. (laughter) (upbeat music)

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