Opinion

Raising the Standard of Care for Hemorrhagic Strokes

As the fifth leading cause of death among Americans, there is increasing awareness about the prevention and treatment of strokes and the uncertainty around recovery outcomes. The primary focus of stroke awareness has traditionally been around ischemic strokes, which represent nearly 85 percent of all strokes that occur in the Western world. However, on the perimeter of these numbers – making up the remaining 15 percent – is the most debilitating, more fatal, and most costly per incident type of stroke.

This “other type of stroke,” called intracerebral hemorrhage (ICH), also known as hemorrhagic stroke, is more likely to result in death, with a mortality rate ranging from 35-52 percent. ICHs carry the most severe deficits, with 80 percent of survivors left significantly disabled in speech, motor skills and cognitive functions. For the 100,000 people who suffer an ICH each year, the traditional standard of care has been marked by extreme caution, with 95 percent of patients currently medically managed through a “wait and see” approach and treated without surgery.

Patients arrive at the hospital as emergent cases, many already displaying significant deficits from the bleed, such as paralysis and speech impairment. And in this emergency situation, more than 95,000 people who suffer an ICH this year will be managed in the intensive care unit, with substantial medical costs totaling nearly $13 billion annually to handle patient care, recovery and rehabilitation.

The American Stroke Association reports hemorrhagic strokes render most lives forever changed by severe disability and high medical bills. Brain surgeons like myself have seen too much risk in operating on a brain bleed, mainly due to location of blood clots deep in the brain. Cutting through the brain tissue governing speech, motor and cognitive function, called white matter, to get to the clot risks even greater deficits for the patient and the uncertainty that functional recovery will be regained.

But there is good news in the form of innovation in the way we approach hemorrhagic strokes.  New hope is emerging from an elegant and innovative surgical approach bolstered by new clinical evidence and data from medical literature.  Rather than wait and see, more options are available, creating more operable scenarios and a faster, more complete recovery from surgery. This new surgical approach works because we can access the clot without cutting through the white matter of the brain, using new technologies that allow for a non-invasive surgery.

Those of us who are trained in this new approach access the clot through the natural openings and folds in the brain, called the sulci, displacing or gently pushing aside white matter. Using these tools, surgeons can now access brain bleeds and operate through a dime-sized hole without causing further damage or trauma to the brain. This is a game changer in helping to achieve improved patient recovery and regaining normal cognitive and functional abilities for appropriate patients. I believe this approach could be a first step in potentially leading us to a new standard of care for treating hemorrhagic strokes—one that all but rules out surgery and a bleak outlook for those who survive.

There is a wealth of clinical evidence from surgeries performed using the BrainPath technology that show remarkable results. There are currently 12 abstracts, 3 peer-reviewed publications and more than 7 presentations published from leading U.S. surgeons and medical institutions, assessing both ICH and brain tumor cases.

At the International Stroke Conference in February, a two-year multi-center study was presented that included 10 centers and 35 patient cases showing on average, there was 90 percent evacuation of the blood clot in ICHs with limited impact on the brain fiber tracts. Patients showed statistically significant improvement of their pre-operative deficits, with lasting functional responses post-surgery, no new deficits and no mortalities. The results were cited by the National Stroke Association as a breakthrough in hemorrhagic stroke following the meeting.

Today, I will be speaking at and attending a first-of-its-kind educational meeting for hemorrhagic stroke that is bringing together neurosurgeons, neurologists, stroke specialists, nurses and stroke care support teams, and Chief Medical Officers from throughout the U.S. This meeting will allow us to look at and discuss the peer-reviewed evidence and provide in-depth education on new concepts and techniques being successfully implemented in applicable hemorrhagic stroke cases. I am very excited about this opportunity for patients who suffer from this deadly disease, and I am confident that a multi-disciplinary approach will improve our collective success rate.

If you asked me two years ago, I would have told you operating on an intracerebral hemorrhage was an “almost never” scenario. Today, thanks to crucial innovations, I no longer have to speak in absolutes.  Brain surgeons can safely operate on these devastating strokes. We can gain safe access, evacuate the clot, manage bleeding, and most importantly, we can do so while improving functional recovery.

Ronald L. Young II, M.D. is Chief of Pediatric Neurosurgery at St. Vincent Hospital in Indianapolis, IN.  Young sits on the Board of Directors of the Subcortical Surgery Group.

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