January 21, 2019

Each year, more than 795,000 Americans have a stroke and about 140,000 of them die—accounting for 1 of every 20 deaths in the US annually.^[1][2],[3] Although a relatively small state, South Carolina (SC) had the nation's sixth highest stroke death rate in 2016.^[4]Within SC, stroke is the fifth leading cause of death (2,627 deaths in 2016).^[5] Stroke is also expensive. Nationally, the annual cost of health care services, medications, and missed work days due to stroke is estimated at $34 billion.^[6] In SC, stroke hospitalizations cost more than $952 million (2016 data).^[7]

Many people mistakenly think stroke does not affect younger people. However, over a third of strokes occur in people under age 65.^[8],[9]In 2016, of the 16,484 hospitalizations in SC for stroke, 39 percent were in people younger than 65 years old.^[10]

The majority of strokes, about 87 percent, are ischemic in nature which means they are caused by a blockage of blood flow to the brain.^[11] When the brain is deprived of blood, cell death quickly sets in, causing long term disability or death.^[12]

Alejandro Spiotta, MD, MUSC Professor of Neurosurgery and Neuroendovascular Surgery and Director of the Neuroendovascular Division, sees over 300 stroke cases per year, but recently found himself in a rare situation. "A young stroke patient came in through the emergency department with bilateral carotid terminus occlusions," he explains. "The case was unique because he had two separate clots–they'd most likely come up from the heart–affecting the arteries on both sides of the brain’s main trunks. It's really uncommon to have blockages in both the left and right sides at the same time. They were like mirror reflections, one side to the other."

The patient needed an urgent thrombectomy procedure to restore oxygenated blood flow to his brain. While Spiotta and his team have done the procedure hundreds of times, it is usually performed on only one artery at a time, and on one side of the brain at a time. They had to decide which side to clear first and the clock was ticking. "Time is brain," says Spiotta, "We identified this critical situation and there wasn't much time to think. Every day we treat strokes from blocked arteries–sometimes two clots are side-by-side in the same branch–but to have one on the left and one on the right with both main branches plugged–that's the most unique of all presentations." The challenge was that whichever side the team decided to clear first, the other side would have to wait–and each passing minute made an irreparable stroke more likely. 

"While the patient was en route to the angio suite, we were debating which side to go up first. Either way, the patient was in a super time crunch. All the odds were stacked against him," says Spiotta, "Then, half joking, a member of our team suggested that maybe we could do both at the same time. Little did she know, I was already thinking about the logistics and weighing the risks and benefits of doing just that." Spiotta decided to give it a try.

The obvious advantage was that it would take half the time to clear both clots than using a traditional, one-side-at-a-time approach. The downside was that simultaneous, bilateral thrombectomies had never been attempted before. Max Donohoe, a neurointerventional radiology technologist who was in the  neurointerventional suite that day, recalls how they had to hustle to double the procedure set up, "I found out as we were getting the patient on the table. We were opening up double catheters and instruments at the same time the patient was rolling into the room and pulling a second suction machine from another room. My first thought was, 'Oh, God.' There were two physicians and two techs–one on each side–and they were both looking to get their wires through at the same time. You're sharing connections. There's only one flush back. We had to really focus on not getting things mismatched and making sure that everything was properly flushed when they exchanged catheters and suctioned the clots. We had to make sure we did everything in the exact same order every time. It was definitely a little intimidating!"

Visualizing the procedure was one of the biggest challenges. The contrast dye that illuminates the patient's vascular road map and guides the catheters from the groins, up through the chest, and to the carotid clots had to be injected simultaneously. In addition, when one physician was looking for access and the other was changing out catheters–having already gained access on his side–they had to ensure that the physician who was still getting access did not have his view blocked by the other's hardware.

In the time it would have taken to clear just one of the clots using standard techniques, the patient regained blood flow to both sides of his brain. Spiotta says, "It turned out to be more of a mental hurdle. The execution was actually not that challenging. The message is that, when time is brain, you have to be efficient and open the arteries as soon as you can. I think it might not occur to other treating physicians to go up both sides at the same time. So, it's important to let people know that it can be done."  

Because cases like this one are so rare, Spiotta thinks it is unlikely that bilateral simultaneous thrombectomy will become commonplace. But, now that his team has conducted the first one ever reported, it is another option for patients facing this extremely dangerous situation. 

 

1. Centers for Disease Control and Prevention. Stroke Facts. Available at: https://www.cdc.gov/stroke/facts.htm
2. Centers for Disease Control and Prevention. Vital Signs: Recent trends in stroke death rates – United States, 2000-2015. MMWR. 2017;66.
3. Benjamin EJ, et al, on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update: A report from the American Heart Association. Circulation. 2017;135:e229-e445.
4. SC Department of Health and Environmental Control, Chronic Disease and Injury Prevention: Division of Population Health Data. Fact Sheet: State of the Heart and Stroke in South Carolina. January, 2018. Available at: https://www.scdhec.gov/sites/default/files/Library/ML-002149.pdf
5. Ibid.
6. Benjamin EJ, et al, on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update: A report from the American Heart Association. Circulation. 2017;135:e229-e445.
7. SC Department of Health and Environmental Control, Chronic Disease and Injury Prevention: Division of Population Health Data. Fact Sheet: State of the Heart and Stroke in South Carolina. January, 2018. Available at: https://www.scdhec.gov/sites/default/files/Library/ML-002149.pdf
8. Hall MJ, et al. Hospitalization for stroke in U.S. hospitals, 1989–2009. NCHS data brief, No. 95. Hyattsville, MD: National Center for Health Statistics; 2012.
9. SC Department of Health and Environmental Control, Chronic Disease and Injury Prevention: Division of Population Health Data. Fact Sheet: State of the Heart and Stroke in South Carolina. January, 2018. Available at: https://www.scdhec.gov/sites/default/files/Library/ML-002149.pdf
10. Ibid.
11. Benjamin EJ, et al, on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update: A report from the American Heart Association. Circulation. 2017;135:e229-e445.
12. Ibid.