Robert Kane says he is alive today because of Sunnybrook’s leading research in stroke prevention, treatment and rehabilitation
In 2004, a clot-busting drug lessened the damage to Robert Kane’s brain after he suffered a stroke. It was the second time tPA (tissue plasminogen activator) had given him a second chance at life.
The first was in June 1987 when Robert was just 37. After a major heart attack, he was given the then-experimental drug, saving his life.
Despite dieting, quitting smoking and a new interest in cycling, he suffered two more heart attacks on the August long weekend in 1996. The first hit him at work, the second in the hospital three days later. In early 1997 he received quadruple bypass surgery to remove blockages in four of his arteries.
That brings us back to January 2004, when he was hit by an intense headache at work. He was taken to Sunnybrook, where he was greeted by a stroke team neurologist and offered tPA.
“I said, ‘Well, say no more,’” he laughs. “Go ahead.”
The drug – which dissolves blood clots – induced blood flow back into Robert’s brain, preventing more brain cells from dying. It must be given to patients intravenously within about three hours of a stroke to be most effective, and reduce the chances of serious bleeding in the brain.
“I certainly have been lucky,” Robert says. “I have been in the right place at the right time, every time.”
He credits Dr. Sandra Black – an internationally renowned stroke expert – and her team for his amazing recovery. His speech was only minimally affected, though he had to relearn how to move his left side and to walk. By June 2004, just months after he was stricken, he could walk again and actually cycled 50 kilometres in the Heart & Stroke Foundation’s Ride for Heart. Today, the 62-year-old is back working full time as a salesman for a high-end appliance company, and still an avid cyclist. In 2011, he and one of his sons rode from Toronto to Algonquin Park – a 300-kilometre trip.
“He has had his ups and downs, but he still has a very enjoyable life. He almost died, but there are plenty of stories like that, people who do really well after stroke,” Dr. Black says.
Sunnybrook can take credit for many of those amazing stories. The hospital has a long history of focusing on research, driven by the clinical needs of a high volume of stroke patients, says Dr. Rick Swartz, medical director of the North-East-GTA Regional Stroke Program and a clinician-scientist with the Brain Sciences program who specializes in strokes in young people. Spurred by Dr. Black’s legacy of stroke research, Sunnybrook has a strong culture of innovation and new discoveries, Dr. Swartz adds, and stroke is one of the hospital’s strategic areas of focus.
“We have plenty of patients and plenty of need so we have a connection between the bedside and the science.”
He says Sunnybrook is also a research heavyweight because of its collaborative approach. The hospital has partnerships with leading brain scientists worldwide and with clinics dedicated to a variety of disciplines. In July of 2012, for example, the hospital merged with St. John’s Rehab in nearby North York. The two institutions are intertwined as a single health-care organization that provides seamless care for patients, including stroke, cancer and burn victims. The merger means stroke patients will receive acute care at Sunnybrook and intensive rehab to help recovery at St. John’s.
Because stroke is such a prevalent disease (about one stroke occurs every 10 minutes in Canada), there is an impetus to improve prevention and recovery rates. The disease is estimated to cost the Canadian economy $3.6-billion a year.
Sunnybrook began building its foundation for stroke innovation and care in the 1970s, Dr. Black says. It became the first Canadian hospital with a designated stroke unit, consisting of five electrocardiography-monitored beds. Many ground-breaking observational and treatment studies were conducted at that time, which helped establish the centre’s recognition as a stroke leader. For example, a clinical trial showed administering stroke patients an intravenous steroid was actually harmful, leading to the practice to be abandoned worldwide.
“We had built a reputation by the mid-’70s as being the “stroke” hospital,” Dr. Black says.
In the 1990s, there was a renewed interest in the importance of stroke units, with research coming from Europe showing patients in a stroke unit experienced shorter lengths of stay, reduced mortality and better outcomes in a year. Support of Sunnybrook’s unit continued to grow, and last year Sunnybrook opened a new 16-bed unit providing rehab team care seven days a week. This means stroke rehabilitation can begin on Day 1, with the aim of maximizing recovery.
Sunnybrook was also one of the first in Canada to be authorized to use tPA as a treatment for patients.
“With tPA, Sunnybrook’s stroke research started being glamorous because we could sometimes reverse a stroke and cure people,” Dr. Black says. “The tPA trials and funding by the Heart & Stroke Foundation became a catalyst for improving the system for care in the province.” Sunnybrook’s work on stroke was instrumental in the creation of the Ontario Stroke Network, an organization that oversees the province’s regional stroke centres and strives to improve care and recovery across Ontario.
Sunnybrook’s stroke scientists also began to make it possible for those living in remote communities to benefit from tPA. In the late 1990s and early 2000s, with funding from the Canadian Stroke Network, Sunnybrook and Toronto’s University Health Network led the development of the innovative Ontario Telestroke service, which allows neurologists to consult with ER physicians in communities across Ontario via videocameras to assist in the delivery of tPA.
“I think Telestroke is a jewel in the crown of the Ontario Stroke System,” says Dr. Black, noting the service provides tPA treatment to almost as many patients in all smaller cities combined as the bigger regional stroke centres, 50 to 70 a year.
More recently, Sunnybrook has developed a rapid response clinic aimed at diagnosing and treating “mini-strokes” before they become major episodes. The Dr. Thomas and Harriet Black High-Risk TIA Unit consists of a team of specialists that provides fast-track care to those who have had a transient ischemic attack and who are at imminent risk of suffering a major stroke. Patients are able to quickly receive diagnostic tests and treatment to reduce the risk of a major stroke by up to 80 per cent.
IN THE SPOTLIGHT
Sunnybrook continues to make important breakthroughs in stroke research, says Dr. David Gladstone, director of Sunnybrook’s Regional Stroke Prevention Clinic.
Last year, Drs. Gladstone, Richard Aviv and colleagues launched SPOTLIGHT, a multicentre clinical trial of a new image-guided treatment protocol for the deadliest form of stroke, intracerebral hemorrhage. The study aims to help patients with bleeding in the brain. Eligible patients are randomly assigned to receive the drug recombinant activated Factor VII, which has shown promise to stop bleeding.
“There currently is no proven treatment to stop bleeding in the brain. The hope is that this treatment approach, if administered quickly enough and to the right patients, will save lives and reduce disability,” Dr. Gladstone says.
The trial came about based on observations during the daily workload at Sunnybrook. Neuroradiologist Dr. Aviv developed the “spot sign” method which predicts which patients are actively bleeding and at highest risk of getting worse due to the bleed expanding. Meanwhile, Drs. Black and Richard Swartz also focus on the cognitive effects of stroke and stroke recovery, increasingly relevant to Canada’s aging population, about 25 per cent of whom have evidence of small, silent strokes that increase their risk of dementia.
Small vessel disease can occur in the brain’s white matter causing white spots or patches to show up on an MRI scan in 95 per cent of seniors. In 20 per cent it can be severe, slowing down thought processes and causing balance problems and falls, associated with aging and scarring of the small veins deep in the brain. Research has shown the importance of making people aware of changes they can make to their brain health, not only by control of hypertension and other vascular risks but also by including a healthy diet and exercise, which promotes healthy blood vessels in the brain and body and can help to offset the impact of stroke.
“As more people live to be an age where they are at very high risk for these dementias, they are a major challenge for our society,” says Dr. Black.
Dr. Swartz is currently testing a novel tool to screen stroke clinic patients for cognitive impairment, as well as depression and obstructive sleep apnea. These conditions each affect up to 50 percent of people after stroke, are associated with worse outcomes, less recovery, higher risks of future strokes yet are frequently under-assessed.
“These are very complex brain disorders and we have a long way to go, but in the last decade alone, it’s amazing the things we can do now,” says Dr. Black.
THE EMBRACE TRIAL
Sunnybrook’s stroke research made international headlines in February when a breakthrough study by Dr. David Gladstone revealed a significant portion of people who suffer unexplained strokes have silent atrial fibrillation.
This condition causes an irregular heartbeat — a major risk factor for stroke because it can cause blood clots to form in the heart which can travel to the brain. Catching this problem early could prevent many strokes, as these patients can be effectively treated with anti-clotting medications. Anti-clotting medications can cut the risk of clots and strokes by at least two-thirds.
The EMBRACE trial, conducted over three years and funded by the Canadian Stroke Network, is the world’s first and largest clinical trial to study advanced heart monitoring in stroke patients. The major finding of the study, says Dr. Gladstone, is that an advanced heart monitoring strategy led to a five-fold increase in detection of silent atrial fibrillation, and resulted in almost a doubling of patients who could be treated with anticoagulant therapy. One in six patients who underwent prolonged monitoring was found to have atrial fibrillation, which otherwise would have gone undetected and untreated.
These findings are forcing experts to rethink the diagnostic and treatment approaches for such patients with so-called "cryptogenic" strokes, a medical conundrum for years. A half-million stroke patients a year may have untreated atrial fibrillation and not know it.
Dr. Gladstone presented the trial at the International Stroke Conference in Honolulu, Hawaii, and sparked worldwide attention. “This study provides the strongest evidence to date to support the use of prolonged cardiac monitoring in elderly patients with unexplained strokes or stroke warning events when the standard diagnostic tests are unrevealing.”
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