SPRINGFIELD - When Dr. Edward Feldmann finished his residency at New York Hospital-Cornell Medical Center in 1987, he hoped that he would see "strokes treated like heart attacks."
He sees it regularly now as a neurologist specializing in strokes at Baystate Medical Center, but it took a wait time of almost 30 years.
Stroke kills about 140,000 Americans each year, and are a major cause of disability. The majority of strokes are caused by blockages, like blood clots, that impede the flow of blood to the brain and cause the death of cells from the lack of oxygen.
A revolutionizing intravenous drug treatment was approved by the U.S. Food and Drug Administration, in 1996, to help preserve brain tissue in certain patients whose strokes are caused by blood clots.
In 2016, the FDA approved the marketing of a medical device for use in an expanded use of a therapy for certain of these patients and initially for up to six hours after stroke onset.
"It has taken the last two years for this to happen," said Feldmann of the wider approval of the therapy whose name, thrombectomy, is rooted in Greek for "to remove clot."
"You can open arteries emergently now and reverse the process of tissue dying, and that is pretty nice."
The procedure is similar to other cardiac catheterizations in which a wire inside a catheter is inserted into an artery in the groin area of the leg and, in the case of a heart attack patient, guided to unclog a coronary artery blocked with fat, cholesterol and other substances.
In the case of patients who have had an acute ischemic stroke, that is, a stroke caused by a blood clot in the brain and not a bleed, a thrombectomy can be done in some to unclog the artery by threading a catheter from the groin and using a suctioning device or a stent retriever.
The clot-dissolving drug tissue plasminogen activator, or tPA, approved by the FDA in the 1990s, is more effective with smaller clots in restoring blood flow to the brain, and must be given within 4.5 hours of stroke onset. A thrombectomy is generally done on patients with large vessel clots in the brain and after they receive tPA.
"Any patient is a candidate for both treatments. They may not be when you actually see the patient. They need to come to the emergency room and be evaluated," said Feldmann, who does the evaluations based on CAT scans and MRIs.
Newer studies are showing a thrombectomy may be done on some select patients who have suffered an ischemic stroke as long as 24 hours after stroke onset to restore blood flow and save brain tissue.
"A stroke patient comes in and you look at them - you take a picture of the brain and a picture of the arteries - regardless of what the arteries look like, if they meet certain criteria they are going to get the drug in the vein," said Feldmann whose stroke patients span all age groups.
"Additionally, if a big artery is blogged and they meet the appropriate criteria, they also get the catheter treatment. But, if you don't have a big artery blocked, there is nothing to do with the catheter, but you still get the drug treatment."
He said Baystate does about 40 thrombectomies a year.
"All the hospitals in the area give the IV drug that has been around 20 years," Feldmann said.
"We are the only one right now doing the catheter-based treatment. Albany Medical does it. Hartford Hospital does it. UMass Medical does it. We are the only one in between so we cover most of Western Massachusetts."
Feldmann added, "The idea of treating stroke as an emergency has been around since 1995."
"For most of those years, we could only give a drug in the veins up to four-and-a-half hours after a stroke started," said Feldmann of the evolution in care for some stroke patients.
"The idea of a different treatment - putting a catheter into an artery to take out the blood clot that is causing a stroke - has been tested and tested and tested for about 10 years. It
exploded on the scene in February 2015 when five trials testing its devices showed tremendous benefit treating people up to about six or eight hours after stroke onset."
He added, "Since then, there have been two trials that showed that we could treat people up to 16 or 24 hours after stroke onset, if they are chosen correctly."
He said Baystate began "doing the extended window last year."
"We have been doing thrombectomies for awhile," Feldmann said. "The recent studies just gave us more information."
"It is a minority of stroke patients who need a thrombectomy but to have the potential for it to be reversed is pretty exciting," Feldmann said.
This extended window of treatment for certain patients gives hope that restoration of blood to brain cells in the stroke area will result in less permanent neurological damage.
"The patient has to have a big artery blocked by a clot so you can pull the clot out, and the person has to have a certain amount of tissue that can be saved in order for them to benefit from the procedure. If you select the patient correctly, it is remarkable how beneficial it can be," Feldmann said.
"We started treating people up to 24 hours out last June when the first study was published. The more recent study has just provided new information, though the general idea is the same. If you are selected correctly, you can get stroke treatment with the catheter that works very well up to 24 hours after stroke onset."
Feldmann is hoping that further studies will show more patients can be candidates for the extended window of treatment with a thrombectomy.
"The question is how much tissue at risk needs to be there for it to be worthwhile to do the catheter," Feldmann said.
He added the "message to all patients is the same" in terms of treatment even with the possibility of an extended window of time for treatment.
"Learn about stroke symptoms and call 911. Don't call your primary care doctor, don't go back to sleep, don't asked the dog if you are OK. It is time to get to the emergency room," Feldmann said.
"Strokes kill brain cells. You have lost whatever those brain cells do forever."