A breakthrough stroke treatment is saving lives. If you can get it in time.

CLIP You are listening to a Frequency podcast network production.

CLIP Now he’s been wanting to put garlic Chis in everything. Well, not everything. Dad, side of your face is drooping. Mom, it’s probably nothing. Dad, are you okay? You’re slurring. Why are you slurring? Raise your arms up in the air for me. Dad, are you okay. Gracie? Call 9 1 1.

Jordan Heath Rawlings If you are of a certain age, that public service announcement, courtesy of the heart and Stroke Foundation is seared into your brain and with good reason. Strokes kill millions of people annually. They’re the second leading cause of death in the world, and they are a top five killer here in Canada. Recognizing the signs quickly, as you just heard, is the best way to help someone survive. But even if they do, there’s usually severe damage done. Strokes can often be debilitating, requiring months or even years of rehab, and there’s no guarantee the victim ever gets their life back. It’s been that way for a long time, but things are different now, just not for everybody. A relatively new procedure known as an E V T can turn a stroke from a potentially deadly and definitely life altering experience to something that can sometimes be rehabbed in a week or two. Not always, of course, but the success rate. It’s staggering. This is a procedure that can change everything and it is being performed right now if you happen to be in the right place when the wrong time strikes. But what does it take for this incredibly complex procedure? To go from a handful of hospitals to available to everyone everywhere who needs it? I am Jordan Heath-Rawlings. This is the Big story. Eva Holland is a freelance writer based in Whitehorse, Yukon. She has been featured, in Wired, Bloomberg and the Walrus, and for this story in the New York Times Magazine. Hello, Eva.

Eva Holland Hey, Jordan.

Jordan Heath Rawlings Thank you for having me. Of course. Why don’t you start by telling us about Chris? Who is he? What happened to him?

Eva Holland Chris Walson is a man who lives in Calgary and last spring he had a stroke in the middle of the night and his mother was able to get an ambulance. He, he lives with his mother who’s in her eighties and she was able to get an ambulance to come get him cuz he didn’t fully understand what was happening to him. As is often the case when you’re having a stroke and he went to. Ultimately to Foothills Medical Center. He made a stop at another hospital on the way and went to Foothills Medical Center in Calgary, which is a large hospital that has an acute stroke care team. That is sort of the subject of my story.

Jordan Heath Rawlings Why don’t you, maybe this is for my benefit, but probably also some listeners like, tell us when someone has a stroke, what is happening?

Eva Holland Right. So there’s two major kinds of stroke. Ischemic stroke is caused by a blockage in a blood vessel that’s, you know, blocking blood flow to part of the brain. So that’s usually a, uh, a clot that’s causing the blockage. It can be other things as well. And so it starves part of the brain of oxygen. And if those cells are starved of oxygen for too long, they die. So a stroke is cells in distress and ultimately dying. The other kind of stroke is less common. It’s called hemorrhagic stroke. It represents about 15 to 20% of strokes, and it’s when there’s a bleed. So what you might hear called a brain bleed on a TV show, for instance, is a hemorrhagic stroke. It’s when a blood vessel has ruptured rather than being blocked, and then blood touching brain cells when it shouldn’t also kills them.

Jordan Heath Rawlings What kind of stroke did Chris have? Chris had an ischemic stroke. And how bad was it? Like what kind of impact would we usually be seeing from this kind of stroke?

Eva Holland Chris’s stroke was classified as severe. It was also what’s called a large vessel occlusion, which means the blockage was in one of the major branches of his, um, his arteries in his brain, and so he could have died. That would be the worst case scenario. He was also at real risk of severe permanent disability. We’re talking, you know, feeding tube, unable to walk, unable to get out of bed, unable to speak level, level of consequences. But his outcome was different. Right. How, how did he recover? That’s right. He was discharged from hospital. Less than four days after his stroke, back to his baseline, um, he was back to his sort of previous condition that he’d been the night before the stroke, and that’s because he received a relatively new treatment called endovascular thrombectomy that basically stopped the stroke in progress, stopped it dead in real time, and then also allowed some of the effects to be reversed because the cells that hadn’t yet been killed were able to recover so quickly.

Jordan Heath Rawlings Can you explain what this is?

Eva Holland This procedure, we’re gonna call it an E V T, like what it looks like and what’s done so that people can kind of picture it For sure. It’s, it’s a little sci-fi. Yeah. So it only applies to ischemic stroke, which like I said, is 80 to 85% of strokes in Canada and previously our only treatment. For ischemic stroke was what are sort of informally called clot busting drugs. Drugs that kind of try to dissolve the, the clot that’s causing your stroke in time to to save you. But an E V T is a little bit more direct what they do Endovascular means inside the arteries. So what they do is they, they access your artery usually through your femoral artery in your, in your groin, and they send a series of microcatheters up through your body threading all the way from your thigh up to your brain. And, um, and then they, they send up a little device called a stent retriever, and they try to capture the clot. In this device, it’s sort of like compressed when it’s inside the microcatheter, and then it unfurls and expands similar to what you might get if you have an angioplasty for a, for a heart issue. It expands, it fixes the blockage in the vessel, and then it captures the clot in its mesh, and if it, if it works correctly, the devices then withdrawn and takes the clot with it and the, and the stroke is over.

Jordan Heath-Rawlings These are like the little nanoparticle things that you see on Star Trek that go in and like, fix people from the inside.

Eva Holland Right. Like, it’s crazy. I mean, yeah, they’re, they’re a little bigger than you would think. Like our, our major arteries are not small right. In the, in the scheme of things. So it’s not as, as minuscule as you would think, but yes, it is very, we’re talking about threading, you know, wires and very small tubes through, through our, uh, arterial system.

Jordan Heath Rawlings So how come more people, myself included, had never heard of this kind of procedure? I mean, give us a sense of how many people around the world are impacted by strokes every year. This should be, you know, kind of a miracle cure, right?

Eva Holland Yeah, it’s, uh, so between six and a half and 7 million people die of stroke every year around the world. It’s the second leading cause of death. In Canada, it’s more frequently fourth or fifth, partly because we’ve got better access to primary prevention care here than in other parts of the world. So if you have high blood pressure, you might get put on statins, that sort of thing, that’s gonna help you prevent a stroke. But it, you know, it was a huge deal when this procedure came online in, in stroke neurology circles. It was, it was a really big deal. Uh, the, the studies that sort of established it, As an evidence-based treatment came out in 2015, so it’s still fairly recent. And my story was sort of about the process involved in implementing a research breakthrough like that at scale. So it’s famous within its niche, but I think, I think people broadly don’t think about stroke that much for how large its impact is. And so we don’t tend to hear about things like this sort of breakthrough because it’s not something that’s top of mind for most people. Even though most of us will be affected by stroke one way or another, whether through a loved one or or ourselves at some at some time.

Jordan Heath Rawlings In a moment, I want to get into the challenges of rolling out something like this at scale, but first, maybe just for a little bit of context, how has this procedure been informed by, you know, the past few decades, I guess, of our dawning understanding of what a stroke is? You know, in your piece you kind of detail hundreds of years of us just trying to figure out what causes them and what’s happening inside us.

Eva Holland Yeah, it’s been a few things that have allowed these breakthroughs. A big one is medical imaging. So these procedures are done in tandem with, you know, the first thing they would do when a stroke patient who might be a, a candidate for E V T gets to the hospital is they rush them to a, a CT machine and they try to locate the clot in the brain and see if there’s a viable sort of pathway for extraction. Whether it’s a viable target is how they would, how they would put it. So having access to CT and, and MRI. In sort of every hospital is a big piece of it. And then developing these techniques, even just sort of the, the device manufacturing of these, these wires that they use that are soft enough to be pushed through the body without causing harm, but firm enough that you can. Stand by someone’s thigh and push a wire all the way up to their brain. You know, not to make it sound gross, but there’s a skillset element. There’s, um, a knowledge element, there’s a technology element, and a, a bunch of these things sort of came together and, and people started experimenting with this procedure in the late nineties. But, but the devices got a lot better and that helped improve the outcomes. Um, and then they started sort of making really custom made devices. And so it’s, it’s one of those things where it’s a convergence of a whole bunch of factors that allowed this kind of breakthrough to occur.

Jordan Heath-Rawlings And when you talk about technology like this, and I guess we also need to talk about the people who are talented enough to work that little wire through the artery up to the brain. Like what goes into making this kind of treatment available at, you know, the hospital nearest to where somebody suffers a stroke?

Eva Holland The people who actually do this procedure are called neuro-interventionalists. I don’t know if you follow the New York Times first said Twitter bot account, but neuro-interventionalist had not been in the New York Times before my story, so I got a, I got a New York Times first said.

Jordan Heath-Rawlings Congratulations.

Eva Holland Thank you. It was very exciting, uh, highlight of the experience. It does sound like an incredibly complicated job. It is. So it’s, it’s actually a hybrid position so you can become a neuro interventionalist if you are already. A neuroradiologist. Um, so a specialized type of radiologist or a neurosurgeon, or a neurologist. And so people from those backgrounds do an additional maybe a, let’s say a two year fellowship to get this specialized neuro interventionalist training to do these. There’s a various procedures, this isn’t the only neurological procedure that uses endovascular techniques. So training is a piece of it as well. Uh, making sure there’s enough specialists. And it’s interesting, you know, the goal with something like this is not actually to have it, in every hospital eventually, because these personnel are so specialized that they have to stay busy to keep their skills up. And so if it was in every hospital, they wouldn’t get enough patients. So it’s, it’s what they call a hub and spoke model. So for instance, in Alberta where my story is set, the really specialized E V T teams are in Calgary and Edmonton. And there’s just the two of them. One for north, one for south, but then the, the province’s whole e m s system is set up to rapidly transfer stroke patients to either Calgary or Edmonton if they’re gonna need an A V T in another context. For instance, I know there’s a hospital in Sudbury that is the hub for Northeastern Ontario, and that’s part of the challenge of getting access to this treatment is that it’s making sure that we have the hub and spokes and that people can access the hubs when they need them, that the hubs are ready to receive people and people can get there.

Jordan Heath-Rawlings So you need the specialist, you need to be able to do the CT scan right away. What else do you need and what else is in the way of a hub and spoke model everywhere?

Eva Holland Yeah. You need what’s called an angiography suite. So this is the, the sort of quasi operating room where the procedure is actually done and they do the procedure with x-rays sort of going on and off throughout. So they use sort of real-time x-rays, like tracking it? Yeah. To guide themselves like a, like a map through the body. So it’s sort of a specialized facility for the actual procedure. And you need an acute stroke team that can respond 24 hours a day. That’s a big piece of it. You need paramedics who are trained to identify these patients and route them accordingly. You need emergency room personnel who are gonna, you know, not leave them sitting in the waiting room for three hours who are gonna move them through triage and into CT and into the hands of the stroke team.

Jordan Heath-Rawlings So given that this is, you know, six, 7 million people per year, how widespread is the availability of this stuff?

Eva Holland You know, it’s good to know that it’s at, uh, a few Canadian hospitals. What about the rest of the world and how do we get it there? That’s the big question. It access is improving, but it’s. It’s very unequal as we, as we know with so many things. So for instance, the British Stroke Association recently put out a report saying that a resident of London was eight to 10 times more likely to receive an E V T than a British person elsewhere in the country. And then you get into the disparities between high income countries and low and middle income countries, and it gets much more significant. There’s a number of countries that don’t have it yet at all, and there’s others that have it, but their access is, is still very imperfect. India is an example of a country that’s putting some resources into trying to build access to E B T, but a lot of, even in the, the, you know, rich countries, the access is often around 20 to 30%. It varies a bit place by place. A province like Alberta is, is closing in on a hundred percent access, but they’re sort of the model.

Jordan Heath-Rawlings When we talk about where these treatment centers are and getting people to them, you know, we’re implicitly talking about time and from the very little I knew before talking to you, uh, about strokes. I know time is of the essence. So maybe we could start at the very beginning. What role does the average person play in improving stroke outcomes and getting people to this therapy in time for it to be effective?

Eva Holland That’s so important and thank you for asking me about it. It was interesting to talk to the stroke doctors about this, you know, this amazing technological advance this, this sort of amazing treatment that they have. And they said our biggest problem is still just getting people to the hospital in time.

Jordan Heath-Rawlings Why is that?

Eva Holland It’s a few things. It can be hard to recognize a stroke in progress, especially the ones that are less sort of dramatic in their immediate consequences. And you know, a lot of us live alone and it’s very difficult to recognize a stroke in yourself because, one of the effects can be cognitive impairment, right? A lack of understanding of, of the way your body is, is experiencing the world. So the signs for people to look out for the sort of classic signs are sudden, uh, weakness or paralysis on only one side of the body. So if the, if your one arm is suddenly, feeling limp, for instance, looking at people around you, it’s if the one side of the face is slumped, so sort of if they have sort of an uneven smile or like one corner of their mouth is suddenly turning down. Slurred speech grip strength. If you hold somebody’s hands and they can’t make a fist with the other, with one hand, for instance, that would be a classic sign of stroke. These are things that we can look out for in each other, and it’s sort of a when in doubt. Check it out kind of a situation. It’s not something to ignore and wait and see if it goes away because you know, like you said, time is of the essence. Every minute that goes by, brain cells die. And, and the faster you get to the hospital and, and stop that stroke, the, the better your outcome will be.

Jordan Heath-Rawlings This is a fascinating technology and thank you for walking us through how it applies to strokes, before, I let you go. I have to ask because the actual procedure itself in the applications are so cool and futuristic, as you pointed out. What other applications does this tech have, what could we use it for, especially as it presumably gets better and better.

Eva Holland Right. Really, I think in some ways this is one of the late stage applications of this, of this technology. What it’s been used so far to really change lives is, is in cardiac care. This endovascular technology has, has. Done a ton of good for people with heart attacks and other heart conditions, and now we’re finally able to apply it to the brain too. And that’s, that’s really exciting because brains are tricky, trickier than hearts in some ways, I think. And so it’s, it’s really exciting to see the possibilities open up for the brain as well. Eva, thank you so much for walking us through this.

Eva Holland Thank you, Jordan.

Jordan Heath-Rawlings Eva Holland writing in the New York Times Magazine. That was the big story. For more head to the big story podcast.ca, you can talk to us anytime on Twitter at the big story fpn or via email hello at the big story podcast.ca. Let us know if you enjoy these extra Saturday episodes. We’re thrown on sometimes we’re having fun making them. We would love to hear what you’d like to get out of them if you’d like to see something a little different on Saturdays. Or if you want us to just shut up and let you have your weekend to yourself, I can’t promise we’ll do that because we like doing this show for you, but we are always open to suggestions and if nobody speaks up, I’m gonna turn it into a sports podcast. You’ve been warned. You can also call and leave a voicemail. (416) 935-5935. And you can find this podcast wherever you get ’em. And if you could spare us a review, we would be thrilled. Thanks for listening. I’m Jordan Heath-Rawlings. We’ll talk on Monday.