Attacking Stroke on All fronts
WVU is changing the outcome for patient Jimmy Boehler and the 795,000 people who have a stroke in the U.S. every year.
WVU is changing the outcome for patient Jimmy Boehler and the 795,000 people who have a stroke in the U.S. every year.
Every time Jimmy Boehler turned his head to back up his truck, he’d get dizzy and feel like passing out.
Then the dizzy spells grew more frequent. Finally, Boehler, of Fairmont, W.Va., had enough and planned on making a doctor’s appointment.
Boehler didn’t get a chance to make the call before a dreary, rainy day cut into
his 12-hour shift at a construction site. He went home and logged onto his computer.
His right eye began to throb. His right field of vision became pixelated with
bright, white spots. A jarring pain emerged in the right side of his head, as
if someone prodded it with a hot poker.
He shut down the computer, walked over to turn on his television and sat down, hoping the agony would subside.
What he remembers next is waking up three hours later — on the floor between the loveseat and the coffee table.
He couldn’t move the right side of his body. Relying solely on his left side, he crawled over to a phone to dial 9-1-1.
“9-1-1, is this an emergency?” the booming operator asked.
Boehler thought, “Of course, it is. Why would I be calling 9-1-1?”
But Boehler’s thoughts and words weren’t on the same playing field. While his mental awareness remained crystal clear, he struggled to vocalize what he needed to say.
His brain was under attack.
Boehler — along with approximately 795,000 Americans every year — had suffered a stroke.
Across the U.S., on average someone dies from a stroke every four minutes, and the disease is a major cause of disability.
Most of us can avoid stroke through the management of high blood pressure, tobacco use, irregular heartbeat and physical inactivity, according to the American Stroke Association. When a stroke does happen, identifying and treating stroke quickly can prevent long-term effects.
Boehler’s stroke is an example of what can happen next.
In a stroke, blood supply to part of the brain is cut off. Without oxygen and nutrients, brain cells die. Three major stroke signs include facial drooping, arm weakness and speech difficulty. Boehler had all of those.
Once stroke is suspected in a patient en route to WVU Medicine Ruby Memorial Hospital, its Medical Command Center is alerted, setting off the beepers of two dozen staff.
Upon admission to the hospital, nurses scramble to draw blood, check blood pressure and insert IVs while doctors examine the patient.
Hospital staff are also tasked with uncovering another layer of information: What type of stroke?
About 85 percent are ischemic strokes, caused by a blockage that reduces blood flow. The remaining 15 percent of strokes are hemorrhagic, when a blood vessel in or around the brain leaks or ruptures.
Doctors concluded that Boehler’s stroke was ischemic. He did not reach the hospital within the timeframe for a clot-buster called tissue plasminogen activator, which must be given to the patient within 4.5 hours after the stroke symptoms first occur. And things were about to get worse.
He went into locked-in syndrome, a paralysis of nearly all voluntary muscles in the body except for the eyes.
“I could see, think and hear very clearly, but I could not move or speak,” Boehler said. “That’s a pretty scary feeling.”
And then somehow after all of this, Boehler recovered in a week. Nobody really knows why. He was released from the hospital and went home.
Three days later, he had another stroke, which initially felt like leg cramps. This stroke would incapacitate his left side for a long time.
That extensive treatment would take him to WVU’s stroke lab where the future of stroke is changing.
Three years ago, WVU laid the groundwork to challenge stroke’s place in our lives.
Enter Dr. Jim Simpkins, with more than 40 years of experience in pharmacology and neuroscience.
Simpkins was named director of the WVU Center for Basic and Translational Stroke Research and the Highland Chair of Stroke/Neurology.
He came to WVU with one goal in mind for himself and the research team he was about to build: To grow stroke research at WVU and take away the power of stroke to cripple lives across the state and beyond.
A $10.7 million grant from the National Institutes of Health is the latest step in attacking stroke through supporting junior researchers looking into the unknowns of stroke and making critical breakthroughs.
Stroke is the No. 5 killer in West Virginia with more than 1,000 deaths annually. Considering the population’s general poor health attributes (higher than average rates of smoking, obesity, sedentary lifestyle), stroke cases and fatalities will continue to rise.
On average, three or four people are rushed daily to Ruby Memorial Hospital with stroke symptoms. But the healthcare provided is just a slice of WVU’s far-reaching blueprint to advance stroke care and research.
“We’re building facilities to study stroke and training young investigators, such as grad students and postdoc fellows, so they can become leaders in stroke research,” Simpkins said. “We’re building up the facilities and the human capability, and I think we have started to address the real problems that directly relate to what we see in the stroke field.
“Someday, we’ll be able to say, ‘This is what we’re good at, and this is where people come to learn and heal.’”
“We must engage a lot of people in order to solve West Virginia’s stroke issue,” Simpkins said. “Stroke prediction, cause, prevention, acute treatment and rehabilitation are all linked, and a national center for excellence in stroke research will provide the most advanced research into all of these areas.”
Inside the Erma Byrd Biomedical Research Center at WVU, moveable whiteboards bear algorithms incomprehensible to the non-scientist.
It’s the office of Sergiy Yakovenko, assistant professor of exercise physiology and neuroscience, who is leading a WVU team in developing algorithms that could ultimately help create prosthetics for amputees; prosthetics that feel and respond like real-life limbs.
This innovation can also change the outcome for stroke patients — people like Jimmy Boehler.
Nearly eight years after sustaining two strokes, Boehler does not have full feeling and functioning in his left hand. If you shake his left hand, you’ll have to pull away from his grip. He can’t release it.
Yakovenko’s research could uncover how nerve signals interact in the brain to control your body. Yakovenko believes a small chip inserted into the body could potentially restore limbs to their full function.
“It’s still a bit of science fiction,” Yakovenko said, “but the goal is to provide an embedded neurochip that would recreate the function that was lost.”
Yakovenko compared the technology to cochlear implants, which are surgically implanted electronic devices that provide a sense of sound to the hearing-impaired.
“Stroke often leads to motor disabilities, ranging from severe to mild, in patients,” Yakovenko said. “Some of it can be overcome with physical therapy. Our hope is that our research will help the patient overcome these negative outcomes faster and more optimally than with the current therapy.”
“We’re building facilities to study stroke and training young investigators, such as grad students and postdoc fellows, so they can become leaders in stroke research.”
In recent years, Boehler has volunteered to assist Yakovenko and his colleagues, including Valeriya Gritsenko, assistant professor of physical therapy.
He has undergone tests, ones involving the Xbox One game system in addition to mobile apps, to record and measure body movements comparing his “good side” and his “bad side.”
Lab space at the research center — overseen by Yakovenko and Gritsenko — at the research center is filled with 3-D TVs, virtual reality gadgets, motion and muscle activity sensors and robotic treadmills specialized for biomechanics. It looks like a haven for tech geeks, only it could be the difference between recovering from stroke and not.
Gritsenko’s research looks at how spinal pathways regulate movement after stroke. She also examines brain control movement. She hopes that information can prove useful for designing individual therapy techniques.
“Right now, we don’t have a good way to compare how physical therapies work in different clinics and how effective they are in interventions,” she said. “We want to tailor therapies to individual impairments. No stroke patients are alike.
“Every little morsel of knowledge we can gain about how the brain works and its potential to impact people and their quality of life is fantastic.”
Some of that knowledge begins in lab rats. Yakovenko, for instance, uses a metal contraption called a multielectrode array that measures and communicates with the neural signals in a rat’s peanut-sized brain.
“We use it to study how they recover from stroke,” Yakovenko said. “The cells are supposed to talk to each other and exchange information that is picked up by our tools in real time.”
When a rat has a stroke, it must then relearn tasks. Yakovenko said the research is done humanely and that the rats receive care and full support, such as pain relief, much like a human would.
He said the rats recover, but they develop similar-to-human deficits such as having more weakness on one side and problems with movement coordination.
The future looks promising for stroke patients, Yakovenko believes, as he compares today’s potential neuroscience breakthroughs and innovations to those around space travel in the 1960s.
“In the ’60s, we knew how to build rocket parts, and then we practically developed enough technology to launch people into space. That was the golden age. This is what it feels like today in neuroscience.
“There are a lot of expectations in neuroscience right now. This technology is going to lead to innovation, commercialization and will create jobs. Most importantly, it will not only prolong lives, but it will make lives more productive.”
As some researchers tackle the recovery and outcomes associated with stroke, others are trying to pinpoint its exact causes.
Stephanie Frisbee, assistant professor in the School of Public Health, is studying the effects of anti-wetting agents that can be found in products — such as paper coffee cups, pizza boxes, clothing and carpet — on stroke incidence.
But even if you try to steer clear of such products, chemicals and toxins associated with stroke are unfortunately ever-present in the environment, Frisbee said.
“We are living in a chemical soup,” Frisbee said. “There’s evidence that these chemicals do not degrade. They don’t break down at all. We got ’em, baby.”
The chemicals are known as PFCs, perfluorocarbons, or by their longer names, PFAAs, perfluoroalkyl acids. Earlier this year, a group of 200 scientists from 38 countries signed a statement, included in the scientific journal Environmental Health Perspectives, urging restricted production of the chemicals.
The prevalence of these chemicals rose in manufacturing plants post-World War II, Frisbee explained. They do serve a viable purpose — they coat pizza boxes to prevent them from getting soaked by grease, they enable hot coffee to be contained within a paper cup and they waterproof cotton clothing, among other uses.
“We walk around with our coffee every day and don’t think anything of it,” Frisbee said. “But you know, cardboard usually should not be able to hold scalding, hot water. So it’s been treated with this chemical. We use these chemicals in a lot of products and don’t even know it.”
“We want to tailor therapies to individual impairments. No stroke patients are alike. Every little morsel of knowledge we can gain about how the brain works and its potential to impact people and their quality of life is fantastic.”
Within this class of chemicals, two of the so-called 8-chain chemicals were popularized by DuPont and 3M in the use and production of Teflon and Gore-Tex. Because of increasing scrutiny and concerns for their human health effects, including cancer, the use and manufacture of those chemicals in North America and Europe has largely stopped.
More modern chemical configurations are now being used. But it’s unknown how these new chemicals might affect the environment or human health.
“We have no idea about the long-term effects of these chemicals,” Frisbee said. “The only testing has been within context of an acute dose. We know much of the stuff can kill a rat. But what we don’t know is its effects over a long-rate exposure.”
Frisbee said the chemicals are associated with elevated levels of cholesterol, thyroid diseases and blood pressure — all of which are contributors to stroke.
“Biology has not found a way to metabolize them,” she said. “Once they’re in the body, they stay there for years.”
Frisbee’s study will also collaborate with a National Institutes of Health project called the Reasons for Geographic and Racial Differences in Stroke, or REGARDS. This project aims to understand why people in some parts of the country — the southeastern U.S. and Appalachia — develop more strokes than those living elsewhere. It also examines why African-Americans develop more strokes than Caucasians.
Frisbee, Yakovenko and Gritsenko are just three of the people who are chipping away at understanding and treating stroke at WVU.
Xuefang “Sophie” Ren, a research associate in physiology and pharmacology, has formed a better understanding of the blood-brain barrier — a filtering mechanism of the capillaries that carry blood to the brain. In stroke, the blood brain barrier breaks down, worsening outcomes. Ren discovered that by enhancing the production of energy by cell mitochondria, stroke outcomes could be more promising.
Paul Chantler, assistant professor of exercise physiology, is studying the role of the cardiovascular system in stroke outcome. His team is studying patients who’ve had a stroke within 48 hours to examine the health of their blood vessels and heart. Chantler’s research is aimed at aiding in the restoration of blood flow to the brain.
And Taura Barr, until recently an assistant professor in the WVU School of Nursing and Emergency Medicine, is studying what genes can tell us about stroke and immune suppression in individuals through genomic biosignatures. Barr points out that most people don’t die from stroke, but they instead die from immune suppression (i.e., infections, sepsis) after suffering a stroke. Also while at WVU, Barr helped to found a start-up company called CereDx, which created a diagnostic blood test to measure the presence of stroke.
First Jimmy Boehler went to the emergency room, then he experienced long hours of treatment and participated in Gritsenko’s and Yakovenko’s research.
He also keeps up with one other part of WVU’s response to stroke: the awareness team, preventing strokes before they happen and shortening response times through patient awareness.
The two have a strong connection at WVU. Multidisciplinary meetings are held twice a month — when providers and researchers share stroke problems encountered in the ER and the lab.
Stroke coordinator Martha Power meets with Boehler regularly at 9 East at Ruby Memorial Hospital in Morgantown. Power is one of the first people to get involved with a stroke patient’s progress and recovery — as soon as they come through the hospital.
As stroke coordinator, she meets with the family to learn the patient’s story. Most importantly, she tries to nail down the time when the patient was last “their normal self.”
Power also created a stroke survivors support group, which meets once a month over dinner, a guest lecture and a swapping of stroke stories.
Boehler is active in this group — and other voluntary efforts at WVU.
Following an appointment with Power in September, Boehler spent time roaming room-to-room offering encouragement to stroke patients at their bedside.
“Jimmy is motivated,” Power said. “He wanted to get better and he has gotten better.
“What WVU provides is not just about those first few hours after a stroke. We’re loving them through the entire continuum. We hang onto them after they leave the hospital and let them know that we still care.”
Power hopes WVU’s multifaceted approach to stroke can help more and more people like Boehler.
“We have vascular neurologists specifically trained in stroke, not just general neurology,” Power said. “We have layers of people like myself who talk to families and spread awareness. We have nurses who are stroke certified — you don’t get that everywhere else.”
Boehler credits WVU for his road to recovery. After his second stroke, Boehler could barely use his left hand. It took seven years before he could start using it again to steer a vehicle.
“I was driving home from Texas last November and my left hand jumped up on the steering wheel,” he said. “I was, ‘Woah. Where have you been?’
“You’ve got to be very patient. You don’t notice improvements so fast but all of a sudden, ‘boom.’ You have to retrain your brain to do things, like opening a jar, doing dishes, lifting that foot up high enough so you don’t trip over a throw rug. You take those things for granted.”
Gritsenko, who tapped Boehler to participate in their lab studies, said he is a perfect example of how people can overcome stroke.
“Jimmy has recovered amazingly,” Gritsenko said. “We know from the literature there is no limit to improvement after a stroke. Unfortunately, the medical practice only allows for a certain period of time for physical therapy after a stroke, and then they think it’s not going to be effective. Jimmy is living proof that, years after a stroke, you can keep recovering if you work at it.”
Through WVU’s help, from the movement tests in the research labs to what Boehler described as “aggressive medical management,” the former engineering technician said he’s in the best shape of his adult life, despite the strokes.
He’s dropped 150 pounds, quit smoking, quit drinking and resolved his diabetes, high blood pressure and high cholesterol levels.
“Everyone I have encountered at WVU, from the doctors to the nurses to the people in the labs, they have provided me with the means to educate myself and better myself,” Boehler said.
“I’ve become a stronger person — WVU has been a blessing in my life.”