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Mobile Stroke Units May Speed Up Brain-Saving Treatment

Every minute counts after a stroke. Mobile scanners may be the breakthrough doctors need

spinner image a photo of the inside of the mobile stroke unit c t scanner
The mobile stroke unit is a specialized ambulance equipped with a portable CT scanner.
Dan Winters

It happens something like this. You're talking with friends at dinner when your spouse asks why you're slurring your speech. Or maybe you're out for your morning walk when your movements suddenly turn jerky, as if half of the invisible strings that guide your limbs had suddenly been cut.

Maybe pain is the herald, a crushing migraine or a starburst in the back of the head. Maybe you're alone. Or, worst of all, driving on the highway.

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That's how it was for Buddy Bailey, who at the time was a 70-year-old investment adviser, golf ball hunter and steadfast husband of 51 years. It was a bluebird day in Houston. Bailey was breezing south toward Galveston on a courtesy call to a valued client. The Gulf Freeway was just rising up to cross El Dorado Boulevard, and for a fleeting moment the view through the windshield was reduced to the gray race of the road and the untroubled sky.

There are no exact words for what happens next. Darkness, dizziness, the world withdrawing, inputs going dead. A silent, mindless, timeless drift through four lanes of traffic — and then being jolted awake by the crash of his Mercedes-Benz against the freeway barrier, and swerving back into the chaos and light. When the Benz finally comes to rest, Bailey knows the danger still hasn't passed. Even so, there is nothing he can do. Because the violence is still taking place inside his head.

It is among the most feared medical emergencies. What else but a stroke could make you think you'd rather have a heart attack? Sure, heart attacks are more fatal, but at least if you survive you can carry on more or less as before — without a dimming of the mind or the loss of key bodily functions.

With strokes there is no such assurance. Fully 40 percent of stroke survivors require some kind of special care, 25 percent experience significant cognitive decline, and an average of 17 percent will be discharged into long-term care. This is not the vantage from which to sit back and reflect on one's life accomplishments.

The comparison with heart attacks is not incidental. The vast majority of strokes — or “cerebrovascular accidents,” to use the textbook term — are caused by a blockage in blood flow. Yet unlike a heart attack, for which there are dozens of immediate interventions, a stroke has proven infuriatingly difficult to treat. More than 1,000 drugs have been tested—mostly to no avail. The lack of progress has led researchers to explore offbeat solutions. Brain cooling, transcranial magnetic stimulation, lasers delivered through the nose. Drugs derived from peach pits and the venom of the Malayan pit viper. By the early ‘90s, doctors were no closer to finding a treatment for strokes than they had been 50 years prior. It was “diagnose and adios,” as the saying went. Nothing to be done.

spinner image a photo of the mobile stroke unit at u t health in houston texas
The UTHealth Mobile Stroke Unit Consortium lead by Jim Grotta, M.D.
Dan Winters

Stroke is a story of anguish and frustration. Although the Food and Drug Administration (FDA) has approved two treatments (a medicine, tPA, that can break up the clot in a minority of strokes and, in 2016, a surgical procedure to remove clots from a sufficiently large blood vessel), people are still dying by the thousands — 150,005 in 2019. This has led some people to look for other solutions. And in the past several years, a new approach to strokes has been gaining adherents all over the country. One day it might save your life.

In the makeshift headquarters of the UTHealth Mobile Stroke Unit Consortium on the 14th floor of an office building in downtown Houston, a robotic female voice announces the latest disaster — Buddy Bailey's car accident. “Stroke. Cat. 1. Gulf Freeway near Exit 26. Key Map 617. Alpha Bravo 10.”

The stroke team, like a house of firemen, spends much of its time waiting for just this type of call. Team leader Jim Grotta, M.D., along with a paramedic, a nurse and a CT technician, grab their gear and head for the door.

The elevator ride is a killer. The ride from the 14th floor takes 30 seconds, or about 1 million neurons at the rate that oxygen-deprived brain cells die. At last the doors scrape open onto a dim corridor leading to the alley where the mobile stroke unit has been charging up. Rudy Perez, the paramedic, takes the wheel of the truck. Grotta rides shotgun. The CT tech unplugs the charging cables and climbs in back with the nurse and the half-ton computerized tomography scanner.

The mobile stroke unit (MSU) is a specialized ambulance equipped with a portable CT scanner. Rather than take stroke patients to a hospital, the idea is to take the hospital to the patients. The onboard scanner allows the doctor to diagnose en route to the hospital, eliminating the transport time, which could be as much as 40 minutes.

With a stroke, those minutes matter. Currently, only 1.3 percent of eligible patients receive treatment in the first hour after having a stroke, and nearly 20 percent are treated between three and 4 and a half hours later.

Brain tissue dies fast. For every 30-minute delay the relative likelihood of surviving a stroke with no deficits decreases by 15 percent. By eliminating some of those minutes, MSUs could (in theory, anyway) save millions of brain cells — and perhaps thousands of lives.

spinner image an illustration depicting the two types of stroke
Chad Hagen

The key is the CT scanner, a doughnut-shaped X-ray machine capable of rendering 3D images of the brain. The scanner determines the kind of stroke the patient is having — hemorrhagic or ischemic. An ischemic stroke is caused by a blood clot that cuts off blood flow to the brain. A hemorrhagic stroke — seven times less common but four times more deadly — is caused by an aneurysm or burst blood vessel. The difference matters, because tPA, the only drug available to treat strokes, works only for ischemic strokes. When given for a hemorrhagic stroke, it can be fatal.

Historically, CT scans were available only in hospitals. But with the MSU, scans can be done virtually anywhere.

The first U.S.-based MSU debuted in 2014, right here in Houston, under Grotta's direction. MSUs now are in 19 other U.S. cities, even though research of their clinical benefits is just coming out, and nothing has been conclusive. This tells you something about how frustrating strokes can be and how impatient doctors are for solutions.

Few know more about the frustration than Grotta. Fewer still deserve more credit for the progress that's been made. Because Grotta was there from the very beginning.

For him, the story began with a stray remark over an operating table in northern Israel, 1971. Jim Grotta was on an elective surgery rotation in Safed, just east of the Golan Heights. At this point he was still deciding what kind of doctor he wanted to be — psychiatrist, neurosurgeon, maybe a neurologist. 

"Why neurology?” Daniel Rice, his mentor at the time, asked. “You can't treat neurological diseases."

Rice was a military surgeon, and he treated nearly everything. At a time when the Golan Heights was still heavily mined and regularly bombarded by Syrian mortars, Rice would strap a gun to his hip, hop in his little car and drive around to all the hill clinics.

Rice was a dynamic guy. Grotta liked that about him. What's more, what Rice said about neurology was hard to deny. People regarded the brain as this intimidatingly complex, quasi-mystical organ, one resistant to real treatment. But Grotta considered Rice's words a challenge; at the end of the day it was all just anatomy, and a stroke was simply a plumbing problem, right? One for which fourth-year medical student Jim Grotta could maybe, one day, help to find a solution — as a vascular neurologist.

Within five years the advent of CT scanning began to suggest that he might be right. With scanning you could penetrate the vaulted brain and clearly identify the infarct — the tissue killed by loss of blood flow. By the late ‘70s, advances in imaging technology had revealed that not all brain tissue impacted by a stroke died immediately. The area around the infarct — the penumbra — could survive for several hours.

The implications were huge. For the first time it became clear that there was a window of time in which the devastating effects of a stroke could perhaps be averted. The next step was to figure out exactly what that effective intervention might be.

It took two decades, but Grotta helped make a viable response to strokes finally happen. He was one of the principal investigators in the landmark drug trial that lead to the FDA approval of the clot-buster tPA for ischemic strokes in 1996. It remains the highlight of his career.

But Grotta is far from done. At age 76, he projects a wiry, Army-colonel intensity, with ice-blue eyes and a quiet, almost murmured delivery. In the MSU, Grotta tabs through the dash-mounted laptop as Rudy makes a sharp right turn, running hot. Tuesday at 10:15 a.m. is not a bad time to have a stroke; traffic is light. Monday mornings can be rough, ditto Friday afternoons, and heaven help you if there's road construction.

Like bottlenecked traffic, clots, too, are more likely to form in some places than others: in the heart, where inefficient pumping (often due to an erratic heartbeat) can lead to stagnant, clot-prone blood; in arteries narrowed by atherosclerosis; around “construction sites,” where surgery has left some irregularity in the arterial wall.

At some point the clot will break loose and get carried downstream. Where it ends up is largely a matter of chance, a pachinko game that plays out amid branching currents of blood. The size of a clot determines its impact, too. A larger clot will get stuck sooner, blocking blood flow to a larger area and causing greater damage. But a small clot can have a devastating impact, too — blindness, for instance, when lodging in the small blood vessels at the back of an eye.

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Waiting for help to arrive, Bailey isn't worried. If there's one thing you learn with age, it's not to waste energy worrying about things you can't control. He's calm as they load him into the MSU and prepare to crank up the CT.

spinner image a portrait of carol and buddy bailey
Buddy and Cindy Bailey
Courtesy Buddy Bailey

Buddy Bailey is a man who has always enjoyed a certain confidence and ease. This may be due to how he has lived his life, which has been narrow in scope by some measures but, for that reason, twice as deep. He has always lived in Houston and has followed the city's NFL teams — first the Oilers, then the Texans — since age 14. He's had the same close friends since 1975. In his entire life, he's only had three jobs.

"I always knew where I was going on Monday,” he'll say.

It's this that makes him such an asset to his work clients: If the investment is quality, there's no reason not to keep it forever. This brings us to Cindy Bailey, Buddy's wife, and his prize of a lifetime. He first caught sight of her in 1966. He was a new arrival at the University of Houston, knowing no one. Then, amid a sea of strangers at the student union, there she was, he recalls, bright as a button and just as cute.

To clinch the deal he drove her home in his new Mustang, with three on the floor. He was 19 years old and just growing out of his knucklehead stage. The timing could not have been better.

That was more than half a century ago.

Now the scanner hums to life and Bailey's head enters the ring.

Initially it was thought that scanners couldn't be made small enough to fit in an ambulance — not that anyone was planning for that at the time. Just as no one was planning for rocket-propelled gurneys or operating room mood lighting or designer scrubs. The idea was a non sequitur. The kind of thing you'd have to be a bit out of your head to even imagine.

As it happens, they are fond of beer in Germany.

A medical breakthrough

Like other neurologists, Klaus Fassbender, M.D., had been frustrated by how long it took to treat stroke patients. By the time they arrived at his Mannheim clinic, it was usually too late to help them.

Then one day in 1999, he attended a lecture on strokes by a visiting neurologist. The lecture was provocative, and when it was over Fassbender and 10 of his colleagues retired to a beer garden to mull. An unknown number of hours later, Fassbender, sufficiently lubricated to be fully unconstrained in his thinking, conceived the idea of the mobile scanner that today could save Bailey's life.

When Grotta got wind of Fassbender's project, he instantly recognized its promise. It reminded him of his old mentor, hopping in his little car and delivering care wherever it was needed. Except instead of packing a gun, he would pack a compact CT scanner.

Now Grotta sits in the MSU in a parking lot outside a home-improvement store, studying images of Bailey's brain on his laptop. Since emergency services are stationed all over Houston, they're more likely to arrive on scene first, so often a transfer rendezvous from the EMS van to the MSU will be arranged at some convenient waypoint — a gas station, a firehouse or a parking lot like this one.

Technically, Grotta doesn't even need to be here — the images could just as easily be sent to some neurologist's phone on a beach in Tahiti. But he likes the action.

Grotta has no idea who Buddy Bailey is, what he loves or lives for, but he does know that a clot has lodged in Bailey's middle cerebral artery. That makes his an ischemic stroke, so Grotta can go ahead and administer the tPA immediately.

Suddenly Bailey's phone rings. The paramedic answers. It's a friend of Bailey's wife, looking for the name of her car mechanic. The paramedic tells her what's going on. That's how Cindy Bailey gets the news.

It's always amazing the way the specter of death walks casually into your life like it owns the place, without so much as stamping its feet.

A devastating phone call

Cindy Bailey is at a drugstore when she gets the call. A few words are spoken, followed by an unholy lurch as her world tips off its axis. She hangs up and calls her husband's number, praying that someone will pick up. Someone does. But the paramedic doesn't have many answers.

In the paramedic's defense, there's a lot going on at the moment. Even if he did have the time to explain, the bottom line is still a lot less clear than you'd expect.

Take this miracle drug, tPA, currently feeding into Bailey's arm. When it was first introduced they called it Brain-o, after the plumbing product Drano, which works much the same way.

But not every drug is as miraculous as, say, penicillin. Countless studies have been done on the effectiveness of tPA (which stands for tissue plasminogen activator), and the results vary widely depending on when it is given. Even though Bailey received tPA relatively quickly, there's still only a 1-in-5 chance that he'll benefit.

"No one's saying tPA is a panacea,” Grotta says. “But it's something, and it works dramatically in some."

This is the half-full view. Grotta was around when the glass was bone dry. He fought hard to get this far. And if optimism is something that grows with age, so does patience. The fight against death is a long game, and not to be won in a single sitting. After tPA, for instance, it was 20 years before the FDA green-lighted another treatment for strokes called mechanical thrombectomy, a surgical intervention in which a wire is used to fish out the clot like a wedding ring from a drain. Like Grotta thought, nearly half a century earlier: plumbing.

To reduce disability 90 days post-stroke, thrombectomy has a good track record. What's more, the procedure doesn't have to be done immediately; it offers a time window five times as long as tPA. True, thrombectomy only works where the blocked vessel is wide enough for the wire to navigate. But in a way this new option underscores how our understanding of strokes has changed over the years — from a single, monolithic event to a highly variable event that responds differently to different treatments. Sometimes progress is not a matter of inventing new treatments so much as understanding which ones work best for which conditions.

spinner image the mobile stroke unit taking a patient in for fast treatment
The UTHealth Mobile Stroke Unit Consortium in action.
Nash Baker/UT Health

The MSU serves an important role here, triaging patients so they can be quickly routed to the most appropriate care. Bailey's clot, for instance, was a big one. This made it more dangerous. But it also made him a candidate for a thrombectomy which, combined with an early tPA intervention, gave him a far greater chance for reduced disability — and an 11 percent greater chance of returning to the same level of health he had before the stroke.

Outside the emergency room at Houston Methodist Hospital, Cindy Bailey is waiting. The waiting is horrible. The only way she can keep sane is by writing in her journal. The words emerge from the raw pit of love and anguish. She addresses them straight to God. “Give me courage to put my trust in you in the days and weeks ahead. You are my comfort. Draw Buddy close to you. Help him not to be afraid. Show me how I can help Buddy. Give him hope."

At last the MSU arrives, having shaved somewhere between 15 minutes and two hours off the clock, depending on whether Bailey would have otherwise gone to a community hospital and then transferred, as is most likely the case.

Bailey does not know it, but he is now a part of a huge study that Grotta is running to determine exactly how much time the MSU saves, how it affects clinical outcomes and whether it is cost effective. The upshot will not be known until the trial is finished and all the data is in and published, but Grotta is optimistic. If the study is positive he believes eventually every city in the country will have a mobile stroke unit. The MSU itself may spur further innovation. Why not, for instance, a specialized ambulance for cardiac cases? Or for trauma?

Given the weight of human effort devoted to solving strokes and the promise of MSUs, there is good reason to be optimistic. Advances in telemedicine and AI-assisted imaging analysis suggest a future in which rural communities may have the same access to stroke expertise as high-level stroke centers.

As the gurney rolls through the sliding doors, there's a pause for a quick evaluation en route to the thrombectomy suite. Grotta is there, and so is Cindy Bailey, along with Orlando Diaz, M.D., the neurosurgeon.

"How many fingers am I holding up?” Diaz says.

"Three,” Bailey says.

"Do you know where you are?"

He does. He's at Methodist. But even though he can picture the word he finds that he cannot say it. It's as if a river has coursed through the center of his mind, leaving one side cut off from the other.

Diaz glances at Cindy Bailey.

"Do you know who this lady is?” he says.

Bailey looks at his wife of 51 years.

"Yes,” he says, hesitating. Because her name is stuck there on the other side where he can't get it. So he goes for the next best thing.

"She's my sweetie pie."

As Bailey recalls the story three years later, his wife's hand shoots out to touch his arm. One artifact of the stroke is that he's more vulnerable to emotion, more likely to tear up. His temper can flare, too, especially when he's exposed to loud noises. Cindy Bailey says his brain works just a bit differently — “not better or worse, just differently,” she says. Bailey was never big on multitasking, for example, but now he's more deliberate and focused, preferring to complete a job before moving on to the next. In every other respect he's like his old self. The words, the names — it all came back eventually, settling in his mind like disturbed birds.

The road to recovery

In the days after the thrombectomy they practiced recalling his birthday together, and for a long time he kept saying 1998, as if he had lost the ensuing 19 years. As if they were back in time, but wiser, more aware of how much each day is worth.

Physically, the stroke seems to have left nary a mark. The day after the thrombectomy, a physical therapist walked him up and down the hospital hallways, to see how much rehab he'd require. “After a bit the therapist said, ‘Well, I'm going to take you back to your room and go find someone who actually needs me,' ” Bailey recalls. He was as physically graceful the day after the stroke as he'd been the day before.

As for Grotta, he recently found himself addressing hundreds of colleagues at the annual International Stroke Conference. The MSU study is done. He has the data. And the data is good.

Ordinarily, less than 3 percent of patients receive tPA within the golden hour. With the MSU, Grotta raised that number to 33 percent. As a result, these people, Bailey among them, survived their strokes with minimal or no disability — 10 percent more than the non-MSU group.

"The results are actually really impressive,” says Amytis Towfighi, M.D., chief of neurology and associate medical director of research neurological services at LAC+USC Medical Center. “Ten percent difference in outcome at three months may not seem like a lot, but it's almost the same improvement you get with tPA itself.”

Grotta, meanwhile, is already on to the next thing: a study to see if MSUs can help with hemorrhagic strokes. Different pathology, but the logic's the same: Why wait around for the problem to come to you, when with the right set of wheels you can go to the problem?

Oliver Broudy, a 2009 National Magazine Award finalist, is the author of The Sensitives, a book about the effects of chemicals and allergens on the body.

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