By Jeroen Coppens, MD

It’s the third leading cause of death among Americans and the leading cause of serious, long-term disability. It’s STROKE. More specifically, hemorrhagic stroke – bleeding that occurs from a broken blood vessel within the brain and statistically, the deadliest, costliest and most debilitating form of stroke with no proven surgical answer.

Where once there was little we could do after a hemorrhagic stroke (ICH) except “watch and wait” to see if blood absorbed back into the brain, which is toxic outside the blood vessels and can be the root cause of many long-term or permanent deficits, the outlook has dramatically improved for a surgical answer because of new and innovative technologies available to surgeons. These technologies are proving to be very effective in providing access to deep regions of the brain where the bleed starts and in surgically removing or evacuating the clot in a matter of hours in appropriate patients. The results, now published in more than 18 peer-reviewed papers and abstracts that included 221 cases, are showing improved functional and cognitive patient recoveries that are also being seen here at Saint Louis University.

At Saint Louis University (SLU), we have treated more than 25 hemorrhagic stroke cases using these technologies that include a navigation-compatible port-based device and an automated scissors and suction tool that is used through the port device for safe and maximum clot removal. Together, these technologies improve the evidence that early surgical ICH evacuation can potentially lead to the improved functional and cognitive recovery of patients.

Saint Louis University was the first institution to bring this technology to Missouri, and our experience has shown robust results with significant improvements in survival and function for patients afflicted by this condition. In addition to improving survival, patients have regained consciousness faster and we feel have had better functional outcomes. We have been successful at removing more than 95 percent of the clot volume and surgery is performed on admission, often on an urgent basis.  We are very excited to be participants in what we believe this standardized surgical approach will become the new standard in the management of hemorrhagic stroke.

Our integrated approach with SLU neurology stroke experts enables us to be at the forefront of defining how this new technology and surgical approach can be applied. Patients are evaluated by a neurosurgeon and stroke neurologist in the emergency room, which has enabled us to be much more proactive in the management of hemorrhagic stroke and also gives patients the maximum benefit of surgery. Our stroke experts and surgeons have felt a new sense of empowerment with this technology because of our ability to offer patients an effective surgical option at treating hemorrhagic stroke.

Hemorrhagic stroke, while much less common than ischemic stroke, makes up about 20 percent of all strokes. Despite its lower incident rate, I bring attention to it during Stroke Awareness Month because of its deadly and debilitating nature – a mortality rate range of 35-52 percent and of this percentage, 80-90 percent are left significantly disabled in speech, motor skills and cognitive functions.

For the 100,000 people who suffer a hemorrhagic stroke each year, they arrive to the Emergency Department already displaying significant deficits from the bleed, such as paralysis and speech impairment. Even though it is the most serious type of stroke, 95 percent of patients receive the standard of care of medical management – the “wait and see” approach without any surgical intervention. That means more than 95,000 people who suffer an ICH this year will be medically managed in the intensive care unit under current standard of care treatment protocols that come with substantial medical costs, totaling nearly $13 billion annually for patient care, recovery and rehabilitation.

In the past, brain surgeons like myself have seen too much risk and too little positive clinical data around operating on a brain bleed due to the location of blood clots deep in the brain and not having the right technologies to reach the bleed safely. Cutting through the brain tissue that controlled speech, motor and cognitive functions to get to the clot risked even greater impairments for the patient. But this new surgical approach allows me access the clot without cutting through important brain tissue.

I believe this approach could be a first step in potentially leading us to a new standard of hemorrhagic stroke care that all but rules out surgery and a bleak outlook for those who survive. It offers innovation and hope where very little existed before.

Evidence supporting the use of these technologies and surgical techniques in ICH is now being gathered through a multi-center clinical trial called ENRICH (Early Minimally-invasive Removal of IntraCerebral Hemorrhage), which SLU is participating in with 24 other major academic and community centers across the country. The trial will compare standard medical management to early surgical clot evacuation using this new surgical approach. Our hope is that the favorable, consistent outcomes we have seen in early cases will be repeated and eventually lead to a new standard of care for patients who experience this deadly form of stroke.

The progress in technologies that are revolutionizing how we deliver improved patient care leads us all to be very optim
istic to what is on the horizon for ICH. Two years ago, operating on an intracerebral hemorrhage was an “almost never” scenario. Today, thanks to these crucial innovations, neurosurgeons no longer have to speak in absolutes. We can safely operate on these devastating strokes in appropriate patients. We can gain safe access, remove the clot, manage bleeding, and most importantly, we can dothis with the strong promise of improving functional recovery. V

Jeroen Coppens, MD
Assistant Professor, Neurosurgery
Saint Louis University
Site Principle Investigator, ENRICH Clinical Trial