Experimental Procedure Saves a Man's Life
Joseph Pagone, 53, collapsed in his shower with a loud thud. The impact startled his wife, Jan, who ran to the bathroom to find him struggling to get up. His dominant right side was useless.
Pagone, of Park Ridge, Illinois, quickly was diagnosed at a local hospital with a life-threatening intracerebral hemorrhage (ICH), a type of stroke that affects more than 100,000 Americans each year. Between 30 and 50 percent of them die, and of the survivors, more than 90 percent are left with serious disability.
Intracerebral hemorrhage occurs when a diseased blood vessel bursts within the brain. The blood forms a hematoma, or clot, that grows and creates pressure on surrounding brain tissues. This cuts off oxygen to the brain tissue and can cause severe damage to the brain cells.
Pagone was whisked by helicopter to the University of Chicago for a state-of-the-art experimental procedure called minimally invasive surgery with thrombolysis in intracerebral hemorrhage evacuation, or MISTIE. In the procedure, a clot-busting drug, recombinant tissue plasminogen activator (rtPA), is used to thin the hematoma so it can be evacuated from the brain through a catheter. The University of Chicago Medicine is one of few hospitals nationally participating in the ongoing MISTIE clinical trial, funded by the National Institutes of Health.
Issam Awad, MD, professor of surgery and director of neurovascular surgery at the University of Chicago, knew the relatively young Pagone was a good candidate for the procedure. Awad is a pioneer in neurosurgery for stroke victims, having performed minimally invasive intracerebral hemorrhage surgery nearly 100 times (only a handful of neurosurgeons worldwide have done as many, Awad said). He conducted and published some of the earliest rigorous studies on the viability and safety of MISTIE and has been refining the MISTIE approach for more than 20 years.
The work has profound implications for those who suffer from intracerebral hemorrhage, which accounts for less than one-sixth of all strokes, but is responsible for half of all stroke-related deaths, disability and cost of care. Even after one year, nearly 60 percent of survivors completely depend on others for their daily activity.
Pagone was home one month after his stroke, having spent less than 2 weeks in hospital, and about two additional weeks in inpatient rehabilitation. He welcomed visitors at his front door with a firm handshake and a hearty greeting. He still receives rehabilitation therapy twice a week for speech and writing, but he has regained most of the movement he lost to paralysis and is expected to have minimal residual disability. He was able to attend his daughter Lauren’s Senior Day soccer game at De Paul University. "It just meant so much and it was so great he was able to walk with me on the field," Lauren Pagone said.
Open-brain surgery always has been an option for those who experience ICH, but traditionally has shown mixed success. Medical treatment, therefore, has focused on minimizing the bleeding and size of the hemorrhage, then letting it dissolve while placing the patient in rehabilitation to regain as much function as possible. Prior to the development of minimally invasive surgery, most intracerebral hemorrhage cases were considered to have a poor prognosis, Awad said.
"There was no effective treatment of intracerebral hemorrhage in the past because most of the treatment advances were for other types of stroke," Awad said. "We were doing what became the MISTIE procedure because it gave us a way out. Evacuation of the blood leads to quicker and greater recovery."
In addition to confirming MISTIE safety and effectiveness, neurosurgical teams are testing various ways to place the catheter that drains the blood and various doses of the clot-busting drug. Another refinement: Awad now can navigate the hemorrhage and adjacent tissue with precision using spatial guidance that works like a GPS on the brain’s topography. Once placed into a dime-sized hole in the skull, the catheter is positioned through the use of CT scan images of the patient’s brain taken just prior to the surgery.
Jan Pagone credits her husband’s recovery to Awad and to the neuro-critical team led by Fernando Goldenberg, MD, associate professor of neurology and surgery. Awad said swift action and the expertise of the medical team helped save Pagone’s life. "Optimal neuro-critical care is extremely important in preventing additional damage to the brain and secondary conditions such as pneumonia," Awad said.
Adds Goldenberg: "One of the characteristics of the University of Chicago Medicine -- and this is absolutely rare -- is the collegiality. It makes it very easy to relate to others and combine treatment, to decide amongst all of us what the best treatment is for each patient."
During rehabilitation, Pagone met another intracerebral hemorrhage patient. "He had no movement in his arm or leg," Pagone said. "He had had no surgery done; they just let it be. That really hit me. I thought, ‘Why is he not progressing?’ That could have been me."
The Pagones have no regrets. "If anyone asked me about the procedure, I’d say do it," Jan Pagone said. "I’d be the first to say it’s the next best step in intracerebral hemorrhage recovery. The team’s caring for our family was huge to me and I felt they catered to that. I won’t forget the care they gave us there. Every time we see Dr. Awad, I want to give him a hug."