In a Stroke Patient, Doctor Sees Power Of Brain to Recover

'Neurointensive' Care Gains Adherents, Despite Risk
Of Raising False Hopes 'Too Often, People Give Up'

By THOMAS M. BURTON

Devastating strokes on both sides of his head drove 31-year-old Mark Ragucci into a deep coma. As seizures swept through his brain like silent electrical storms, his gaze froze. His arms were paralyzed at his sides in a syndrome neurologists call man-in-the-barrel, signaling serious brain damage.

The most likely fate for the patient was death or survival in a state of near-total disability, concluded Stephan A. Mayer, director of neurointensive care at Columbia University's medical center. "I really thought there was no hope" of a meaningful recovery, recalls Dr. Mayer.

But the family of Dr. Ragucci, who had just started a career as a doctor before his stroke, wanted every possible effort made to spare his life. So Dr. Mayer and his colleagues aggressively treated Dr. Ragucci's pneumonia, septic infections and roller-coaster blood pressure. They also dramatically cooled his body and brain to protect brain tissue.

A month after his stroke, Dr. Ragucci had recovered somewhat physically, but not mentally. He was still officially in a vegetative state. Six weeks after the stroke his family transferred him to a rehabilitation facility, and that was the last Stephan Mayer saw of Mark Ragucci.

The last, that is, until the day nearly a year later, in late 2002, when Dr. Ragucci walked into Dr. Mayer's Columbia office and introduced himself. The former patient spoke in a monotone and his fingers were tightened into claws, but that was the extent of his disability. "When he walked in, I almost fell over," Dr. Mayer recalls. "It was at that point I realized that we knew absolutely nothing about the recuperative power of the brain."

Doctors often make minimal efforts to save the lives of advanced stroke victims, especially those who are days or weeks into a coma. They often see the prospects of survival as low and question the value of saving a life that they expect, in the best case, to be severely constrained by mental and physical damage.

Now proponents of neurointensive care are challenging these assumptions. They say many of the studies underlying the earlier consensus are out of date, and they believe newer treatments such as one designed to cool the brain may help stroke patients in comas. "Doctors are telling people there's no hope when, in fact, there is," says Dr. Mayer.

Dr. Ragucci, who is now at 35 back to practicing rehabilitation medicine, says he was somewhat conscious even when his doctors perceived no brain activity, and it bothered him to hear nurses and doctors referring to him in the past tense. "Somebody has to realize that you're in there," he says. "Just because you can't move doesn't mean there's not somebody in there."

The newer approach faces skeptics. Justin A. Zivin, a professor of neurosciences at the University of California, San Diego, says he is concerned that neurointensivists haven't yet proven many of the therapies they use on patients. He cites the common practice of inserting a pressure monitor into the brain and injecting salt water to draw off fluid if pressure seems too high.

"It would be extraordinarily helpful if they had evidence," he says. "Have they proven that these therapies are better than nothing? I'm not saying it won't ultimately be proven." Dr. Zivin says this is one reason many hospitals have yet to embrace the idea of a separate neurocritical care unit.

Dr. Mayer agrees that techniques such as monitoring and regulating pressure within the skull have yet to be proven in human trials. But he says, "We have to push the envelope and do things that at least are well-grounded in the scientific evidence that is available."

Aggressive treatment of stroke victims can have a serious downside. If a patient is kept alive for a few extra weeks in an intensive-care unit only to die at the end, the cost may be tens of thousands of dollars with no benefit. The American Stroke Association estimates that the annual U.S. cost of stroke care is $35 billion.

The treatment may raise unrealistic hopes in family members. Even if it saves patients from death, they may survive only in a state of severe disability or remain in a vegetative state, burdening family members for months or years. Many people eager to avoid being kept alive in such a condition have drafted documents designed to stop medical intervention as soon as a doctor decides brain recovery isn't possible.

Yet some neurointensive-care specialists now believe that many doctors are too quick to reach that conclusion and encourage families to abandon hope. "The fatalistic attitude toward treating brain disease is very prevalent -- and untrue. All too often, people give up," says Owen B. Samuels, chief of neurointensive care at Emory University. "We've all been humbled by the brain's ability to recover."

Some studies support the notion that medicine could be saving the lives of more stroke victims, especially those with hemorrhagic strokes that involve bleeding in or near the brain. A study of hemorrhagic stroke patients at Emory shows a higher percentage are becoming well enough to go home since the university opened a neurointensive care unit, says Dr. Samuels. However, the studies generally aren't clinical trials in which patients are divided randomly into groups prior to treatment to see what works best. Such trials often provide the evidence doctors trust most.

In a 2001 study of 87 patients in the journal Neurology, University of Washington researchers reported that nine of the 15 sickest hemorrhagic-stroke patients who got aggressive care survived despite severe bleeds and bad comas. Doctors stopped treating other patients with the same severity of condition -- and all of them died. "Practitioners tend to be overly pessimistic in prognosticating outcome," the authors wrote.

The authors also described the same cases to neurologists, without disclosing the outcomes, and asked how the doctors would have handled the cases. The authors found that as many as one-third to one-half of the surveyed doctors would have given up on patients who ended up alive six weeks later.

A 2004 study in the journal Stroke looked at 8,233 hemorrhagic stroke cases at 234 California hospitals, many of them comatose patients on ventilators. Some of the hospitals withdrew treatment frequently during the first 24 hours by issuing "do-not-resuscitate" orders. Other hospitals waited longer. After researchers adjusted for severity of illness, they found patients in the hospitals that waited longer to withdraw care had a better survival rate.

Being Realistic

Presumably the doctors who withdrew care more quickly thought they were being realistic and saving families anguish by hastening the inevitable. But these doctors were in fact sometimes giving up too soon, says J. Claude Hemphill III, the researcher at the University of California, San Francisco, who headed the study.

A 2001 study in Critical Care Medicine by Michael N. Diringer and Dorothy F. Edwards of Washington University in St. Louis studied records of more than 40,000 patients with bleeding in their brains. Patients in a regular intensive-care unit were 3.4 times as likely to die as patients in a neurointensive unit, after adjusting for the severity of the bleeding, the study found.

At Columbia, Dr. Mayer's own career offers an example of how thinking has changed. Now 43 years old, he took charge of the neurointensive program there in 1994. In his first years, he says, he encouraged the unit to be more aggressive about recommending that families remove ventilator tubes when their loved ones lingered in a coma. Dr. Mayer thought that was the kinder approach. Of neurocritical patients who died at Columbia in 1996, about 50% had ventilator support withdrawn, up from 8% in 1994, he says.

Continued ...

Thanks, Michelle!  Very interesting.  I'm going to give a copy to my neurologist!

Take care,
Shan

p.s.  How's Shane?  Please tell him we're still thinking of him...