jerusalem | Most people over 40 probably know at least some signs of a heart attack, even though these may be somewhat different in men and women. But how many can identify the initial symptoms of a “brain attack” or stroke, which is no less deadly? Probably not many.
Go immediately to a hospital emergency room if you or anyone you know displays even one of these symptoms: sudden numbness or weakness in the face, an arm or leg (especially on one side of the body); sudden confusion, difficulty in speaking or understanding; difficulty in expressing or comprehending words; slurring; sudden trouble seeing through one or both eyes or double vision; unexpected trouble walking, dizziness, loss of balance or coordination; an abrupt, severe headache with no known cause or a sudden decline in consciousness. A false alarm is better than delaying or not going at all.
Until a decade ago, if a person was having a brain attack, there wasn’t much doctors could do to reverse damage or prevent disability and death.
“Stroke patients were given tender loving care, or oxygen and a drink of water, but nothing else,” recalls Dr. Jos Cohen, neurosurgeon and interventional neuroradiologist at Hadassah University Medical Center in Jerusalem’s Ein Kerem. But new drugs and technologies, he told The Jerusalem Post, have dramatically changed this. Since there is a limited “window of opportunity” — about six hours after the appearance of these initial symptoms before damage becomes irreversible — prompt treatment is of the utmost importance.
Cohen, 38, was born and trained as a physician in Rosario, and subsequently specialized in Buenos Aires before coming on aliyah nearly four years ago to work at Hadassah. His stroke unit keeps him on call 24 hours a day, 365 days a year. Cohen was home last April when Rahel, a 47-year-old Jerusalem mother of six who helps run a day center for Alzheimer’s patients, was attending a party in Mevaseret Zion and suddenly felt a terrible, piercing headache.
“I was told to sit down and relax, but I felt a pain in my neck and couldn’t move it from side to side. I felt nauseous,” she recalls. “Some guests said to call Magen David Adom, others said my health fund wouldn’t cover the ambulance if it was nothing. I decided to go to the emergency room at Shaare Zedek Medical Center because the day center where I work is there. At the emergency room, the doctor initially said I had a migraine, but my sister, who knew something about migraines, said that couldn’t be, as looking at light didn’t bother me. Emergency room doctors quickly performed a CT scan and realized I was having a stroke. Since the hospital doesn’t have a neurosurgery department, they rushed me to Hadassah in Ein Kerem. I was vomiting and felt terrible. I just wanted to sleep. I don’t remember anything after that.”
Alerted by the emergency room, Cohen arrived quickly. Tests showed that Rahel had suffered an acute ischemic stroke that required delivery of thrombolytic (clot-busting) therapy via angiography to a vital artery in her brain. Subsequently she also underwent surgery.
“I was there until April 28. I feel like new. I am absolutely normal, with no disability,” Rahel says in amazement. “I thank God, and Dr. Cohen, who was His emissary! He is an angel.”
Asked what advice she has for someone who develops similar symptoms, Rahel says without hesitation: “Don’t take an aspirin and go to sleep. That’s what a woman in the ward next to me did, and she is now seriously paralyzed.”
“I regard myself as a simple plumber, clearing up clogs,” Cohen says with sincere modesty. But colleagues say he “drags people back from the edge of their graves.”
The brain, he explains, weighs only 3 pounds but demands 20 percent of all cardiac output, much more than the heart muscle itself. The brain can’t store oxygen; after four or five minutes without it, parts begin to die.
There are 12,000 to 14,000 brain attacks in Israel and 400,000 to 500,000 in the U.S. each year, making it the third most common cause of death, and the major cause of physical disability.
There are risk factors you can avoid.
“If you don’t smoke, you significantly lower your risk of brain and heart attacks,” says Cohen. People who suffer from high blood pressure, diabetes or high cholesterol are at high risk, but if they control these conditions with exercise, a weight-loss diet and drugs, the risk drops greatly.
There are two types of strokes, Cohen continues: the ischemic type, in which a clot blocks a blood vessel and starves the brain of oxygen, comprises 80 percent of all brain attacks; and cerebral hemorrhages, half of them due to aneurysms (an “explosion” of a brain artery), comprise the other 20 percent. Obviously, neurosurgeons must know which type of stroke is involved, since using clot-busting thrombolytics when there is a hemorrhage would be catastrophic, while giving drugs to stop hemorrhaging in a patient with ischemic stroke could kill him. A CT scan — neither an X-ray nor an ultrasound — is performed immediately to determine which type of stroke is involved.
“Eventually, we hope CT scanners will become miniaturized and cheap enough to put in ambulances to scan patients en route to the hospital.”
An MRI (magnetic resonance imaging) scan may be performed as well to get an image of the penumbra, a broad area surrounding the initial site of the stroke. Cohen says that careful selection of patients suitable for this intervention is a key to successful treatment.
Just two weeks ago, Cohen and his multidisciplinary team of 20 physicians, nurses, computer experts, technicians and others inaugurated Hadassah’s $3 million brain angiography room, donated by Judy and Sidney Swartz. The room is believed to be the most advanced facility of its kind in the country, and its staff the most experienced.
When a stroke is considered appropriate for clot-busting treatment, a tiny catheter with a wire thinner than a human hair is pushed through the femoral artery in the groin, past the heart and through the carotid artery into the brain. In an extremely delicate procedure, a drug called urokinase is delivered directly to the site of the clot to dissolve it and restore blood flow. This technique, says Cohen, was first carried out by Prof. Raoul Carrea of Buenos Aires in 1996.
“It was the first carotid treatment in a stroke victim. The U.S. Institute for Neurological Disorders later published the results of a study which proved that the intravenous administration of anti-thrombolytics can benefit stroke patients.”
The neurosurgeon, whose parents are accountants and whose siblings are dentists, says his surgeon uncle, Prof. Adolpho Rajz, influenced him — Rajz urged him to get involved in a field where patients can benefit dramatically.
“He died, but I thank him every day.”
Sent by his parents to the Bialik School, where he learned excellent Hebrew and got a Zionist education, Cohen was “ready for plucking” by Israel when he encountered Felix Umansky, Hadassah’s Argentinean-born director of neurosurgery, at a medical conference in Brazil. Umansky, a native Argentinean himself, heard one of Cohen’s lectures about treating acute strokes, and invited him to open such a service in Jerusalem. It took only a few months before Cohen agreed to come.
The Hadassah medical organization has taken a strategic decision to invest in treatment of stroke from its director-general Prof. Shlomo Mor-Yosef, through colleagues in the neurosurgery and neurology departments. “This is a very small country, and unlike the U.S. or even Britain, almost anybody can reach Hadassah within two hours, if not by driving, then by helicopter.”
Cohen declares that Hadassah never turns away a stroke patient suitable for this expensive treatment, even though it is not yet covered by the health funds. At present, Cohen and his team treat six or seven patients a week.
Other hospitals, including Rambam in Haifa, have recently started to offer clot-busting treatment, but the Hadassah team says the most experience and most advanced equipment are in Jerusalem. The minimally invasive approach to managing complex cerebrovascular disorders has made enormous progress over the past two decades. This is mainly due to technological advances in imaging, which include MRI, magnetic resonance angiography, computed tomography, ultrasonography, transcranial doppler and high-resolution rapid sequence digital substraction angiography. There are also better catheters, liquid adhesives and refined techniques that have improved safety.
It takes many years for a doctor to become a neurosurgeon; becoming an expert in this sub-specialty takes many additional years, exquisite technical skill and a profound understanding of neuroscience. Cohen trains doctors who come to learn from him, and welcomes the opportunity to spread his knowledge.
He is also conducting studies on neuroprotective agents: When a stroke occurs and brain tissue begins to die, it releases harmful chemicals that further injure the brain. Experimental drugs being tested at Hadassah and abroad are aimed at protecting nearby brain cells from these toxic byproducts.
“It would be wonderful if we could use these drugs to freeze the damage and keep the brain steady for many more hours, and not just the few hours after initial symptoms appear,” he adds.
Aside from treating strokes, Cohen has also used multiple soft platinum coils inserted by a tiny catheter to stop bleeding inside torn blood vessels. One dramatic case involved an Israeli soldier from an elite unit shot by terrorists near Bethlehem last year while in pursuit of the head of the local Hamas military wing. He arrived at Hadassah in critical condition with blood pouring from his mouth.
A CT scan showed metal fragments scattered through his mouth and neck, where the vertebral artery had been destroyed. In the neurovascular angiography suite, the first priority was to seal the ruined artery, but this could not be done surgically. Cohen’s team inserted one endovascular coil after another through the femoral artery in his leg and guided them up to the damaged vessel. In all, they inserted 16 coils (each costing $1,000) before the hemorrhaging stopped.
The soldier, whose wife was pregnant at the time, has recovered completely.