A New Era for Brain Care

When Dr. John Greenfield joined the UConn Health Department of Neurology in 2016, the treatment options for acute stroke were limited.  UConn could provide a clot-busting drug to appropriate patients, but did not have treatments to offer if you arrived more than a few hours after your stroke or had bleeding into the brain. Now, the UConn stroke team includes interventionalists who guide catheter tubes into brain arteries to pull out blood clots, and neurointensivists who manage severe brain hemorrhages. Patients can get state-of-the-art care right in their own backyard.

Neurologists treat an enormous variety of diseases of the brain, nerves, and muscles.  Stroke, Parkinson’s disease, epilepsy, and multiple sclerosis are all very different, and each of these conditions is best managed by a neurologist with advanced training in that specific area. UConn Health has developed programs directed by subspecialty-trained experts to treat all of these diseases and more.

“When I went into neurology 30 years ago, it had an undeserved reputation as a field where you could diagnose a huge variety of diseases and not treat any of them,” said Greenfield, who is an expert in epilepsy and chair of neurology at UConn Health. “The tag line was ‘diagnose and adios.’ Now, we have effective treatments for almost all of these conditions. It’s an exciting time to be a neurologist, with the tremendous advances in our understanding of the brain and its diseases. We have so many more treatments than we had 20 or 30 years ago.”

Greenfield outlined the growth of neurology services at UConn Health in a recent interview.

Q. Can you say more about the stroke program?

A. It started in 2013 after we recruited Dr. Sanjay Mittal from Geisinger. He had built the stroke program there and knew how to bring together the people and resources at UConn to make it work like a well-oiled machine. We have improved over the years how quickly patients get access to clot-busting drugs. This year, we received the American Heart Association’s “Get with the Guidelines” award for excellence in stroke care. That means that most patients who come in with acute stroke get tPA (tissue plasminogen activator, the clot-busting drug) within 60 minutes of arrival.  Being fast is important, since the longer you wait before treating a stroke, the more brain cells you are losing. Getting the award means that the system of stroke care works really well, since a lot of things have to happen quickly. We’re also certified by The Joint Commission (a patient safety organization) as a Primary Stroke Center, which means we meet their criteria for providing high-quality stroke care.  We now have a great reputation, and the ambulance services and EMTs know that patients will do best if they are treated at a hospital like ours, so the number of stroke patients we see goes up every year.  Stroke is the fifth leading cause of death in the country.  We see strokes in patients of all ages, but the norm is people in their 50s through 80s and higher. We have given tPA to people in their 90s, and they do quite well.

Q:  What happens when a stroke patient arrives at UConn?

A. First, patients have a CT scan to make sure there is no hemorrhage. We find out when the symptoms came on, and if there are any contraindications, like if the patient has had surgery recently or is on a blood-thinning drug. The tPA is an enzyme that basically chews up blood clots.  If you don’t give it early enough, the part of the brain affected by the clot can’t be saved, and there’s also a risk that tPA can cause a hemorrhage.  We have a window of 4½ hours from when the patient was last seen well. We get a CT angiogram to image the arteries in the neck and brain to see if there is a clot blocking the flow. There is also CT perfusion scan that looks at blood flow to the brain.  Dye is injected into the blood stream to image the blood vessels and how quickly blood gets into the brain.  We use an artificial intelligence software called RAPID/AI that can help us interpret the blood flow in the brain to see if the patient is a candidate for intervention. The software analyzes the flow and color-codes how long it takes the blood to get there. Green is the savable area that gets blood late but is still alive, and red is the dead area where there is no blood flow, that won’t survive. If the green area that shows brain that can be saved is big enough, and there is a clot that is reachable with a catheter tube, we call the thrombectomy team to remove the clot.  Thrombectomy is effective in saving the brain as long as 24 hours after the onset of a stroke, so even patients who arrive too late for tPA may still be able to get thrombectomy.  We’ve seen some pretty dramatic results.  Patients who had a clot in a brain area that commonly causes severe paralysis or death have walked out of the hospital.

Q: What happens next?

A. Once the patient gets the tPA or thrombectomy, they’re watched closely in the intensive care unit to be sure they don’t have a hemorrhage as a result. After 24 hours, they go to an intermediate care unit.  We do an intense workup to figure out why the stroke happened so we can prevent another stroke from happening in the future. Everybody gets a brain MRI to show exactly what part of the brain was damaged by the stroke.

We help patients manage the known risk factors like high cholesterol and smoking. We start them on a medication to prevent new strokes from happening, either low-dose aspirin or another platelet inhibitor or a blood thinner. People with AFib (atrial fibrillation) are prone to forming clots in the heart and do much better on anti-coagulation. We do an echocardiogram to be sure there is no blood clot in the heart. Sometimes we send patients home with a loop monitor to record the heart rhythm for up to a month. The longer you monitor the heart rhythm, the more often you pick up AFib.

Q: Are there any new developments in the treatment of multiple sclerosis?

A. MS is a less common disease, but it has a huge effect on patients’ lives since it often strikes when they are young adults.  It’s an autoimmune disease, which means the patient’s own immune system is attacking the nerve fibers in the brain. The attacks can cause loss of vision in one eye, or double vision, or weakness or numbness in the arms or legs.  The symptoms usually get better after a few weeks, at least early on, but later the symptoms persist and the patient gets progressively worse.  If you look at brain MRI images, you can see little plaques in the white matter of the brain. MS attacks the myelin coating of the nerve fibers and slows down neurotransmission. In the early stages, the attacks are limited. As the disease progresses, you lose different areas of function. There can be weakness, spasticity, or inability to walk. When I was doing my neurology residency training in the early 1990s, nothing was available to treat MS.

Now, there are a lot of drugs that actually prevent MS attacks. One of the newest is ocrelizumab, an antibody treatment given as an infusion every six months. It costs about $65,000 a year, and fortunately, is covered by most health insurance including Medicaid.

Q: And you have specialists who treat MS?

A. We have a great MS program led by a physician-scientist, Dr. Jaime Imitola. He is doing basic science research into the causes of MS by studying stem cells in the spinal fluid of MS patients.  Dr. Imitola is involved in patient advocacy and the National MS Society.  He helped create the guidelines for COVID vaccination for MS patients.  He recently received the 2020 Inspiration Award from the National MS Society.   We also have an amazing nurse practitioner for MS, Marina Creed.  She received the 2021 UConn Nightingale Award for excellence in nursing.

Q. Movement disorders are another major area of neurology. Any new developments here?

A. Movement disorders are conditions where people either have too much movement, like tremors, tics, or chorea (quick random movements) or too little movement, like dystonia, where certain muscles become stiff.  One of the most common movement disorders is Parkinson’s disease, where people have slowed movement, tremors, stiffness, and balance problems.  More than half the patients in our Movement Disorders Program have Parkinson’s disease.  Since it affects a lot of the activities of daily living, it can be a big challenge for patients and their families to deal with.  We have a new program for this called Supportive Care and Planning, which is spearheaded by the Director of the Movement Disorders program, Dr. Bernardo Rodrigues, and an advanced practice nurse, Elaine Cournean.  This program helps patients and their families meet the challenges of the disease so they can achieve their best quality of life.

Q:  I heard that UConn is developing a program for normal pressure hydrocephalus. Can you tell us about that?

A. Some of the patients referred to our Movement Disorders Center for symptoms of Parkinson’s Disease don’t actually have Parkinson’s.  When we look at their brain MRI, the cerebral ventricles (fluid-filled cavities in their brains) are enlarged. This suggests a condition called normal pressure hydrocephalus or NPH. The fluid is not being reabsorbed normally and causes pressure on the brain that can cause difficulty in walking, slowed thinking, and bladder incontinence. NPH can be treated surgically by inserting a tube into the lateral ventricle that drains the excess fluid continually into the abdomen where it can be reabsorbed. That’s called a ventriculoperitoneal (VP) shunt.  Removing the fluid can quickly reverse the symptoms in appropriate patients. But before sending the patient to the neurosurgeon, we need to identify who is going to get better.  As a test, we do a lumbar puncture, take out a fairly large volume of fluid and determine whether they are better in thinking and walking after the spinal tap. We are starting a new program to do this assessment, led by Dr. Neha Prakash.  She coordinates a multidisciplinary evaluation over a single day.  She has recruited neuropsychologists and physical therapists to test these patients before and after the spinal tap, so she can make the best prediction of who is going to get better. It’s a great example of how we can pull together all of the expertise available at UConn to provide the best care for  our patients.

Alix Boyle’s work has appeared in a variety of publications, including The New York Times and Bloomberg News. She lives on the Connecticut shoreline with her husband, Josh, and Helen of Troy, a pug who rules their home.

Photography courtesy of UConn Health