Laser Photo Therapy May Save Brain Cells After Stroke - @ JEMS.com


Laser Photo Therapy May Save Brain Cells After Stroke


 
 

John Fauber | | Tuesday, January 22, 2008


MILWAUKEE -- It was 4 a.m. on a snowy Christmas Eve as Linda Quire lay in her hospital room with her head shaved.

She and a doctor wore special goggles to protect their eyes as the physician aimed an experimental laser device through her scalp and skull into her brain.

Quire's treatment at the University of Wisconsin Hospital in Madison last month was part of a clinical trial to test a novel method for protecting brain cells hours after a stroke. Doctors say such therapies are desperately needed because most stroke victims don't get to a hospital soon enough.

As the device beeped every second, Quire dozed off, tired from the 24-hour medical ordeal that had landed her at UW Hospital.

Nearly a day earlier, Quire, 54, had been in the kitchen of her home in Browntown, about 45 miles south of Madison. As she stood at the sink, her right arm suddenly felt like it was floating. Her face drooped.

Emergency medical personnel quickly arrived and took her to Monroe Hospital, a few minutes away. As tests were being done, her symptoms subsided, and doctors decided she would spend the night there.

"But then I started to get worse," she said. "I couldn't remember, and it was harder to speak."

Now doctors needed to quickly get her to UW Hospital. The drive in the snow took nearly an hour and a half. The snow also would slow Justin Sattin, the University of Wisconsin neurologist who was called in the middle of the night.

"My car was snowed in, so I took the bus to the hospital," said Sattin, medical director of the UW Hospital stroke program.

When Quire arrived in Madison, she was long past the therapeutic window for t-PA, the only approved clot-busting drug, which usually must be administered within three hours of the onset of symptoms.

Because most patients don't recognize they are having a stroke early enough and because some hospitals still don't offer t-PA, the vast majority of people who have strokes don't get the drug, said Harold Adams, a professor of medicine and director of the stroke program at the University of Iowa.

As the night wore on into the early morning, doctors talked to Quire and her family about one last experimental option: a near-infrared laser that could penetrate into her brain and activate a substance inside her brain cells.

The University of Wisconsin is one of several sites around the country testing the treatment. Nationally, researchers hope to treat 660 stroke patients. So far, UW, the only hospital in Wisconsin offering the treatment, has treated five people. The trial is being funded by PhotoThera Inc., the Carlsbad, Calif., company that makes the device.

"This [the laser treatment] would be a new type of protection," said Adams, who is not a part of the study. "It's kind of unorthodox."

If further testing shows it is effective, it could substantially extend the window of treatment, he said.

For Quire, the laser would be too late for the brain cells that already had died, but in the blood-starved area surrounding the clot, untold numbers of neurons likely were in danger of dying and in dire need of nutrition.

During a typical stroke, tens of millions of neurons die every hour. In Quire's case, the laser might be able to save them and, in doing so, preserve valuable brain function for her.

"The dying brain is a process," Sattin said. "It doesn't happen instantly."

Quire's stroke was moderate in size and occurred on the left side of her brain, he said.

As part of the protocol of the study, Sattin used a hand-held device that looks like a hair dryer to deliver two minutes of laser light to each of 20 silver-dollar-sized spots all over her head.

"It [the laser] does, in fact, get into the brain, he said. "Once it's in the brain, the million-dollar question is what does it do?"

In neurology, doctors refer to this stressed but still viable region of brain tissue as the penumbra, an allusion to an astronomy term for the gray, partial shadow that forms between complete darkness and complete illumination during an eclipse.

To prevent Quire's penumbra from going over to the dark side, two things had to occur.

First, the laser treatment would have to work. Although animal studies and limited human research suggest it might be effective, the treatment still is in the experimental stage and its value has yet to be proved.

Second, Quire would have to get the actual laser treatment. Under the protocol of the clinical trial, half the patients get the treatment and half get a sham treatment. Neither the doctor nor the patients know who is getting treated.

Essentially, Quire had a 50-50 chance of receiving an iffy treatment. Still, there is reason to believe the laser treatment, which can be given up to 24 hours after the onset of symptoms, might be beneficial.

An earlier trial involving 120 patients found that 70 percent who got the laser treatment had a successful outcome, such as complete recovery from their stroke, compared with 51 percent for those who got a sham treatment.

"The prospects are very good," said Harry Whelan, a neurologist who practices at Children's Hospital of Wisconsin and Froedtert Hospital.

Whelan, who has done extensive research on so-called photo therapy, said that when infrared laser light reaches brain cells, it improves energy metabolism in those cells, which can be starved of glucose and other energy sources when the blood supply is inhibited. The laser light activates an enzyme that controls production of an energy source known as ATP.

For Quire, it could be another year before the study is unblinded and she learns whether she got the laser treatment or the sham. However, she said she has recovered extremely well from the stroke after initially having some problems with language.


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