New Wave
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
Staff Reporter of THE WALL STREET JOURNAL
November 23, 2005; Page A1

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.
[Stephan Mayer]

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consensus are out of date, and they believe newer treatments such as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.
[U. S. Stroke Facts]

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.

Questioning His Policy

One by one, however, patients led Dr. Mayer to question his own
policy. An 80-year-old patient from Harlem who became comatose
following the rupture of a swollen artery, or aneurysm, in his brain
survived after Dr. Mayer and colleagues treated him by putting metal
coils in the artery to cause clotting and stop bleeding.

This contradicted a 1968 study that was considered definitive in the
field. It concluded that death was virtually inevitable when a patient
with such a ruptured artery arrived in a coma. Dr. Mayer and his
colleagues began making it a regular practice to treat such patients
and found that about half survived, though many still had
disabilities. When he examined statistics for all bleeding strokes
caused by aneurysms -- including cases where the patient wasn't in a
coma -- Dr. Mayer found a survival rate of 80% in his clinic, compared
with 65% in the 1968 study.

The case that most altered Dr. Mayer's thinking was that of Mark
Ragucci. On Dec. 3, 2001, Dr. Ragucci underwent surgery to repair an
aneurysm in his aorta, the body's largest artery. Following surgery,
for reasons no one has determined, Dr. Ragucci's heart stopped. For 24
minutes, blood wasn't getting to his brain -- well beyond the time
that doctors usually say brain function can survive.

Due to the halted blood flow, he suffered three massive strokes on
both sides of his brain. His brain started to suffer seizures --
electrical storms that interrupt the brain's normal signaling and
sometimes lead to permanent injury.

He lay in a coma for days in the intensive-care unit of another New
York City hospital. His wife, Laura, and mother became convinced that
doctors there were resigned to his death. The family did some research
and resolved to transfer him to the neurointensive-care unit at the
Columbia hospital, which is officially known as New York-Presbyterian
Hospital/Columbia University Medical Center.

There, Dr. Mayer deemed the patient to be nearly hopeless. Strike one
was the 24 minutes of cardiac and circulatory arrest. The seizures
were strike two. Strike three was the total paralysis of Dr. Ragucci's
arms. "I was taught it is exceedingly rare for someone to recover on
any level from man-in-the-barrel syndrome," says Dr. Mayer. "I had no
expectation at all that we could help."

Dr. Mayer was frank in his first conversation with Mark's wife and
family. In Mark's type of case, even if he survived, "maybe 5% of such
patients could follow commands after one year," Dr. Mayer recalls
telling them.

The family was stunned. Dr. Mayer "basically told me we should be
looking at nursing homes," recalls Laura. Mark's mother lashed out at
Dr. Mayer after hearing him estimate percentages. "Let's get something
straight right now," Mrs. Ragucci recalls telling the doctor. "If it's
something that you don't know for sure, keep it to yourself."

The night of Dr. Ragucci's arrival -- 17 days into the coma -- the
neurointensive team began clearing out his lungs. "He was very sick
with pneumonia," says his mother. Then doctors gave him antibiotics
for septic infection and intravenous drugs called vasopressors to
control his blood pressure.

At the same time, the team set about saving his brain -- the main
mission of any neurointensive treatment. "It's a full-court press,
guns blazing, pedal-to-the-metal," says Dr. Mayer. Without such an
effort, a ventilator to keep a coma patient alive "is a
vegetable-producing machine," he says.

Mark Ragucci's case was one of the first in which Columbia doctors
used a device called the Arctic Sun. It uses gel-lined pads filled
with cold water to cool the patient's blood and brain.

"We've learned that when these patients become febrile, they go into a
deeper coma level," says Dr. Mayer. "They develop something called
central fever, but until about 1998, we had nothing to really cool
people effectively." Doctors often simultaneously use a device called
the Bair Hugger -- blankets that blow hot air on the patient's feet
and legs -- to trick the body into not shivering despite the cooled blood.

Dr. Mayer concedes that some of his techniques, including the use of
sodium solution to relieve pressure, remain unproven. "We're in 'Deep
Space Nine' here," he tells medical residents.

For a while Dr. Ragucci remained in a deep, unchanging coma. Doctors
squeezed his toes hard, shone flashlights into his eyes and talked
loudly in front of him -- all with no apparent response. But by the
end of his stay at Columbia, he had begun to show faint flickers of
emerging from the coma. Dr. Mayer recalls that his patient said two
words at one point, then lapsed back into seeming unawareness.

By then, more than five weeks after Dr. Ragucci entered a coma, Dr.
Mayer and his team had done all they could. Dr. Ragucci was no longer
facing death or suffering brain seizures. He was transferred to a
general neurology floor at Columbia.

Over the following weeks -- first at Columbia, then at New York
University's Rusk Institute of Rehabilitation Medicine and finally at
his parents' house -- Dr. Ragucci slowly regained consciousness.

With the help of his family, he began a program of intense physical
rehabilitation. He worked 12 hours a day with a therapist, squeezing
beanbags, working with pulleys, relearning how to use his arms. In
time, he regained enough physical ability to go to the gym and use
stair machines, often rising at 4:00 a.m. to do so.

Mysteries of the Case

Why Dr. Ragucci recovered consciousness and how much the care in Dr.
Mayer's unit contributed to his comeback remain central mysteries of
the case. Possibly the damage from the original strokes and 24 minutes
of heart stoppage was not as great as feared and, in hindsight, Dr.
Ragucci's return to consciousness shouldn't have been so unexpected.

Dr. Mayer believes the care was crucial and the case reinforced his
belief that neurointensive treatment can save lives. "Mark's great
recovery reflects the brain's innate resilience and ability to
recover, which I believe has been vastly underestimated to date," says
Dr. Mayer. "It has been underestimated because we never saw any
long-term outcomes, because we have always let them die assuming the
outcome would be terrible."

Dr. Ragucci remembers the painful squeezing of his toe during what
doctors thought was a deep coma. "My toe hurt a lot and I tried to
say, 'Stop it.' I thought I mouthed the words." It bothered him that
he could hear one of the doctors remarking, "He's in a persistent
vegetative state."

The greatest milestone in his recovery came in August 2003 when Dr.
Ragucci resumed his work as a rehab doctor. He works at Bellevue
Hospital Center and NYU, where he had been a patient. Today, Dr.
Ragucci often works with patients who have regained consciousness but
have far to go toward recovery, and he shares with them his own
comeback story.

"Even though I'm a rehab physician, I didn't know how hard these
things were," he says. "I thought I was an empathetic person before,
but now I know I am."

Write to Thomas M. Burton at tom.burton@...