When Stroke Strikes

LIfesaving Procedure: Dr. Sung Lee, Northeast Georgia Medical Center’s medical director of neurointerventional surgery, operated on Beth Lisk when she suffered a stroke in 2021. Photo credit: Daemon Baizan

It was the middle of the night in February 2021 when 56-year-old pharmacy technician Beth Lisk awoke with a sharp, sudden headache. Thinking it might be her first migraine, she took over-the-counter medication and waited for it to pass. But it didn’t.

The pain persisted for five days. Lisk ran through a mental checklist: Was it COVID-19? Allergies? Despite her medical background, she had no idea she was experiencing the early signs of a life-threatening brain bleed caused by a ruptured aneurysm.

At the time, COVID-19 was surging, complicating ER visits and even family doctor appointments. But when her symptoms escalated to profuse sweating and a racing heart, her husband called 911. It was a decision that would save her life.

“I really didn’t think it was anything serious at first,” she recalls. “Stroke was the last thing on my mind.”

Georgia’s Stroke Burden

Though their details vary, stories like Lisk’s are far from rare. Georgia – often called the buckle of the “Stroke Belt” – has one of the highest rates of stroke and stroke-related death in the nation.

Yet stroke care in Georgia has advanced dramatically. Cutting-edge treatments, telehealth and hospital partnerships are making expert care more accessible across the state.

For Lisk, who lives in Buford, the 911 call led to her being taken to Northeast Georgia Medical Center Braselton. Once her stroke was confirmed and the type identified, she was transferred to NGMC Gainesville, a comprehensive stroke center equipped for complex cases. There, Dr. Sung Lee, NGMC’s medical director of neurointerventional surgery, performed a lifesaving procedure.

“While I was under anesthesia, they threaded a catheter through my wrist to the base of my brain and placed a platinum coil inside the aneurysm to stop the bleeding,” Lisk says. “Dr. Lee later explained it like plugging a pothole. You put the coil in the damaged area so the blood flows over it as if it were a normal artery. Eventually, it seals in.”

The Need for Speed

Every Second Counts: Dr. Michael R. Frankel, chief of neurology and director of the Marcus Stroke and Neuroscience Center at Grady Memorial Hospital. Photo credit: Grady Health System

Hemorrhagic stroke, like the one Lisk had, occurs when a blood vessel ruptures – often due to high blood pressure – causing bleeding in or around the brain. Ischemic stroke, the more common type, happens when a blood vessel in the brain becomes blocked, usually by a clot that travels from another part of the body.

Regardless of type, stroke is a medical emergency where every second counts. “In ischemic stroke, every minute 2 million neurons die when the brain is deprived of oxygen,” says Dr. Michael R. Frankel, chief of neurology and director of the Marcus Stroke and Neuroscience Center at Grady Memorial Hospital. In hemorrhagic stroke, bleeding can increase pressure in the brain, damaging tissue. Swelling can worsen this pressure and harm areas not initially affected.

Prompt treatment is critical – but only after the stroke type is correctly diagnosed. For ischemic strokes, the first line of treatment is usually the clot-busting drug tenecteplase (TNK), which could be dangerous – or even deadly – if given to someone with a hemorrhagic stroke.

Better Outcomes: Dr. Phillip Amodeo, stroke program medical director for Southeast Georgia Health System. Photo credit: Frank Fortune

“With regard to giving clot-busting medication, the sooner you give it to somebody the better,” says Dr. Phillip Amodeo, stroke program medical director for Southeast Georgia Health System. “The first thing you need to know when a patient comes in with a stroke is to make sure it is not the bleeding kind of stroke. Those are the ones you don’t want to be giving the clot-busting therapy to.”

Coordinating a Fast Response

Across Georgia, hospitals, ambulances and EMT services work together to speed up stroke evaluation. Assessment begins the moment EMTs arrive. If a stroke is suspected, they alert the nearest appropriate hospital.

“If it’s in our county or we’re the closest hospital, they’ll contact our ER and notify our team that a patient is incoming,” says Dr. Fadi Nahab, stroke quality director for Emory Healthcare. “At that point we activate what we call a stroke alert, which mobilizes our team so they’re ready when the patient arrives.”

At Georgia’s nine comprehensive stroke centers – including those at Emory, Grady, NGMC Gainesville and Piedmont Hospital in Atlanta – stroke specialists and advanced treatments are available on-site. Patients at smaller hospitals can access expert care via telehealth and be transferred if necessary.

The Piedmont Health System, with 26 hospitals from Dalton to Augusta and as far south as Macon and Columbus, is a prime example of statewide coordination.

“In ischemic stroke, every minute 2 million neurons die when the brain is deprived of oxygen.” – Dr. Michael R. Frankel, chief of neurology and director of the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital

Novel Treatments: Dr. Fadi Nahab, stroke quality director for Emory Healthcare. Photo credit: Daemon Baizan

“All of our Piedmont hospitals have imaging, AI and communication capabilities that connect the entire system,” says Dr. Michael Stiefel, medical director of the Comprehensive Stroke Center at Piedmont Atlanta and Piedmont’s stroke program. Patients at smaller hospitals such as Piedmont Mountainside Hospital in Jasper and Mountainside Emergency Room in Ellijay are triaged the same way as those at larger centers.

“All of our hospitals have either on-site neurologists or telestroke capability,” he says. “So there’s a specialist either in person or via video able to assess patients.” Doctors across the system can also review imaging from any Piedmont facility. “Although I practice primarily at Piedmont Atlanta, I can look at imaging from any Piedmont hospital,” says Stiefel. “If they call me, I function as if I’m on staff there, just as I would if an ER physician called me from Piedmont Atlanta.”

This system, like other hospital collaborations across the state, allows many patients to receive treatment close to home or to be transferred to Atlanta for advanced procedures when needed.

New Treatments for Clots

“Dr. Lee later explained it like plugging a pothole. You put the coil in the damaged area so the blood flows over it as if it were a normal artery. Eventually, it seals in.” – Beth Lisk,stroke patient

The treatment Lisk got – called vascular embolization – is just one of many now available.

The first of these became available in 1996 when tissue plasminogen activator (tPA), a drug used to dissolve blood clots, was approved by the FDA for acute ischemic stroke. Earlier this year – nearly 30 years later – the FDA approved tenecteplase (TNKase), another form of tPA, for treating acute ischemic stroke in adults. Unlike tPA, which requires a one-hour IV infusion, TNKase is delivered in a single injection, making it simpler and faster to use. “There’s been so much evidence that it’s easier to use – maybe even in some circumstances the outcomes are better,” says Amodeo. “So we switched over to it, and most facilities have gone to it.”

Some hemorrhagic strokes are small enough to be managed with medications that control blood pressure and prevent further bleeding, Amodeo adds.

For strokes requiring more than medical therapy, minimally invasive procedures make it possible to reach blood vessels in the brain without opening the skull. In ischemic strokes, mechanical thrombectomy, a technique similar to the treatment for heart attacks, uses X-ray-guided catheters to remove blockages in the brain. “Removing the clot physically has significant benefit,” says Lee. “Not all patients who have strokes will have a large vessel occlusion, but for those who do … being in a comprehensive stroke center, or facility that’s able to do mechanical thrombectomy, can be a significant improvement in their recovery.”

For hemorrhagic stroke, minimally invasive techniques may be used to fill a ruptured vessel – as was done for Lisk – or to clip it and stop the bleeding.

A surgical approach known as minimally invasive parafascicular surgery (MIPS), refined by Dr. Gustavo Pradilla, chief of neurosurgery at Grady, adapts the technique used for brain tumor procedures to remove clots caused by ruptured vessels in the brain. “So, if an artery ruptures and you can’t move your right side, you can’t speak, or you can’t move your left side, and on CT scan we see a walnut- or plum-sized hemorrhage pushing on vital structures and causing paralysis – typically on one side of the body – we found that removing that, particularly if it is more superficial, is effective,” Frankel says.

Restoring Function: Dr. Dan-Victor Giurgiutiu, interventional neurologist, assistant professor at Augusta University, Medical College of Georgia Department of Neurology. Photo credit: Augusta University MCG

As researchers refine these techniques – using smaller instruments, optimizing timing and studying their use in different brain regions – others are focused on improving diagnosis and recovery.

At Morehouse School of Medicine and Grady, researchers are developing a blood test that could be used in ambulances to identify stroke type. “This could help paramedics deliver clot-busting drugs more quickly in cases of ischemic stroke,” says Frankel.

At institutions across the country, including Augusta University, trials are exploring drugs that may limit or even repair brain damage. “It’s a pretty wide range, and we’re actually looking at different mechanisms,” says Dr. Dan-Victor Giugiutiu, interventional neurologist, assistant professor at Augusta University, Medical College of Georgia Department of Neurology.

“One is an insulin-like growth factor that’s normally found in the body and helps you heal,” Giurgiutiu says. Others are anti-inflammatory drugs aimed at halting processes that worsen damage. “We’re trying to teach the brain to get blood flow back – don’t kill off the cells. Hold onto them, repair them and try to get more function back.”

At Emory University, researchers are investigating vagus nerve stimulation (VNS) to help people who lost upper limb function after an ischemic stroke. VNS delivers gentle electrical impulses to the vagus nerve through a chest implant. “In combination with intensive occupational therapy, VNS allows people to regain hand function even years after a stroke,” says Nahab. “The exciting fact is that people continue to improve out to 10 years.”

“With regard to giving clot-busting medication, the sooner you give it to somebody the better. The first thing you need to know when a patient comes in with a stroke is to make sure it is not the bleeding kind of stroke. Those are the ones you don’t want to be giving the clot-busting therapy to.” – Dr. Phillip Amodeo, stroke program medical director, Southeast Georgia Health System

Stopping Stroke Before It Starts

The most important advance in stroke care would be the ability to prevent strokes in the first place. Prevention means understanding and addressing the causes of stroke, which can vary between individuals. For some, these include treatable conditions such as atrial fibrillation or high levels of lipoprotein(a).

A-fib, an irregular and often rapid heartbeat, can cause blood to pool in the heart and form clots that may travel to the brain. While many people with A-fib seek care for symptoms such as a racing heart, lightheadedness, or dizziness, others have no symptoms, says Dr. Giurgiutiu. “You may not discover A-fib until a clot forms, and often the clot goes to the head first.”

Thanks to new technology, wearable monitors and consumer devices like the Apple Watch can help detect irregular rhythms early, Giurgiutiu says.

Treatments for A-fib include medication or procedures targeting the abnormal heart tissue to reduce stroke risk.

Lipoprotein(a), or Lp(a), is a cholesterol-like substance largely determined by genetics. Although there are no FDA-approved treatments specifically for lowering lipoprotein(a), scientists at Emory and institutions around the world are investigating potential therapies. Unlike LDL (“bad cholesterol”), lipoprotein(a) isn’t significantly affected by diet or exercise. “The reason this is so important is because estimates are that about 20% of people in the population have high lipoprotein(a) levels,” says Nahab. “This may be an entirely new area of focus for novel treatments to reduce heart attack and stroke.”

For most people, the solution to stroke prevention isn’t so high-tech. Preventing stroke – like many other health issues – often comes down to healthy lifestyle habits. “The message is still the same as it has been forever, which is really, see your doctor on a regular basis. If you have high blood pressure, take medication if your doctor prescribes it,” says Frankel. “Don’t smoke. If you’re smoking, stop. Lose weight if you’re overweight. Exercise. Control your cholesterol with medication if necessary. Those messages are still the same. Even though they’re not super, super sexy, they’re super powerful.”

A Remarkable Recovery

Four years after her stroke, Lisk still has follow-up procedures “to check on the spot and make sure it was okay.” She remains awake during them and says she can “actually see the inside of [her] brain up on the big screen.”

Though she has some lingering effects, Lisk says she’s able to care for herself. “I can do just about anything I need to do.” That includes participating in a monthly support group, sharing recovery tips online and encouraging others to stay vigilant.

Her story underscores the importance of recognizing symptoms and acting fast. “The main thing is for people to be aware of stroke symptoms and to know if they have a family history,” she says. “That’s important, too – because it helps you recognize what to watch for, and that a stroke could be what’s happening to you.”

Inside One of the Nation’s Top Neuroscience Centers

While Georgia has long been known for one of the highest stroke rates in the country, it also boasts one of the most advanced stroke centers. Opened in 2010 with support from the Marcus Foundation, the Marcus Stroke & Neuroscience Center at Grady Memorial Hospital was designed to mirror Grady’s world-class trauma capabilities and serve as the region’s leading resource for acute stroke care, research and recovery.

The mobile stroke unit is staffed with specially trained personnel who can begin diagnostic imaging and treatment on the way to the hospital. Photo credit: Grady Health System

“When we started this mission 15 years ago, we were getting about 350 patients with stroke a year, and now we’re over 2,000,” says Dr. Michael R. Frankel, chief of neurology, director of the center and professor of neurology at Emory University School of Medicine. “We wanted to be that regional resource for stroke.”

Patients arrive by ambulance, air EMS, private vehicle or transfer from other hospitals seeking higher-level care. Last year alone, the center received more than 500 stroke transfers. Grady’s reputation as a stroke destination, coupled with its telemedicine outreach through the Marcus Stroke Network, allows hospitals across the region to tap into its expertise in real time.

The center is also home to one of the country’s only mobile stroke units – an ambulance with a CT scanner and specially trained personnel who can begin diagnostic imaging and treatment before patients reach the hospital. “The brain in particular [is] very sensitive to loss of oxygen,” Frankel explains. “So the faster we can get an artery open…the better the outcomes.”

At the hospital, patients benefit from a unique setup: a 30-bed neurological ICU with two angiogram suites and a CT scanner embedded directly into the unit. “There’s no place in the world that has that,” Frankel says. “We wanted to develop a one-stop shopping approach to bring the treatment to the patient, not bring the patient to the treatment.”

As it delivers comprehensive stroke care, the center also trains the next generation of stroke specialists and conducts research with global impact. “We perfected and led clinical trials to show that [thrombectomy] is a beneficial way to treat acute stroke,” says Frankel, referencing a procedure that removes blockages from large arteries in the brain. The center was also pivotal in landmark trials for tissue plasminogen activator (tPA), the first FDA-approved stroke drug for acute ischemic stroke.

Regional Resource: Atlanta’s Grady Memorial Hospital is home to a mobile stroke unit. Photo credit: Grady Health System

In 2024, the center announced results of the ENRICH trial, a 37-site study led by researchers from Emory and Grady, that proved for the first time that minimally invasive surgery could improve outcomes in patients with intracerebral hemorrhage, a less common but often fatal type of stroke. A larger follow-up trial funded by the Marcus Foundation, called REACH, is now underway.

The center’s work extends beyond emergency care. In 2023, it opened a 24-bed inpatient rehabilitation facility to support full-spectrum recovery. “We really wanted to have a full-service, comprehensive approach to stroke care, not just on the acute side, but also on the rehab and recovery side,” says Frankel.

That commitment to excellence drives everything the center does. “It’s always about perfecting what we do… more effective, more accurate, more efficient,” he says. “It’s a never-ending process.”