Widening the treatment window for stroke

photo of raul nogueira

Neurologist Raul Nogueira


Grady Memorial Hospital

Ben Foster thought he was dreaming. He couldn’t move his right side. A woman in bed next to him was yelling, but he couldn’t understand her, couldn’t quite recall her name.

Providing 80% of the care at the publicly funded Grady Hospital, Emory faculty and residents lead programs focused on problems experienced disproportionately by indigent, underserved populations. In 2017-2018, Emory faculty provided $36.3 million in uncompensated care at Grady. All payments for Emory services for patients who have coverage go to the Emory Medical Care Foundation, which uses this revenue—$53.1 million last year—to support Emory’s mission at Grady. 

Foster’s stroke had occurred at night, meaning no one knew the last time he had been OK. The doctor at the local hospital told his frantic wife that too much time had passed for an intravenous infusion of tPA to dissolve the blood clot causing the stroke. That treatment window closed after 4.5 hours. Her husband needed a specialist who could remove the clot by snaking a catheter up through the large artery in the thigh to where it was blocking blood flow to the brain. Foster’s doctor called Raul Nogueira, director of the neuroendovascular service at Grady Hospital, to say the 68-year-old was on the way.

The Marcus Stroke & Neuroscience Center at Grady has one of the largest thrombectomy programs in the country, performing more than 300 such procedures a year. One of the country’s most experienced interventional neurologists, Nogueira also recently helped change the guidelines for use of thrombectomy, as co-principal investigator of a large, multi-national clinical trial.

Previous guidelines had recommended that clot removal take place within six hours of stroke onset. The clinical trial found that thrombectomy could make a significant difference in outcomes in properly selected patients even when performed up to 24 hours after a stroke began.

For years, even before the study, Nogueira had asked families if they wanted thrombectomy, the best he or anyone could do to try to prevent the almost certain devastating result of severe strokes. No one had ever refused. For many, the decision significantly improved recovery. As the new guidelines increase thrombectomy by an estimated 40% nationwide, thousands will have access to those same better results.

Foster gained some movement right after the procedure. Three days later, he was walking independently and talking to the woman whose name he hoped never again to forget!