Researching Brain Blood Clots

More than 80% of strokes are caused by blood clots. These strokes are called "ischemic" because the clot block the flow of blood through a blood vessel, starving brain cells of oxygen and nutrients. My own stroke was ischemic.

There are new treatments to clear the clot and restore blood flow and we talk about them a lot on this show. What we don't usually discuss is the nature of clots themselves and how that impacts patient recovery.

So this episode is a little different. We go deep into understanding the biologfy of blood clots with Michael Gilvarry and Dr. Patrick Brouwer from Cerenovus, a Johnson & Johnson company.

Cerenovus commits a lot of research and resources to understanding clots because they make equipment used in Mechanical Thrombectomy and reduce the impact of stroke on thousands of patients a year.

You can listen to the conversation here or in your favorite podcast app. If you don't see the audio player below, visit http://Strokecast.com/Clots


Meet Dr. Patrick Brouwer and Michael Gilvarry

Dr. Patrick Brouwer, Head, Worldwide Medical Affairs - CERENOVUS

Dr. Patrick Brouwer looks directly at the camera in this professional headshot

Dr. Patrick Brouwer is a clinician and scientist who has made significant contributions in the field of interventional neuroradiology and endovascular surgery.

Before joining CERENOVUS as Head of Worldwide Medical Affairs, he served in senior staff positions for over 20 years as a neurointerventionalist at various university hospitals in Europe. As a key opinion leader in his field, Patrick has published close to 100 scientific papers and book chapters and lectured, including for invited professorships, on more than 400 occasions around the world on a variety of topics related to neurointervention.

Patrick has additionally contributed by serving in various board positions across key societies, such as the European Society of Minimally Invasive Neurological Therapy (ESMINT) and the World Federation of Interventional and Therapeutic Neuroradiology (WFITN).

He received his medical degree, with honors, from the Free University in the Netherlands.

Connect with Dr. Brouwer on LinkedIn.

Michael Gilvarry, General Manager, CERENOVUS Galway

Michael Gilvarry looks directly at the camera in this professional headshot

Michael Gilvarry is the General Manager of CERENOVUS in Galway. With a distinguished career in research and development (R&D) spanning over 20 years, Michael leads the CERENOVUS campus in Galway which is a key hub for producing world-class leading research on stroke and clot science, as well as R&D for the business’ product pipeline.

He leads a distinguished team who informs new innovations and the development of medical devices to address real-world challenges faced by neurovascular physicians in the treatment of stroke. This work has led to many international research projects in collaboration with universities and hospitals in the field of acute ischemic stroke.

He is the recipient of a Johnson Medal, the most prestigious award for R&D excellence within Johnson & Johnson, and is a named inventor on over 60 U.S. patents.

Connect with Michael on LinkedIn.


CERENOVUS, part of Johnson & Johnson Medical Devices Companies, is an emerging leader in neurovascular care. Our commitment to changing the trajectory of stroke is inspired by our long heritage and dedication to helping physicians protect people from a lifetime of hardship. CERENOVUS offers a broad portfolio of devices used in the endovascular treatment of hemorrhagic and ischemic stroke. For more information, visit www.cerenovus.com and connect on LinkedIn and Twitter.

Cerenovus corporate logo

Nature of clots

Most folks who encounter clots only experience them on the surface of the body or when they come out of the body, but we don't think too much about their nature, especially wqhen they stay inside the body.

At the most basic levels, the structure of a clot is determined by the ratio of fibrin to red blood cells. Clots that are high in fibrin tend to be "tougher" and more compact, thanks to the way platelets help tighten them up. That also makes them easier to remove with Mechanical Thrombectomy.
 Clots that are higher in red blood cells may be softer and less dense, but they are also more fragile. Pulling one out of a blood vessel in one piece is a lot harder.

An environment with higher sheer forces is more likely to generate a high-fibrin clot. What is a high sheer environment? Think about a river with a strong, fast flowing current. One way to get a high sheer environment is with high blood pressure. With high blood pressure, blood is coursing through less flexible vessels with greater speed and strength.

A high red blood cell clot is more likely to be formed in a turbulent environment. AFIB, or atrial fibrillation is one such environment. A space where blood flows unevenly or pools can lead to a clot like this which can then travel to the brain.

Clots can also be different shapes. It's not like they are just a disk that closes off a blood vessel. They could be in the shape of a cylinder blocking a blood vessel. The can easily be longer than 8 mm.

Cerenovus recently presented a paper at the American Heart Association's International Stroke conference looking at the impact of clot composition on patient outcomes in mechanical thrombectomy. They showed that thrombectomy had better patient outcomes with high-fibrin clots.

Of course, today there really isn't a way from a neuro-interventionist to know the type of clot before they go in to get it. In the future such information may help inform treatment protocols or refine the type of equipment used in the clot removal process.

You can read more about the research paper here.

What is AFIB?

More than 12 million people in the US live with Atrial Fibrillation. It's a condition that can easily lead to stroke.

Afib happens when the heart gets out of sync with itself. The upper chambers don't beat in the same rhythm as the lower chambers. That results in inefficient blood flow through the heart. Not all the blood that should leave on a beat actually leave.

Bill pulls down the neck of his t-shir to reveal a Zio Patch heart monitor taped to his chestBill's Zio Patch heart monitor is looking for signs of Afib. It did not find any.

This results in blood pooling in the heart and creating a turbulent environment that is a breeding ground for blood clots. Eventually one of those clots will shoot out of the heart and lodge in the brain causing an ischemic stroke.

 When I got home from the hospital, I wore a heart monitor for two weeks that looked for signs of Afib. It did not find any.

Folks with Afib, and especially a history of Afib-related stroke may be put on a lifelong course of anticoagulant medication to prevent those clots from forming. There may be other treatments, as well.

What happened to my clot?

I had a wakeup stroke in 2017. As a result, I was outside the window for tPA and thrombectomy at the time. So what happens when the clot doesn't get removed? I just assumed it would break down over time and blood would start flowing through the dead brain tissue again.

But that's probably not what happened. Because the blood vessel where I had my stroke is so small, it's likely still in place. That clot never went away. It simply became part of the blood vessel itself and that part of the system permanently collapsed. Basically, the cave collapsed and there's no way to dig it out.

And now I'm imaging some sort of Fantastic Voyage/D&D crossover game to go explore that cave.

Meade Musings

I recently appeared on the Meade Musings Podcast sharing my story. We talk about my stroke  and the impact of Sleep Apnea on blood pressure. You can hear the episode here. If you don't see the player below, visit http://Strokecast.com/clots

JoCo Cruise

I just got back from the JoCo Cruise. It's a weeklong cruise in the Caribbean with 1800 nerds, geeks, gamers, creators, and more. We chartered the Nieuw Amsterdam cruise ship for the journey and had a blast. The crew was great and my fellow cruisers were fantastic.

Unlike a traditional cruise, the official programming is all done by the group that charters the boat, led by musicians Jonathan Coulton and Paul & Storm. They bring on a bunch of other well-known and soon to be well known musicians, writers, voice over folks, actors, and generally fun, nice, talented people.

And then the attendees ourselves put together a bunch of programming. I ran a meet up for folks with neuro conditions, a professional networking session, a podcaster meetup, and a photoshoot for the stuffed animals people travelled with.

I have lots of other thoughts and feelings about this year's cruise, but I'm having trouble articulating them in writing this time.

If you'd like to learn more or are thinking about going in 2023 (or in the future) you can visit http://JoCoCruise.com for more details


Hack(s) of the Week

Hack 1

Dr. Patrick Brouwer emphasized the importance of setting goals and appreciating the life around you. At first glance it seems those two things are in conflict, but in reality, they are not.

Setting goals helps you build a plan for the future with tasks you can do today that can get you there.  The steps you take today are what will shape your future. And if the steps you take can get you there, there is fulfillment to be found in taking them.

At the same time, we don't live in the future. We live in the present. It's the only reality we will ever have. We need to appreciate the world and the people around us and if we can't then we need to take steps to change that. And execute those steps while recognizing the sheer power of the here and now. Because before we know it, the here and know will simply be the past.

Survivors who've come close to not having any more future on this earth can appreciate that more than most.

Hack 2

Michael Gilvarry talked about adding additional therapy while doing other tasks. He suggested closing your eyes while you brush your teeth. It's something he found helpful while rehabbing his own knee.

I like this approach especially for folks after stroke because it forces you to work on proprioception - the sense of where your body parts are in space. This is a challenge for many survivors. It's a skill we may need to develop.

It also forces use to focus more on the balance in our core and affected leg while our unaffected hand is busy with the tooth brush.  This can be a good challenge after stroke.

That said, do it safely. Make sure you can stand with your eyes closed without falling, first. Talk to a PT or OT before trying things like this. You want to challenge your brain with these balance tasks, but any fall could undo months of progress.

So don't fall.


Where do we go from here?

Here is the latest episode of The Strokecast


How can you do 1,000 reps an hour?

Again and again, we learn the secret to stroke recovery is repetition. It's about doing the same movement or behavior again and again -- tens of thousands of times.

In a typical session with an OT or PT, a patient might do the same exercise 30-60 times, which is a good start. But what if a therapist could crank that up to 1,000 reps an hour, or one every four seconds? Now you've got some interesting possibilities for recovery.

Bionik, Inc makes devices and software that do just that. This week I talk with CEO Rich Russo about the InMotion Hand and InMotion Arm devices and how they work in conjunction with a therapist to help patients recover.

Listen to the conversation here or in your favorite podcast app. If you don't see the media player below, visit http://strokecast.com/Bionik


Who is Rich Russo?

From the Bionik website:

Rich Russo wears a dark suit, shirt and ties. He;'s outside and looking at the camera

Mr. Russo Jr. has over 15 years of finance and accounting leadership experience and is a Certified Public Accountant.

From March 2017 through November 2020, Mr. Russo was the Vice President of Finance and United States Chief Financial Officer, of IcarbonX, a privately held digital health management company specialized in artificial intelligence and health data, and a predecessor PatientsLikeMe. While there, he was responsible for, among other things, the merger of three companies, fundraising, and the ultimate dissolution of certain affiliated companies.

From 2007-2016, Mr. Russo held various key leadership roles for Nasdaq-listed companies in life sciences, pharmaceutical and medical device industries. From September 2015 to October 2016, he served as Corporate Controller for Pieris Pharmaceuticals, Inc., a clinical stage biotechnology company, and prior to that, he had roles at Juniper Pharmaceuticals, a woman’s health company focused on developing therapeutics, and Cynosure, a medical device company focused on aesthetic treatment systems. In each of these roles, Mr. Russo was responsible for all finance activities and SEC reporting, including partnering closely with management to ensure effective and efficient financial procedures throughout the organizations. Mr. Russo started his career in 2005, where he served as an auditor at Pricewaterhouse Coopers in the assurance group.

Mr. Russo is a graduate of Bridgewater State University in Bridgewater, MA, where he graduated from a dual degree program, receiving his Bachelor of Science in Accounting and his Masters in Management and Accounting.

Other Inpatient Solutions

A patient uses the InMotion Hand

The Bionik system is one for hospitals and rehab units. The rapid reps help in partnership with the rehab professional.

In that respect, it's similar to devices from Restorative Therapies. I talked with the team at Restorative Therapies in episode 92. You can find that episode here. 

The key difference is that Restorative Therapies uses Functional Electric Stimulation (or FES) to activate a patients muscles. The Bionik solutions provide physical assistance to help the patient complete motions. They are different ways to stimulate the brain, increase repetitions, and drive the neuroplasticity that is so key to recovery.

They are also both intended for use in a hospital or rehab facility with the help of a trained therapist.

The other devices I talk about often, like those from sponsor Motus Nova and previous guests with Neofect and Racoon Recovery are for at home use, as a supplement to therapy provided at a medical facility, or as an alternative when those services are not available, for whatever reason. You can learn more about those devices by clicking the links on their names above or from the link table at the bottom of this post.

The point of all these solutions is the same -- drive patient recovery through increased movement and repetitions to neureoplastically teach to brain how to access that limb once again.

Hack of the Week

Wear comfy socks.

It's such a simple thing, but the right socks can make a big difference in how you feel. The right socks can wrap your feet well and wick away perspiration. They can protect your foot from rubbing against an AFO or the heel of your shoe.

The wrong socks will keep you too hot or too cold. The wrong size will leave you with an uncomfortable wrinkle you walk on all day. If they're too slippery, you've got an additional safety hazard to contend with.

The hospital socks they gave me in the hospital were terrible. The had the no slip dots, which was great, but they kept falling down and rotating around my foot. Part if it was they were likely the cheapest that met minimum standards. The other part is that I have large feet for my height (size 12). So my partner ordered me better hospital socks from Amazon,* which helped.

For air travel after stroke, I have made a change to my wardrobe. I now wear knee-high compression socks.* They do a good job of preventing swelling in my feet and legs during long flights. And that helps to prevent DVT or deep vein thrombosis, which is where a clot forms in the legs and causes problems there, or breaks loose and lodges elsewhere in the body. That's how Ted Baxter had his stroke. I talked with Ted back in Episode 34.

Relatively speaking, good socks are still fairly cheap. Try different ones until you find the socks that are best for your feet and life style.

Good socks are worth it.


Where do we go from here?

Here is the latest episode of The Strokecast