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Trailblazing patient care

Dr. Hawkes
Grateful patient Barry Appleby credits Sunnybrook’s interdisciplinary teams with saving his life – and his golf game

Sizing up the third fairway at Oakdale’s Golf & Country Club, Barry takes a few practice swings before hitting the ball off the tee. It’s a dream shot for more reasons than one.

“For me to be able to tee up a tiny golf ball and hit it is a true miracle,” the 82-year-old admits.

In February 2023, while at home with his wife, Barry experienced an ischemic stroke caused by a clot in a blood vessel in his brain. Seeing her husband suddenly collapse and lay paralyzed on the floor, Eleanor called 911.

What happened next was the start of what Barry describes as “a series of strokes of luck.”

Innovative technique

Having awoken just as the paramedics loaded him into the waiting ambulance, Barry insisted the paramedics take him to his nearby community hospital, where he previously received care. “The paramedic told me, ‘You’re going to Sunnybrook,’” Barry remembers. “Somehow he recognized that I was having a stroke.”

As one of three specialized Regional Stroke Centres in Toronto, Sunnybrook provides emergency and often life-saving stroke care to more than 1,000 patients a year, including many of the most complex cases like Barry. Sunnybrook is also home to a leading Regional Stroke Prevention Clinic that provides personalized interventions to reduce the risk of a repeat stroke.

In Sunnybrook’s emergency department, Barry was assessed rapidly by the on-call Code Stroke Team, who used advanced CT scanning (including an artificial-intelligence algorithm for rapid stroke diagnosis). Barry’s scan confirmed that he had a large blood clot blocking one of his main cerebral arteries. The left side of his body had become paralyzed, and the prognosis looked bleak.

Recognizing the need to act quickly – it’s estimated as many as 1.9 million brain cells are lost every minute during a large blood vessel blockage – the Code Stroke Team called in Dr. Christine Hawkes. At the time, she was Sunnybrook’s newest neurology recruit and the only female neurologist in Canada who also performs endovascular neurointerventional procedures.

Until recently, the clot-busting drug tPA had been the only emergency treatment option for patients with this type of ischemic stroke. Sunnybrook’s neurointerventionists are now offering an innovative clot retrieval procedure known as endovascular thrombectomy for selected patients with acute stroke who are eligible for such a procedure.

Barry smiles with Dr. Christine Hawkes by his side.
Barry smiles with Dr. Christine Hawkes by his side.

Through a small incision in Barry’s leg, Dr. Hawkes quickly threaded a catheter all the way up to reach the blockage in the right middle cerebral artery of his brain. She then carefully pulled the clot out, which was effective at restoring blood flow to his brain – and reversing Barry’s stroke.

The Sunnybrook stroke team participated in the pivotal clinical trial involving endovascular thrombectomy, which showed it can significantly reduce the rate of death and disability from certain types of strokes. Sunnybrook is one of only a few centres in Ontario that offer this procedure to eligible patients.

For Barry, he said having rapid access to this innovative treatment at Sunnybrook felt like a stroke of luck to him. The impact was immediate.

In the angio suite right after the procedure, Barry was able to lift up his arms and give a thumbs up to the entire team. It was an absolutely amazing moment,” Dr. Hawkes recalls.

Even more amazing, experts say, is Barry’s continued recovery since leaving Sunnybrook. The father of two and grandfather of two has been able to resume his pre-stroke activities – something Sunnybrook neurologist Dr. David Gladstone calls “absolutely miraculous.”

“Recovery like this from such a severe stroke was almost unheard of when I began my medical training,” says Dr. Gladstone. “Advances in treatment now make it possible to reverse some types of strokes that otherwise would result in permanent deficits and disability – and that is what motivates our team at Sunnybrook, day in and day out

Preventing recurrent strokes

As Medical Director of Sunnybrook’s Regional Stroke Prevention Clinic, Dr. Gladstone and his stroke neurology colleagues work tirelessly to help manage and prevent recurrent strokes after a patient has experienced a stroke or transient ischemic attack (sometimes called a mini-stroke or warning stroke).

Doctor David Gladstone
Dr. David Gladstone, Medical Director of Sunnybrook’s Regional Stroke Prevention Clinic, emphasizes the importance of stroke prevention.

Dr. Gladstone vaulted Sunnybrook’s stroke team onto the international stage in 2013 with research into the link between stroke and atrial fibrillation, a common but often undiagnosed heart condition characterized by irregular heartbeats that can lead to blood clots and catastrophic strokes.

In a 2021 study of more than 800 volunteers over the age of 75, Dr. Gladstone and a team of researchers in Canada and Germany discovered that one in 20 had atrial fibrillation and didn’t know it. They used wearable heart monitors, which increased detection rates 10-fold compared to the standard of care.

Dr. Gladstone emphasizes the importance of prevention. “One of the best ways to prevent stroke is by identification and treatment of atrial fibrillation with anticoagulant therapy,” he explains. Treatment with anti-clotting medications (anticoagulants) is an important stroke prevention strategy for most individuals with atrial fibrillation as they can reduce the risk of a stroke by about two-thirds or more.

For patients like Barry, though, who was already receiving anticoagulant treatment for his atrial fibrillation when he had his stroke, Dr. Gladstone worries about their risk of suffering more strokes. “For high-risk patients, we need to study additional treatment strategies that can prevent recurrent strokes,” says Dr. Gladstone.

Collaborating with the Schulich Heart Program

That is why Barry underwent another innovative treatment intervention at Sunnybrook’s Schulich Heart Program, which aims to further reduce stroke risk in selected patients. In August 2023, a device called Watchman was implanted to seal the opening of his left atrial appendage, a pouch near the heart where blood clots typically develop in patients with irregular heartbeat.

In patients who are unable to take blood thinners, the Watchman has been shown to reduce the risk of stroke by about two-thirds. There is emerging data that this procedure, when used in conjunction with blood thinners, may further decrease the risk of stroke – an important consideration for Barry. Sunnybrook investigators will soon be participating in an international trial to rigorously assess this treatment.

Strokes related to atrial fibrillation are associated with significant disability and health-care costs. The collaboration between the teams in our Hurvitz Brain Sciences and Schulich Heart Programs is critical to optimize the care of patients and minimize their risk of stroke,” says Dr. Sheldon Singh, the cardiac electrophysiologist who performed the minimally invasive procedure on Barry, using a catheter much like Barry’s endovascular thrombectomy.

Sunnybrook’s Schulich Heart Program was the first in Ontario and the second in Canada to use the Watchman. Donor funding made the procedure possible for 40 patients before Sunnybrook’s early successes attracted Ministry of Health funding in 2021.

Dr. Singh and his team have now completed more than 120 cases, and he was recently named the first official proctor in Ontario to train physicians globally to use the device. Sunnybrook was also the first site in Ontario to have fellows (most recently from Chile and Japan) graduate from the Watchman training program, thereby ensuring this therapy can be provided globally.

“This speaks to our skill and maturity as a program and it also means that we’re delivering educational opportunities for others to provide this treatment around the world,” says Dr. Singh.

Doctor Sheldon
Dr. Sheldon Singh, a cardiac electrophysiologist at Sunnybrook, was part of Barry’s care team, implanting the Watchman device.

Back on the green

On the golf course, Barry is reminded of the first question he asked doctors after waking from his endovascular thrombectomy.

“I wanted to know if I’d be able to play golf again,” he laughs.

To thank the entire team – from the paramedics and Dr. Hawkes to Dr. Gladstone and Dr. Singh – with not only saving his life, but also allowing him to continue the activities he loves, Barry and Eleanor recently made a gift to Sunnybrook’s stroke program.

Barry and his family recognize that it took a team effort from the moment the stroke started to the day Barry stepped back on the green this spring.

“I said my life was saved by a stroke of luck,” Barry says, “But that’s not quite true. My life was saved by Sunnybrook.”