When every minute counts: Massive stroke patient has remarkable recovery after rapid treatment

Mary Ann and Rocco Marrese

The clock started ticking for Rocco Marrese when the 71-year-old was on his lunch break at Morgan & Morgan law office in downtown Jacksonville.

11:30 a.m.

The orthopaedic spine surgeon and lawyer was last seen at 11:30 that morning, Oct. 23, 2013. Minutes later, as he sat alone eating his lunch, his right arm went numb. His face started to droop and he lost the ability to speak.

A coworker walked past the break room and called out a friendly “hello.” Rocco didn’t wave. In fact, he didn’t move.

The young woman stopped walking. She doubled back to see if Rocco was alright. Her decision to check on him would save precious minutes. The longer a stroke victim takes to get treatment, the worse the effects of the stroke. An incredible 2 million brain cells die every minute after a stroke, starved of the blood and oxygen they need to survive. Once the cells are gone, they can never be restored.

12:12 p.m.

Paramedics rushed to take Rocco to the hospital. He couldn’t talk, his right arm was paralyzed and his right leg was very weak. His eyes were drifting to one side, and he didn’t seem to understand when people talked to him. Recognizing the signs of a severe stroke, the emergency responders called UF Health’s stroke alert line while in transit at 12:12 p.m.

They chose the hospital because it has advanced capabilities to treat stroke patients, including a dedicated Neuroscience Intensive Care Unit where the staff and equipment is especially geared toward dealing with strokes.

“A stroke can lead to a wide variety of problems, and we have the unique skill set and team members to be able to treat them,” said neurologist Scott Silliman, MD, a University of Florida College of Medicine – Jacksonville associate professor of neurology who has been the stroke program’s medical director since it began in 1996.

Rocco’s wife, Mary Ann, rushed to the hospital from her home in downtown Jacksonville.

“The paramedics told us UF Health was the place to go for a stroke, and we trusted that they knew what they were talking about,” she said. “He was there in a matter of minutes.”

Seven minutes, to be exact.

12:19 p.m.

UF Health’s Stroke Center was ready for action as soon as Rocco was wheeled into the hospital at 12:19 p.m. The stroke team first had to take a computed tomography (CT) scan of Rocco’s brain to determine what type of stroke he had. The course of treatment is different depending on whether it is an ischemic stroke, which is caused by a clot, or a hemorrhagic stroke, the result of a burst blood vessel. A patient’s risk factors must also be considered before administering treatment, because the powerful methods used to stop the damage of a stroke can be a danger to patients with additional medical conditions.

The attending doctor on duty, UF assistant professor of neurology Odinachi Oguh, MD, reviewed the scans and lab results with two neurology residents - Robert Mannel, MD, and Adil Zia, MD - as well as neuroradiology chief Sukhwinder Johnny Singh Sandhu, MD. Compared to general radiologists, Sandhu and his team are specially trained to use high-tech imaging and techniques to rapidly determine a patient’s status during a stroke.

1:15 p.m.

Using the National Institutes of Health (NIH) Stroke Scale, a tool used to determine the degree of impairment caused by a stroke, the team found that Rocco had a score of 21 – a severe stroke. They agreed he had had an ischemic stroke and did not have risk factors that would rule out using the “clot buster” drug, tPA, intravenously. After obtaining permission from Rocco’s family, physicians administered the drug just 56 minutes after Rocco’s arrival at 1:15 p.m. Over the next hour as Rocco received the medicine, he regained feeling in his arm and leg.

2:15 p.m.

After the treatment was complete at 2:15 p.m., cerebrovascular neurosurgeon Lincoln Jimenez, MD, an assistant professor of neurosurgery, still had concerns. Rocco’s NIH score had dropped from 21 to 12, which meant his symptoms went from severe to moderate. But Rocco still couldn’t talk. Some blockage remained in his brain, and Jimenez wanted to target it with additional treatment if it was somewhere he could access. To find out, he sent Rocco for a computed tomography angiography(CTA) scan to pinpoint the exact blood vessel in his brain that was blocked.

3:15 p.m.

The scans were completed in less than an hour. Jimenez examined the results with Sandhu and found the clot in the middle of Rocco’s cerebral artery. The doctors agreed the spot might be accessible using the endovascular method, which involves a tiny tool inserted through a blood vessel rather than traditional surgery.

4:13 p.m.

With the family’s blessing, Rocco was prepped for the procedure and Jimenez went to work at 4:13 p.m. He used a delicate wire-like device called a stent retriever to deliver tPA directly to the clot and then manually remove some of the blockage. The wire was inserted through Rocco’s femoral artery in his leg, and then it was pushed through his blood vessels to the spot in his brain where the clot was. Once the wire reached the clot, Jimenez maneuvered the wire to release the drug, and then he made a mesh-like stent bloom out of the end of the wire. The stent attached itself to the clot, and Jimenez was able to remove it from Rocco’s brain.

When minutes mattered, UF Health had come through in record time.

“Rocco received all of this treatment in less than four hours from the time he arrived. That is a phenomenal timeline,” said stroke program coordinator Diane Falk. “With an NIH score that high, there’s very little chance a person would have been able to walk out the door on his own without this treatment.”

Rocco did walk out on his own. He was home just five days after his stroke with full use of his arms and legs. He had a long road ahead with his speaking ability, but his brain was as sharp as ever. So were his muscles. Even as he began therapy at Brooks Rehabilitation, he found projects at home to keep himself busy. Less than a week after his stroke, he installed dimmer lights in his condominium. Later, he designed custom-made hooks to hold up a heavy mirror his wife wanted to hang.

A year later

Today, despite his limitations in speaking, Rocco continues to work on his legal cases. His son, Michael Marrese, who is also a lawyer for Morgan & Morgan, sometimes speaks for him when he presents his cases.

Rocco continues to make progress in his speech with the help of Janet Whiteside, PhD, at the University of Central Florida Communication Disorders Clinic in Orlando.

“He works with different therapists to get his speaking back and get the words in order. He’s made huge progress, but it’s a long process,” his wife said. “Strokes are like fingerprints – they’re different for everyone. In a way, you become your own experiment.”

Communicating through writing and a few spoken sentences at a time, Rocco said his goal is to continue speech therapy until he fully regains his speech. He and his wife are confident he eventually will.

The couple said they are grateful for UF Health’s stroke team.

“We received great treatment from very professional, hard-working people,” Mary Ann said. “We are amazed how far Rocco has come since we arrived at UF Health that day.”

Featured Faculty

Scott L. Silliman, MD

Scott L. Silliman, MD

Medical Director, Comprehensive Stroke Program; Program Director, Neurology Residency; Program Director, Vascular Neurology Fellowship