New streamlined triage system for "brain attack"

Apr 1 2009

Taking a page out of the playbook developed by cardiologists nearly two decades ago to promote the warning signs and swift treatment for heart attacks, a multidisciplinary team of stroke experts at the University of Rochester Medical Center (URMC) have created a new streamlined triage system at Strong Memorial Hospital's Emergency Department (ED) to provide rapid evaluation and specialized treatments to "brain attack," or stroke, patients.

URMC neurologists, neurosurgeons, imaging scientists, and emergency medicine physicians collaborated on the new protocol, which aims to administer appropriate treatments on stroke patients within 45 minutes of arrival at the ED. The new system takes advantage of new faculty recruits and emerging treatment approaches that expand both the number of treatments available, and the time in which they can be administered.

Stroke is the third leading cause of death in the nation, and is responsible for more cases of disability than any other ailment. About 795,000 Americans each year suffer a new or recurrent stroke, and their access to treatments, and ultimately, the level of their recovery, is linked to how quickly they can get to an ED after the stroke occurs.

"The way we think about and treat stroke is changing significantly.It's only been in the past dozen years that the first treatment for stroke - clot busting medications - was introduced, and while it has proven very useful for eligible patients, its success has been limited because it can only be administered within three hours after the onset of stroke symptoms," Curtis Benesch, M.D.,director of the Strong Stroke Center, said. "Over the past few years, sophisticated imaging technology and newer endovascular treatments have emerged that provide us with more options to aggressively treat stroke. Time is still the critical component to our success - people need to get to an ED immediately if there are any signs of a stroke."

Latha Stead, M.D., MS, chair of the Department of Emergency Medicine and professor of Emergency Medicine and Neurosurgery, recently joined URMC from the Mayo Clinic, where she was instrumental in the development of their rapid stroke triage system. She has applied this experience and extensive research background in acute stroke in developing the new protocols at Strong.

"Like a heart attack, a stroke constricts blood flow, and this has a disastrous effect on brain cells, which quickly die off, thereby impairing brain function," Stead said. "Time literally is brain - the quicker we restore blood flow, the more chances a patient has to live an independent life after a stroke."

That's why the new protocol has the Emergency Medicine department taking the lead in screening patients with stroke-like symptoms; previously, ED staff would place a stat page to the on-call neurologist if a stroke was suspected. Now, ED staff rapidly initiates comprehensive imaging and initial treatment of stroke in ED, while simultaneously a page is placed to the on-call Stroke Team. This multidisciplinary team, comprised of emergency physicians, neurologists, neurosurgeons and neuroendovascular specialists, then quickly assembles to review test results and together determines the best treatment option.

Also new is an expanded panel of blood and imaging tests that is immediately set into motion by the ED physician to confirm a stroke diagnosis. While routine CT scans are always performed for stroke patients, the expanded imaging tests rapidly provide physicians with a more comprehensive view of what is occurring in the brain. They include a CT perfusion scan, which shows the actual location and amount of decreased blood flow in the brain in real time, and a CT angiogram of head and neck arteries, which provides a specialized look at the site of the clot blocking blood flow to the brain, along with the anatomy of the surrounding blood vessels.

"This information is critical when evaluating treatment options for patients," Babak Jahromi, M.D., Ph.D., assistant professor of Neurosurgery, said."We can use endovascular procedures if the CT perfusion and CT angiogram images show that brain function can be restored, and that our instruments can safely enter the blood vessels near the blood clot itself.But those are decisions we can't make if we don't have the imaging at the outset."

"Our new ED protocol takes stroke treatment to the next level," Benesch added. "By having our ED physicians and nurses immediately start the ball rolling with rapid triage, imaging/laboratory workup and initial management of acute stroke, critical time is saved and our stroke team has all the information it needs at the outset to aggressively treat the stroke, thus giving our patients the best chance for a full recovery."

Aggressive Treatments Provide New Hope

When the FDA approved tissue plasminogenactivator (tPA) in 1996, it was the first treatment available to combat the devastating side effects of ischemic stroke, and remains the standard of care today.However, the drug has limitations: it cannot be given to patients with recent trauma, surgery, or strokes causing bleeding into the brain, and it must be given within three hours of the onset of stroke symptoms.As a consequence, researchers estimate that less than 2 to 3 percent of all stroke patients receive tPA nationally.

Locally, the URMC stroke team treats 8 to 10 percent of its patients with intravenous tPA, a rate more than double the national average and achieved through the collaboration among physicians and nurses who care for patients with stroke, and to the community education efforts of local agencies such as the American Stroke Association. In fact, the American Heart Association/American Stroke Association has honored stroke care at Strong Memorial Hospital several years in a row with its highest award, the Gold Sustained Performance Award, in recognition of meeting the organizations' safety and patient care protocols.

For patients ineligible for intravenous tPA, particularly those who are beyond the three-hour time window, URMC physicians can use newer technology to provide additional treatment options. In the past year alone, three additional faculty with stroke expertise have joined URMC, enabling the institution to offer such treatments to patients around-the-clock, every day of the year, including:

• Intra-arterial tPA :A mini-catheter is gently inserted up into the brain, and tPA is inserted directly into the blood clot.
• Endovascular thrombectomy. A micro-catheter is guided into the brain until it reaches the clot.A thin retractable wire is pushed past the blood clot and curls itself into a corkscrew shape. The physician gently retracts the micro-catheter, which in its new corkscrew form can effectively pull the blood clot along until it reaches the carotid artery, where it is suctioned out through the balloon catheter. Similar micro-catheters can also be inserted into the blood clot to help fragment it and suction out the resulting loose pieces, effectively "vacuuming" up the obstructive blood clot.
• Neuroendovascular stenting :A tiny balloon catheter is inserted into the artery, and as it nears the clot location, the balloon is inflated. The physician then carefully inserts a special brain stent designed to be placed deep inside the narrow arteries of the brain, safely "propping" up the artery.With the stent in place, blocked blood vessels are opened, and blood flow is restored.

URMC physicians also are conducting a number of clinical trials investigating potential treatments for stroke using a medication - activated Protein C, or APC, to protect brain cells injured by the stroke or placing a balloon in the aorta to improve blood flow to the brain.The trial using APC is a national, multi-center safety study headed by Benesch and funded by the National Institutes of Health.

About Stroke

A stroke is an interruption of blood supply to the brain due to a clot or leakage of a blood vessel into the brain. According to the American Stroke Association about 780,000 Americans each year suffer a new or recurrent stroke. That means, on average, a stroke occurs every 40 seconds. Stroke kills nearly 150,000 people a year, making it the third leading cause of deathbehind diseases of the heart and cancer.