AcuteCare Telemedicine Blog


Yes America, Time IS Brain

“Time is brain” is such a frequently repeated mantra of stroke neurologists that it seems almost to have become cliché. For more than a decade, fliers, lectures and even billboards have been admonishing us to get to the hospital immediately when we develop symptoms of stroke such as speech trouble or weakness. The longer a stroke victim goes without treatment, the more brain damage accrues and the greater the likelihood of permanent disability or death. Using the latest methods to restore flow to blocked arteries, neurologists can improve the outcomes of stroke victims beyond anything imagined before the “Decade of the Brain.” 

It was distressing to be called recently to see Sam, a 55 year old, via teleneurology consultation. Sam had fallen at home around midnight. When his wife noticed his complete paralysis on the left side, she wanted to call the EMS. However, he refused to let her do so and dragged himself to bed. When he was no better by the morning, they came to the ER more than 12 hours after the stroke started. Sam’s arrival to the hospital was far too late; the damage was complete. He was unable to even wiggle his toes or fingers on the left side, and was suffering severe left facial weakness.

Unless clot busting medicine is given or a clot is physically removed from a blocked artery within a window of just a few hours, brain cells die without exception. The struggle against time to save brain capacity is an uphill battle. Rather than facing a prospect for a good recovery and being able to walk or dance again, Sam is now likely to remain under nursing care for years to come.

Contrast Sam’s story with that of Britt, a young college student who suddenly found himself unable to move or speak while at home. His family also immediately recognized the signs of stroke, but unlike Sam, Britt was brought to the ER quickly. A study of his brain revealed the blocked artery and Britt soon underwent a procedure to open it. Within a day’s time, he was back to normal, his brain cells recovering when oxygenated blood returned after the artery was opened.

Today, Britt can look forward to decades of normal living. Sam? His fateful decision to ignore serious symptoms and go back to bed has cost him his freedom. Regardless of clichés, Time is Brain. The urgency of timely diagnosis and treatment in cases of stroke cannot be understated.



Beyond TPA: Teleneurology for the Current Decade

Before the advent of therapeutic interventions in the field, the old joke about neurology was “diagnose and adios.” Neurologists were known for our abilities to locate exactly where in the nervous system a problem existed, communicate information to patients and physicians, and then move on. The lack of options for intervention was a vexing and frustrating problem.

Congress declared that the 1990s would be the “Decade of the Brain.” Perhaps because of this – or maybe in spite of it – the 90’s did see huge advances in treatments of many of brain diseases. Early on, the first effective therapy for multiple sclerosis was introduced, followed by several others. Suddenly, a once untreatable disease could be controlled in many cases. Likewise, the treatment of migraine was revolutionized by the development of triptans such as sumatriptan and rizatriptan that effectively aborted the headache without the terrible side effects of nausea or sedation common with previous medications. New seizure drugs arrived on the market that were more effective than their predecessors, with fewer side effects. Botulinum toxin proved to be a significant advance for many patients with movement disorders. More recently, the same treatment is effectively used for chronic headache.

In 1995, tissue plasminogen activator (TPA) was approved for the treatment of stroke. Finally, one of the most devastating neurological diseases could be addressed in a meaningful way with real outcome improvements. Thanks to the same medication used by cardiologists for many years for the treatment of heart attacks, hundreds of thousands of patients can now have improved outcomes after suffering a stroke.

Nevertheless, many patients with stroke don’t improve significantly after receiving this medication, in part because the clot inside an artery did not truly dissolve once the medication was given in the vein. To help solve this conundrum, the TPA could be given directly into the blocked artery by a catheter. Unfortunately, this all too frequently was either ineffective or resulted in life-threatening hemorrhages into the brain..

In cardiology, this same problem was essentially made moot by the technique of angioplasty, in which a balloon is inserted into the blocked artery and expanded, pushing open the artery. When the same technique is used in the brain, however, the artery often bursts, in part because the brain arteries lack the tough outer layer that helps ensure such rupture does not happen as often in the heart. Also, a surgeon can come behind a cardiologist and rescue the patient with an open-heart procedure – no such thing can be done in the brain. And so, approaching the new century, neurology was still, as it always had been, about 10 to 15 years behind cardiology. What to do?

The answer came in the form of a slightly different technique. The procedure still opens up the artery, but rather than pushing the artery open with a balloon, neurologiststake a similar catheter and simplyeither suck the thrombus (clot) up the tube, or snare it with a small cage and pull it out. Either method opens the artery to blood flow without actually having to press on it or traumatize it. This is called thrombectomy and is the newest and best treatment for severe strokes. Furthermore, it can be combined with intravenous TPA treatment at the outset, and together, the two achieve much better outcomes than IV TPA alone.

In order to do this procedure, the patient has to be seen at a state-of-the-art hospital with the appropriate equipment and personnel. Since there is a critical shortage of neurologists nationwide, the same problems facing patients who require TPA – little or no neurology consultation available in rural or underserved hospitals – are amplified; even fewer hospitals have the resources to provide both treatments in tandem.Once again, teleneurology can come to the rescue. Through teleneurology consultation, experienced neurologists can determine which patients are appropriate to transfer to an advanced stroke center. AcuteCare Telemedicine has been doing this successfully. Furthermore, as more neurologists graduate with training in the latest and most effective procedures, more patients will not only survive their strokes, but will be far less disabled from them. By the end of this decade, cardiology and neurology will stand on roughly equal footing in the treatment of heart and brain.