Filed under: Stroke Prevention & Care, Telemedicine | Tags: acute stroke, AcuteCare Telemedicine, administrators, advances, arteries, atlanta neurology, brain, brain tissue, clots, communications, devices, effectiveness, free radicals, future of stroke medicine, heart attack, heparin, History, hospital, ischemic penumbra, medication, medicine, morbidity. clinical trials, mortality, neurologist, news, nurses, patients, physicians, remote presence, solitaire, stroke, Stroke Belt, stroke care, stroke treatment, Technology, telehealth, teleneurology, thrombectomy, thrombus, time is brain, tissue plasminogen activator, toxicity, tPA, treatment, trevo retriever
Fifty years ago, the only advice medical textbooks gave physicians for someone suffering with a stroke was to put him to bed and keep him comfortable, hoping that with time, the brain would heal as best it could. For 30 years, promising techniques preceded disappointing trials. First, heparin was going to be the savior, and for most of the 70s and 80s, it almost served as a standard, but better studies eventually showed that the treatment was not just worthless, but in reality dangerous, causing more brain hemorrhages than no treatment at all. Later, drugs that were intended to clear out “free radicals” were going to save the ischemic penumbra, part of viable brain tissue around a central core of dead cells, but all studies showed that either the medication didn’t get to the target, didn’t work, or could even be toxic to the brain.
In the mid 90s, tissue plasminogen activator (TPA), long used for heart attack victims to break up the clots inside arteries of the heart, was shown to be effective in doing the same in arteries of the brain. For the first time, physicians had something to offer patients that actually made a difference. About a third of patients who received TPA had better three month outcomes than those that did not. This success rate was quite good, but patients with severe strokes still did not respond as well because, in most cases, thrombi in the large arteries were not effectively dissolved.
Only in the last few years have studies been done to consider the effectiveness of a thrombectomy, the process of physically pulling out a thrombus inside an artery in the brain or neck, The early devices available to physicians are fairly good at the task, but a substantial number of patients continue to suffer from residual blockages of the arteries following the procedure.
A report of clinical trials using two new types of thrombectomy devices, called Solitaire and Trevo Retriever, show both of these new devices as being up to five times more effective than their predecessors in opening up arteries. Advances this drastic are rare in medicine, but physicians should be optimistic about the potential for these instruments in improving outcomes. Provided that patients can have access to skilled practitioners in time, within eight hours or sooner, the treatment of stroke may be about to enter a dramatic new phase.
Stroke is the most serious disabling condition in adults, resulting in hundreds of thousands of permanent injuries and deaths every year. This decade may witness the greatest advances in the history of stroke treatment. There are still further trials to run, but with these exciting new prospects, the importance of stroke neurologists like the doctors of ACT being present in every emergency room, either in person or by remote presence, cannot be overstated.
Filed under: Brain Health, Stroke Prevention & Care, Telemedicine | Tags: acute care, AcuteCare Telemedicine, anticoagulation, atlanta medicine, atlanta neurolgoy, atlanta telemedicine, candidacy, case study, doctors, Dr. James Kiely, Dr. Matthews Gwynn, healthcare, healthcare provider, hippocratic oath, hospitals, human side of medicine, life saving, mhealth, neurology, patient story, remote presence, stroke care, stroke intervention, success story, telehealth, telemed, telemedicine, telemedicine case study, teleneurology, thrombectomy, tPA
Mr. Rigby was found unresponsive, gazing to the right and unable to move his left side. Just moments ago, his nurse had seen the 91 year old awake in his hospital bed preparing himself for discharge from the hospital. Though the hospital lacked a neurologist, it had invested in telemedicine services. Immediate assessment of his acute neurological deficits would determine whether treatment with tissue plasminogen activator (tPA), a clot-busting medication, or even thrombectomy (direct mechanical extraction of the clot) was appropriate. If performed within a very short time window, tPA or thrombectomy would open arteries and prevent progressive death of brain cells. However, it could also lead to hemorrhage, bleeding into the brain that could be devastating and even life-threatening. Thus, the teleneurologist was charged with not simply recognizing Mr. Rigby’s stroke symptoms, but also those factors which make the risk greater than the benefit.
As the AcuteCare Telemedicine physician on call, I was at the bedside within minutes via remote presence technology. The evidence; left hemiparesis, left visual field loss and inability to speak, made it clear; Mr. Rigby had sustained a large right hemisphere stroke. A large artery, the MCA, was blocked by clot. His nurse knew the exact time of symptom onset. Without treatment he may have survived, but it was likely he would not walk or talk. He met every inclusion criteria for tPA. Unfortunately, Mr. Rigby was not a good candidate. He had undergone a surgical procedure just the day before, his anticoagulation had been restarted that day and his platelets were very low. At the age of 91 years with these risk factors, the likelihood of serious hemorrhage was too great. As I informed the family members that had filled the hospital hallways, a look of desperation filled their eyes. His daughter stated, “This man is worth-saving.” Remembering my Hippocratic Oath, my immediate response in this case was, “I am certain he’s worth saving, but nobody is worth harming.”
Then I remembered this “case” was her father. I asked her to tell me more about Mr. Rigby. A picture of a family patriarch emerged. He was still vigorous, taking walks daily. He was driving. Indeed, he still routinely played 9 holes of golf. But what she told me next illustrated the shortcoming of using population-based inclusion and exclusion criteria as the sole determinant of risk-benefit for an individual. Mr. Rigby was the caretaker of his 89 year old disabled and blind wife. Without the ability to walk and speak not only Mr. Rigby would suffer. I made an immediate call to the Marcus Stroke Center at Grady Memorial Hospital in Atlanta. The Marcus Center stroke physician agreed the criteria for invasive intervention suggested a high risk, but Mr. Rigby would be given a chance because the potential for benefit was irrefutable. Within a few hours the clot was extracted. Mr. Rigby had an opened artery with full reperfusion. His symptoms improved with only residual left arm weakness. Though speaking slowly, his good humor was immediately apparent. A family had their patriarch back.
Filed under: Stroke Prevention & Care, Telemedicine | Tags: acute stroke, AcuteCare Telemedicine, Atlanta healthcare news, atlanta hospitals, atlanta neurology, atlanta telemedicine, brain health, clot busting drugs, decade of the brain, diagnose and adios, Dr. James Kiely, future medicine, future of stroke, heart and brain, Keith Sanders, Lisa Johnston, matthews gwynn, modern medicine, neurology and cardiology, stroke care, stroke emergency, stroke hospitals, stroke medication, stroke prevention, telehealth, telemeedicine, teleneurology, therapeutic intervention, thrombectomy, thrombus, tPA, tPA for stroke, treatment of migraine
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.