Treatment Evolution for
Emergent Stroke Patients

by Mark Richmond, MD, FACEP
Medical Director, Emergency Medicine,
Santa Barbara Cottage Hospital

 

Emergency department stroke management along the central coast and inland regions has been truly revolutionized by the development of the comprehensive Stroke center at Santa Barbara cottage Hospital.

 

In the not-so-distant past, the approach to a patient with onset of stoke symptoms less than three hours from the time of presentation was complicated, arduous and anxiety-provoking.

 

Concerns included medical issues, such as "Will this patient develop an ICH?" And "is this therapy truly efficacious?" Process issues raised questions, including: "How can I get lab results and a CT scan of the brain completed and read within 45 minutes?" or "Who will assume medical care once the decision has been made to administer t-pA?" and "Will the patient receive proper nursing and ancillary care throughout his/her stay in the hospital and rehab facility?"

 

Medico-legal questions abounded as well, including concerns of being sued if a patient developed a complication from thrombolytic administration. even conspiracy theorists held sway that the drug companies had fabricated data to increase the use of an expensive medication.

 

During the last decade, our system has evolved in such a way that acute stroke patients are treated rapidly and efficiently by practitioners with experience in state-of- the-art modalities. the cornerstone of the comprehensive stroke center is the use of the stroke team.

 

Individualized Response

When a possible stroke patient enters our system, either as a walk-in or via EMS, a stroke team-consisting of an emergency physician, stroke neurologist, internal medicine resident, specially trained nurses and ancillary staff-is immediately mobilized. each member of the team knows exactly what he or she needs to do to accomplish the team's immediate goal of administering thrombolytics to patients who may benefit from them.

 

A neurologist or neurosurgeon specializing in stroke care provides input crucial for individualizing care during the patient's stay. specially trained staff members, including representatives of all ancillary services, work to maintain the cottage commitment to comprehensive care through and beyond discharge.

 

t-Pa Power

From a medico-legal perspective, data on the administration of t-pA show emergency physicians are more likely to be sued for not administering thrombolytics than for giving them. Even the Canadian health system has determined that the administration of thrombolytics to appropriate patients results in improved outcomes and reduced overall cost to their medical system.

 

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Ischemic Stroke Treatment:
When Time Is Brain

 

Serious consideration should be given to the transfer of patients who present inside the stroke treatment window. Patients who may benefit from intra-arterial t-PA and/or clot retrieval should be sent to an endovascular neurosurgical program like that at Santa Barbara Cottage Hospital -- the only one of its kind on the Central Coast.

 

Guidelines for ischemic stroke care specify the following timeline:

 •    From onset of symptoms to four and a half hours, consider intravenous t-PA.
 •    Up to six hours after onset, consider intra-arterial t-PA.
 •    Up to eight hours after onset, consider clot retrieval.

Ground or helicopter transportation may be used to deliver patients for these time-sensitive treatments.

 

For 24/7 access to the Transfer Center, call 1-888-MY-CALNEURO.

 

Protocols and support materials are available for review here >>

 

No one can deny that outcomes for stroke patients are improved by a comprehensive team approach adhering to national guidelines. Cottage has invested heavily in infrastructure to maintain the high function of our team. We have ongoing educational programs and host an annual, nationally attended conference. We have dedicated physician and nursing leadership and state-of-the-art technology. In addition, as a comprehensive stroke center, we have access to the latest invasive endovascular techniques.

 

Santa Barbara Cottage Hospital is the only hospital on the Central Coast to be certified by The Joint Commission as a Primary Stroke Center.


Case Study

Timely Stroke Response

by Phil Delio, MD, Stroke Neurologist
Medical Director, Santa Barbara Cottage Hospital Stroke Program

 

The use of t-PA has gained widespread acceptance as the only FDA-approved therapy for acute ischemic stroke.

 

Utilization of t-pA is felt to be one of the prime reasons why stroke has now fallen to the fourth (previously the third) leading cause of death in this country. The following case illustrates the benefits of t-pA when administered in a timely fashion within an organized stroke system of care.

 

t-Pa Intervention

A 78-year-old male with multiple medical problems -- including diabetes, hyperlipidemia and strokes in the past thought secondary to a patent foramen ovale status post repair-was admitted after he was evaluated in the emergency department and thought to have an acute stroke.

 

The patient reported that he had been in his usual state of health and then while at home noticed right arm weakness and speech problems at 9:30 a.m. The patient drove himself right away to the emergency department, asked for help and came in.

 

The patient was immediately seen by a stroke neurologist, at which time his National Institutes of Health stroke scale (NIHSS) score was a 6 with fairly pronounced weakness of the right arm and leg. CT/CTA imaging done urgently within 30 minutes as part of a "stroke protocol activation" did not reveal any large artery occlusion. However, based on the patient's deficits, t-pA was administered at approximately 11:30 a.m., two hours into his symptom onset. The patient was transferred to the intensive care unit post t-pA administration for close monitoring.

 

Within the first 24 hours, the patient made a notable recovery in his right-sided motor function. By his second hospital day, his NIHSS score had decreased to 2, with only some mild clumsiness of his right arm and some mild expressive aphasia. His MRI scan showed some small areas of ischemia in the frontal/parietal areas in the left middle cerebral artery territory, likely consistent with an embolic shower. (He was later found to be in atrial fibrillation during his hospitalization.) It was surmised that he likely had an initial MCA branch artery occlusion due to a cardioembolism that likely fragmented after t-pA administration, resulting in smaller, less significant strokes.

 

He was discharged to home with his wife four days after his initial presentation to the emergency room.

 

This particular case underscores the importance of the following: firstly, recognition of stroke symptoms by the patient, who sought immediate medical attention when his symptoms first began; and secondly, the rapid triage and assessment of patients within an organized stroke system of care. These elements, when successfully combined, can result in significantly improved outcomes and recovery for stroke patients.