Stroke Center Story
At St. Mary’s Medical Center, highly trained professionals utilizing the latest technology and drug therapies are dedicated to the prevention, diagnosis and treatment of stroke
written by JAMES E. CASTO
A stroke is a “brain attack” caused by bleeding in the brain or by blood clots that cut off the brain’s supply of blood and oxygen. Strokes are the third leading cause of death in the United States and the leading cause of long-term adult disability. Each year, about 700,000 Americans suffer one of these life-threatening events – one person every 45 seconds.
The damage from a stroke often is permanent because brain cells that die during a stroke can never be replaced. But, many strokes can be prevented and, when strokes occur, early treatment can reduce the severity of the stroke and save lives.
With that in mind, St. Mary’s developed its Stroke Center, with highly trained professionals and high-tech equipment dedicated to the prevention, diagnosis and treatment of strokes. When a patient arrives in the ER with the symptoms of a stroke, a “stroke alert” is called and the stroke team swings into action.
After conducting a brief physical exam and neurological assessment, the emergency department physician usually orders a stat CT scan of the head to determine what type of stroke is occurring and help guide further treatment. If the CT scan shows a hemorrhagic stroke, or bleeding in the brain, neurosurgery often is needed to stop the bleeding, restore normal blood flow and relieve the pressure on the brain from swelling.
Because only 15 percent of all strokes are hemorrhagic strokes, the CT scans of most stroke patients do not show any bleeding. In this case, the stroke is being caused by a blood clot that is blocking an artery to the brain. Treatment for this type of stroke, called an ischemic stroke, focuses on removing the clot and restoring blood flow, then preventing the formation of additional clots that could cause another stroke.
According to Carl McComas, M.D., medical director of the Stroke Center, if a patient is having an ischemic stroke, careful evaluation is needed to determine the best treatment option.
“In a stroke alert, a neurologist sees the patient in the emergency room to help determine the appropriate diagnosis and the best treatment plan,” Dr. McComas said. “A neurological exam identifies the problems, or neurological deficits, that the patient is experiencing, such as visual disturbances, speech problems, numbness or weakness. Determining what part of the body is affected gives important clues to what part of the brain is being affected.”
Depending on the area of the brain that is being affected, the severity of the stroke, the overall condition of the patient and the length of time since the onset of the symptoms, ischemic strokes can be treated with thrombolytic drugs, which are commonly called clot busters. One such drug is tPA.
“This drug is commonly used for heart attacks,” said St. Mary’s Neuroscience Center Pharmacist Mike O’Neil. “It can also dissolve blood clots in the brain. But, it’s not without risk, so there are very precise guidelines for using tPA safely.”
tPA can’t be used if there is any active bleeding or if the patient has any conditions that might increase his or her risk of bleeding. And, it can only be given within a certain time period after the onset of symptoms.
“During a stroke alert, we use a multi-disciplinary approach to evaluate the patient, and we follow the stroke protocol to make sure the treatment is appropriate,” O’Neil said. “If the physician orders tPA, I help explain the treatment to the patient and family and obtain an informed consent.
“After the tPA is given,” O’Neil continued, “I help monitor the patient for side effects. Sometimes stroke patients have blood pressure problems after tPA, so I work with the physicians and recommend medications to help keep the blood pressure at a safe level.”
For some stroke patients, tPA is given through an IV. But, for patients who meet certain criteria, it can be administered directly to the clot through an arterial catheter. This is done by an interventional radiologist who uses medical imaging equipment to help guide the catheter to the exact location of the clot.
Dr. Mike Korona, a board-certified interventional radiologist at St. Mary’s, first performed this procedure in 1992. “Stroke analysis has been performed for quite a while,” Dr. Korona said. “We insert a catheter into an artery that supplies the brain. Then, we inject some dye and take pictures of the blood supply to the brain. This helps us locate the clot.”
“After we find the clot,” Dr. Korona continued, “we advance an even smaller catheter to the area of the blockage and administer the tPA. The results are dramatic. We have had patients whose symptoms completely disappeared as the drug was being given.”
One such patient was 19-year-old Rachel Adkins, who had an ischemic stroke in 1999. Rachel’s neurologist, Dr. McComas, says her stroke would have been devastating if it weren’t for the intra-arterial tPA she received. “Without treatment, Rachel would have probably ended up in a nursing home. But, with treatment, she made an excellent recovery and now she only has some mild weakness on her left side.”
“I was playing soccer when it happened,” Rachel said. “Suddenly, I couldn’t feel the left side of my body, and I couldn’t talk. It was very scary and not being able to communicate was really frustrating.”
After recovering from her stroke, Rachel, who now is 24, became a registered nurse. She said her experience helped her relate to the stroke patients she takes care of at St. Mary’s.
Because Rachel got treatment fast enough, she is definitely a success story for intra-arterial tPA. Unfortunately, stories like Rachel’s aren’t common.
“Part of the problem is public awareness,” Dr. Korona said. “Most people who are having a stroke stay at home until it’s too late. This treatment is effective, but time is a factor. For most strokes, the treatment has to be given within six hours of the onset of symptoms. After that, it’s no longer an option.”
If it’s too late to reverse the effects of the stroke with tPA, the treatment focus shifts to supportive care. This aims at limiting the size of the stroke, helping the patient regain as much function as possible and preventing future strokes. Prevention is especially important because one-third of all stroke survivors will have another stroke within five years.
“About 30 percent of all ischemic strokes are caused by carotid stenosis,” Dr. Korona said. “That’s a narrowing of the main arteries that carry blood to the brain. These arteries become diseased, just as arteries in the heart do, and the fatty plaque deposits on the artery walls reduce blood flow to the brain and can make it more likely for clots to form. Often, carotid stenosis isn’t detected until a patient has his or her first stroke. But, once it’s diagnosed, it can be treated to help reduce the chance of additional strokes.”
One method of treating carotid stenosis is with stents that were recently approved by the Federal Drug Administration (FDA). “Stents are small tubes that interventional radiologists place inside the carotid arteries to help hold plaque out of the way and keep the artery open so blood can flow,” Dr. Korona said. “After a stroke, we wait for the patient to stabilize and recover from the effects of the stroke, then we can insert the stents.”
Dr. Korona has performed more carotid stent placements than any other doctor in the state as part of clinical research trials. “I’ve done about 50 stent placements, and they work well to prevent future strokes,” he said. “Now that the stents have been approved by the FDA, the interventional radiologists at St. Mary’s will begin using them on a regular basis.”
Raising public awareness is another weapon in the fight against strokes. “We have developed programs to educate people about the risk factors for stroke and the warning signs,” said Christy Franklin, R.N., director of St. Mary’s Regional Neuroscience Center. “We go to schools, churches and community groups to help people recognize their risks, reduce the risks and learn the signs and symptoms of a stroke. We teach them not to wait. If they have the signs of a stroke, they need to call 911 right away. There are things we can do to help, but only if they get here in time.”