Around the Clock Comprehensive Stroke Care
Despite being the third-leading cause of death among adults, stroke is not very well understood by the public. Polls have shown the vast majority of people cannot identify a single warning sign (see “Know the symptoms of brain attack”).
A dedicated group of stroke specialists at Froedtert & Medical College is working to close that knowledge gap — and save lives in the process. They are helped by a 24-7 acute response team, new diagnostic tests that can pinpoint a stroke’s location and cause, advanced microsurgical techniques, a state-of-the-science Neurosciences Intensive Care Unit, comprehensive rehabilitative care, and drugs that, if given early enough, can stop a stroke in its tracks. At Froedtert & Medical College, stroke patients find expertise in diagnosis and treatment, and rapid access to that expertise — day or night.
“We have the critical mass to treat stroke from the very beginning to the very end,” says Panayiotis Varelas, MD, PhD, Medical College of Wisconsin neuro-intensivist, director of the Neurosciences Intensive Care Unit and a member of the Froedtert & Medical College Acute Stroke Team, or FAST. This multidisciplinary team — the only one of its kind in eastern Wisconsin — is made up of stroke neurologists, critical care neurologists (neuro-intensivists), neurosurgeons, interventional neuroradiologists, emergency medicine doctors and nurse specialists, all working around-the-clock to beat stroke.
“The team is the patient’s first line of defense in the 24 hours after a ‘brain attack’,” says Michel Torbey, MD, Medical College of Wisconsin neuro-intensivist and director of the Stroke Critical Care Program.
Upon a patient’s arrival at the Froedtert & Medical College Emergency Center — or even beforehand — the FAST team is paged and springs into action. “Minutes count, so we literally drop what we’re doing and we’re in the ER in minutes,” says Dr. Varelas.
The first step is a comprehensive assessment and a CT scan to determine the type of stroke and the best course of action for that patient. “To say that someone has had a stroke is only the beginning of the diagnosis,” says Diane Book, MD, Medical College of Wisconsin stroke neurologist and medical director of the Neurovascular and Stroke Program. “We need to determine the specific causes in order to optimize treatment for that event and prevent further problems.”
The team employs an array of state-of-the-science diagnostics, many of which were not available a few years ago, including new, more sophisticated CT scans that view the stroke within the brain; MRIs that show which parts of the brain are permanently damaged and which can be repaired; blood flow tests to show how much blood is getting to the brain and more.
Among the treatments to combat stroke, perhaps the most revolutionary is the drug tPA — tissue plasminogen activator. Originally developed to treat heart attacks, tPA is known as a “clot-buster,” because it can literally stop an ischemic stroke as it is happening by breaking up the blockage and restoring blood flow to the brain. “I have seen patients with very disabling symptoms be completely cured in the first hour after receiving tPA,” says Dr. Book, one of the FAST team physicians specially trained to administer tPA.
The catch to this miracle drug: It must be administered intravenously within the first three hours of the onset of symptoms. The American Stroke Association reports that only three to five percent of people who might benefit from tPA reach the hospital in time to receive it, largely due to ignorance about stroke symptoms and the necessity of treating them urgently.
FAST staff members have successfully used tPA since it was approved for stroke in 1996 and are active in teaching other hospitals how to safely administer the drug.
Going inside the brain to beat stroke
Ischemic stroke patients who have missed the three-hour window for intravenous tPA may still benefit from the drug, thanks to new technology that allows doctors to work inside blood vessels in minute detail. Medical College of Wisconsin InterventionalNeuroradiologist Lotfi Hacein-Bey, MD inserts a catheter — a soft, narrow, plastic tube — into an artery in the arm or leg and guides it to the brain with the use of x-ray imaging. The clot-buster is then injected near or directly into the clot to stop the stroke. “We can use much less of the drug and direct it to the exact site of the problem,” he explains, adding that this form of tPA must be given within six hours of the brain attack’s onset.
For those suffering hemorrhagic strokes, the same technique can be used to deposit tiny blocking agents, such as plastic balloons, or steel or platinum coils. Other microsurgical procedures include grabbing clots with tiny clot retrieving devices, breaking up clots with wires and implanting stents to restore blood flow.
The goal of surgery is to prevent further damage to the brain. “You can have some brain cells die and still make a very good recovery — unless the stroke continues to snowball,” says Grant Sinson, MD, Medical College of Wisconsin neurosurgeon. Surgery to prevent further damage includes removing abnormal blood vessels, clipping the end of an aneurysm and relieving pressure build-up in the brain.
Know the Symptoms of Brain Attack
A stroke is caused by the sudden interruption of blood flow to an area of the brain. Deprived of oxygen-rich blood, brain cells quickly die. The results can be disastrous to quality of life, including impairment of the senses, motor skills, memory, thinking, strength, behavior and ability to communicate — or death.
There are two types of stroke. Most are ischemic, caused by blockage; about 20 percent are hemorrhagic, caused by bleeding. Symptoms include:
- Sudden weakness or numbness of the face, arm and leg, especially on one side of the body
- Sudden confusion, trouble speaking or understanding
- Sudden trouble seeing in one or both eyes
- Sudden trouble walking, dizziness, loss of balance or coordination
- Sudden severe headache with no known cause
Like its cousin, the heart attack, a “brain attack” requires immediate medical attention. But unlike heart attack, stroke’s urgency is not widely understood, and its symptoms are all too often ignored.
The FAST team’s message is simple. “Know the warning signs, and if you think you may be having a stroke, call 911.” says Wende Fedder, RN, stroke team nurse and coordinator for the Neurovascular and Stroke Program.
Ongoing expert care
At Froedtert & Medical College, care for stroke patients continues in the 12-bed Neurosciences Intensive Care Unit (NICU). Patients there receive comprehensive monitoring for subtle changes that could indicate a complication, expert intervention and coordinated care. The NICU team includes National Institutes of Health Scale certified nurses with an average of 11 years of experience, specially trained to care for patients’ complex needs; two neuro-intensivists with fellowship training in neurology critical care; social workers and psychologists to help the patient and family adjust to this life-altering event, and rehabilitation specialists who work with the patient from the beginning to minimize disability and maximize quality of life.
“Rehab is tailored to each individual,” says John McGuire, MD, Medical College of Wisconsin stroke physical medicine specialist and director of stroke rehabilitation. “We look at where patients were before the stroke, where they need to be and how to get them there.” This may involve working with physical, occupational and speech/swallowing therapists to regain function. Patients requiring ongoing support may be transferred to the Rehabilitation Unit, or continue receiving services as an outpatient, or at home.
The Neurovascular and Stroke Program is currently involved in several research studies, drug trials and investigational procedures designed to further advance the understanding and treatment of stroke. These include investigations into drugs to protect nerve cells during a stroke, growth factors to promote the development of new brain cells, faster and more precise imaging techniques and a robotic arm-training device for use in rehabilitation. Researchers are also exploring effective treatments for spasticity and enhancing motor control after a stroke.
Froedtert & Medical College is also helping prevent brain attacks with stroke screenings at Small Stones and participation in Operation Stroke, an American Heart Association/American Stroke Association initiative to reduce heart disease, stroke and risk by 25% by 2010. Daniel Worman, MD, Medical College of Wisconsin emergency medicine specialist, has chaired Operation Stroke for several years.
Dr. Worman emphasizes the team’s message: “Call 911 if you think you may be having a stroke. Getting yourself to a hospital with a dedicated stroke program and an acute response team is your best chance for a good outcome.”