Stroke center enacts regional rapid-transfer system

Credit: Norbert von der Groeben MRI scans

JJ Baumann and Maarten Lansberg review MRI scans of a patient who had recently been at the Stanford Stroke Center.

When the 82-year-old woman arrived at Stanford's Emergency Department, a stroke had left her paralyzed and unable to speak.

She immediately received a CT scan, and then was treated with tPA - tissue plasminogen activator, a clot-busting drug - to restore blood flow to her brain. That's routine at most hospitals.

But what happened next is far from routine. When the tPA did not dissolve the large clot that had caused her stroke, the elderly woman underwent a much more detailed MRI of her brain. Within minutes, a software program, specially developed at Stanford Hospital & Clinics, produced a map of her brain with neon green calling attention to the extent and location of at-risk tissue. Doctors then used a mechanical device to remove the large clot in her carotid artery and restore blood flow.

The software system, developed with the help of a local donor and known as RAPID, is one of a series of measures SHC has instituted to expand its capacity to quickly provide state-of-the-art care to stroke patients throughout the San Francisco Bay Area. Working with community hospitals in Santa Clara, Alameda and San Mateo counties, SHC has established a rapid-response transfer system to take in referrals and immediately determine the best course of treatment. It is a critical step forward in treating a disorder that can go from minor to crippling, and even fatal, in a matter of minutes.

'The key thing is timing: When did the symptoms begin?' Greg Albers, MD, director of the Stanford Stroke Center, said about using the mechanical retrieval device. 'The sooner you can do a procedure, the better, and in general, we're looking at a maximum window of eight or nine hours.

'We want to be able to offer these procedures to people outside the immediate area,' he added. 'And that means transferring patients in from community hospitals with a new, streamlined system that will get them here in a more timely way.'

With every passing minute, victims of stroke lose more than 1 million brain neurons, which die from an abrupt interruption of blood flow. 'Time is brain,' JJ Baumann, RN, MS, clinical nurse specialist at the stroke center, explained. 'Stroke happens fast, and we need to act fast. As more time passes until treatment is delivered, more brain cells die.'

Beginning with a sudden headache, slurred speech, facial droop or weakness on one side of the body, stroke can be a killer - the third leading cause of death in the United States, after heart attacks and cancer. Experts predict that more than 780,000 Americans will have strokes this year. Some 88 percent of them will be ischemic, the clotting type, and 12 percent will be hemorrhagic, caused by a burst blood vessel.

Stanford's new rapid-transfer process for patients from community hospitals who need acute stroke therapy 'has been a big project,' neurologist Maarten Lansberg, MD, PhD, said about the changes in procedures that have been accomplished in the past year. Lansberg chaired the committee that developed the process. 'It's been a gradual launch, and we're almost at the platinum phase.'

Streamlined communication is one key in the new transfer process. 'There used to be 50 different phone calls you had to make, to get the right people to the right place, at the right time,' Albers said. 'Now there's a paging system and a protocol set up so that it flows much more efficiently and much more rapidly.'

Time is specified for each step (five minutes for the transfer center to contact a neurologist), and a new checklist reminds Stanford physicians and nurses what information they need to confirm in incoming phone calls from physicians at community hospitals. As stroke patients are being transferred to Stanford, a simultaneous page goes out to mobilize responders from all corners of the hospital, including anesthesia, imaging, diagnostic radiology, critical care nursing, pharmacy, respiratory therapy and the medical intensive care unit, among others.

Clinical decisions are made by the team of multidisciplinary specialists from stroke neurology and interventional neuroradiology who assemble to assess the incoming patient. Neurosurgeons also are on standby, and neurointensivists will take over care of the patient when he or she gets to the ICU.

Saving critical time has been a driving force behind the new transfer process. But the speedier response also turns on being able to deliver the most advanced stroke therapy. 'We have new devices available to pull blood clots out of the brain, and a terrific team of interventional neuroradiologists who are available 24/7 to do these procedures,' Albers said.

Five years ago the U.S. Food and Drug Administration approved the Merci Retriever for removing large blood clots from the brain - the device that was used to address the problems of the 82-year-old woman in the emergency department earlier this year. A small, corkscrew-like device, it is threaded through a catheter in an artery, then into a blood clot, where it's used to withdraw the clot, like pulling a cork from a wine bottle. Last year, the FDA approved the Penumbra device, which also is threaded through a tiny catheter to the brain. It suctions clots out, like a tiny vacuum.

'The Merci and Penumbra devices have gotten a lot better,' Lansberg said. 'Where interventional neuroradiologists used to be able to open up the blood vessels in 60 percent of patients, today it's more like 90 percent.'

Stroke patients alternatively may be treated with blood clot-busting medications that are delivered intravenously or injected directly into the brain. Some so-called 'drip and ship' patients receive medication in an ambulance, en route to the hospital. And occasionally a tight blockage in a blood vessel will be opened with an angioplasty, inserting a collapsed balloon that inflates to widen the passage, then placing a stent.

On a recent morning, Albers turned to his computer for the latest reports.

At 8:10 p.m. the previous evening, Stanford Hospital's transfer center had received an urgent call from a community hospital that wanted to send a stroke patient for treatment. By 9:20 p.m. the patient had arrived at the Stanford ED, where a team of specialists conferred about his condition. It turned out that the intravenous tPA the sending hospital had given the patient had worked so well that no additional intervention was needed.

Albers was gratified to read about the patient's outcome - and ecstatic about the numbers. 'Safely transporting the patient and getting him to the cath lab in a little over an hour - that's fantastic!'

And then he reviewed the outcome for the 82-year-old woman who had arrived at SHC paralyzed and unable to speak. 'That patient walked out of the hospital,' Albers said. 'She had a phenomenal recovery.'


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