Enhancements, Coordination Help Stroke Treatment Beat the Clock

San Jose, CA (July 31, 2012) – An enhanced stroke program scheduled to launch August 1 at San Jose’s O’Connor Hospital (OCH) will give stroke victims a number of brain saving benefits, including the most crucial — enough time to safely and effectively launch treatment.

The new intra-arterial revascularization treatment program will approximately double the time available to safely and effectively administer brain protecting tPA (tissue plasminogen activator), notes neurologist Raul Guisado, M.D., stroke center medical director at O’Connor. Imaging and specialized tools will allow the team to place tPA or mechanically remove blockages at the site of the clot.

Shannon Crawford, M.D.

Shannon Crawford, M.D.

To launch the program, Shannon Crawford, M.D., has come to O’Connor from subspecialty training in neuro-interventional radiology at UC Davis Medical Center. He is joined in the new program by colleague Anup Singh, M.D., and by the rest of O’Connor’s nationally certified Stroke Center team, says Guisado, and Karen de la Cuesta, FNP-C, Stroke Program Coordinator.

The new program employs sophisticated imaging techniques to insert the tPA directly at site of the clot, rather than infusing the chemical into the bloodstream, a technique that while effective, has a shorter window of opportunity to circulate through the body and bust up the clot, says Guisado.

“But perhaps more importantly, in situations where it makes sense, we will be able to thread tiny wires equipped with miniaturized tools — catheters — to mechanically remove the clot from the blocked vessel,” he adds. “We will have both mechanical and chemical solutions flexibly available as needed.”

Anup Singh, M.D.

Anup Singh, M.D.

The tPA given to patients is a concentrated and synthetically manufactured chemical similar to the natural clot busting chemicals present in normal blood. Patients must have their stroke identified within three hours of the brain blockage for traditional tPA to be used because otherwise dangerous bleeding can occur. But that safety window expands up to six hours, says Guisado, if tPA is placed directly at the site of the blockage.

“This is a crucial time difference,” says de la Cuesta, “because some patients suffer a stroke while sleeping, and so the number of hours from onset is often uncertain. Our intra-arterial revascularization program will allow our imaging specialists more flexibility. Moreover, some patients with a variety of medical conditions might respond better to the more directed infusion of tPA and our ability to target the blockage directly.”

Most patients, notes de la Cuesta, will continue to receive conventional tPA immediately after anischemic (blood clot induced) stroke is identified because of the technique’s long proven record.

“Regardless of the treatment selected, the most important criteria for a successful stroke program such as ours is accurate identification and response as part of our hospital’s overall program of safety and high quality patient care,” says George Block, OCH’s chief medical officer.

De la Cuesta notes that identification is crucial. While 80 percent of the 700,000 strokes that occur each year in the United States are ischemic and respond well to tPA, about 20 percent of strokes result from a burst blood vessel. For these hemorrhagic strokes, a different treatment strategy is required, she says.

Block, Guisado and de la Cuesta, a nurse practitioner working on a specialized certification in stroke management, proudly note that OCH has received the American Heart Association/American Stroke Association Get with the Guidelines — Stroke Plus Performance Achievement Award for the two most recent consecutive years. The Joint Commission, the nation’s primary hospital accreditation organization, recognizes OCH as a Certified Stroke Center.

“The bottom line for us is that day after day for the past two years, we have consistently been able to initiate tPA within 60 minutes of a stroke patient’s arrival,” de la Cuesta says. “The mantra of stroke professionals around the world is ‘time is brain.’”

To highlight the rapid damage caused by an ischemic or clot-caused stroke, Jeffrey L. Saver, M.D. of UCLA Medical Center’s Stroke Center reported in the January 2006 issue of the AHA’s journal, Stroke, that 1.9 million neurons, 14 billion synapses, and 7.5 miles of myelinated brain fibers are destroyed each minute after an untreated stroke. Moreover, the untreated ischemic brain ages the equivalent of 3.6 years for every hour the stroke-attacked brain goes untreated when compared with the slow but continuous neuron loss everyone experiences as they age.

“Because literally each minute counts, it’s important for anyone who suspects he or she has suffered a stroke to have someone drive them or request an ambulance to take them to the nearest certified stroke center, if one is available, as it is throughout urban Santa Clara County,” says Block. “As for our center, the data that we and our peer hospitals share document our door to needle time and consistency is unsurpassed in our region. This reliability is the result of coordination that starts at the Emergency Department door,” notes Block.

“We put a lot of emphasis on training for our medical and our nursing staff, and one of the first things our triage nurses look for when a patient arrives is any evidence of stroke,” says Meenesh A. Bhimani, M.D., medical director of OCH’s Emergency Department.

Nevertheless, patients and family members can help the hospital team by learning to recognize and point out to medical personnel the most common symptoms of stroke they are experiencing or observe:

  • Sudden numbness, tingling, weakness, or loss of movement in face, arm, or leg, especially on only one side of the body;
  • Sudden vision changes;
  • Sudden trouble speaking;
  • Sudden confusion or trouble understanding simple statements;
  • Sudden problems with walking or balance;
  • A sudden, severe headache that is different from past headaches.

De la Cuesta says the hospital has taken a number of carefully thought out steps to ensure speed and accuracy of stroke identification and treatment.

“For example, radiologists now call a neurologist directly rather than first call the Emergency Department to report that they’ve found brain blockage that will require treatment. This saves about 15 minutes every time we need to start tPA,” de la Cuesta says.

“Strokes require a multidisciplinary approach among several care teams, so streamlined communication, including minimizing the number of calls or messages among caregivers, is crucial,” adds Bhimani.

Underlying speed, however, is safety, and O’Connor was cited in the August issue of Consumer Reports with the highest overall safety rank among the San Jose area hospitals that participated in the study.  “This honors our commitment and offers us and our peer institutions an opportunity to continue work on this most basic of patient care issues,” Block says.

In addition to tPA, including enhanced neuro-IR, O’Connor offers follow-up services for stroke patients, including two National Institutes of Health clinical trials. One of these is studying a promising protective treatment using albumin protein for persons who suffer from serious strokes, while another trial is seeking to learn if providing antiplatelet medicines for persons who suffer mild strokes are protected against a more serious stroke in the future.

“The common element of successful stroke programs is close coordination and the hard and effective work of strong champions of the program. We have that here at O’Connor with Dr. Guisado, Karen de la Cuesta, and the entire team,” says Block.