Advances in treating strokes expand the time window and allow for remote diagnoses

08/22/2014 1:53 PM

08/23/2014 11:59 PM

When it comes to stroke detection and treatment, doctors have a saying: “Time is brain.”

That’s because strokes, caused by blood clots that cut off circulation to the brain, kill or damage two million brain cells for every minute they’re left untreated. They can leave patients disabled or dead if not treated in time, but because the symptoms — facial drooping, arm or leg weakness, slurred or otherwise impaired speech — aren’t painful, people suffering a stroke often don’t recognize them or think they’ll pass on its own.

Traditional wisdom about strokes dictated certain things: Doctors could only help patients who arrived at the hospital within a 3- or 4 1/2-hour window from when they had the stroke. And outcomes were less promising for patients in rural areas without a nearby stroke center.

But recent advances in stroke treatment have turned these assumptions on their head. While doctors still stress that stroke patients should call emergency services as soon as possible, new techniques and equipment are allowing doctors to help some stroke people up to eight hours later. And telestroke technology — videoconferencing software that lets doctors treat patients remotely — is helping patients in rural and urban areas alike.

Strokes are still in many ways a numbers game: Even among patients who arrive at the hospital within 3 to 4 1/2 hours from when they last seemed normal and are administered the clotbusting drug tPA, only up to 30 percent will see their condition improve, according to Dr. Tarek Zakaria, director of neurology at Memorial Regional Hospital in Broward County.

But a new treatment option can allow some patients — outside of the 4 1/2-hour window, but with a blood clot that puts more of the brain at risk than has been damaged — to get a thrombectomy, removing the clot without risking brain damage.

While widening the window presents opportunities for some patients who otherwise wouldn’t have received treatment, this type of intervention is far trickier than administering tPA, according to Dr. Ralph Sacco, chair of the neurology department at the University of Miami Miller School of Medicine, chief of neurology at Jackson Memorial Hosptial and the former national president of the American Heart Association.

For one, patients only qualify for the procedure if they have a blood clot in a large artery. Clots in small arteries — harder to reach and putting less brain matter in danger — may not be worth the risk, he said.

What’s more, using a thrombectomy for these types of patients is still controversial and has not yet been approved by the Food and Drug Administration, according to Sacco. And even as this procedure expands the time window, time is still of the essence: Eight hours is the maximum window, and the sooner the vessel is opened up, the better. Moreover, only comprehensive stroke centers are equipped to do these types of procedures.

But thrombectomies do allow for a “significant” increase in the percentage of acute stroke cases doctors can treat, according to Memorial’s Zakaria, particularly for so-called “wake-up strokes.” These strokes, which happen mid-slumber — making it difficult to know when in the night they occurred — are one of the major reasons patients don’t get to the hospital within the 4 1/2 hour window, he said.

“In the past, there was no stroke treatment for them, and they ended up with a major deficit,” Zakaria said. “A lot of studies have showed with tPA, only 20 to 30 percent of stroke patients are a candidate for treatment. A majority of them don’t present on time.”

Time, above all, is crucial in stroke detection and treatment, doctors emphasized. Even with advances in stroke technology, Sacco stressed that, without exception, stroke patients have better outcomes the sooner they arrive at the hospital.

“Even if we have treatments we can use beyond 4 1/2 hours, the sooner a patient gets treatment, the better chance they have for meaningful recovery,” Sacco said.

Another stroke advance that focuses on the element of time in stroke detection is telestroke technology, which allows doctors to examine patients’ tests as well as the patients themselves via webcam and determine whether they’ve had a stroke.

Miami, with its surplus of major hospitals, hardly fits the bill for such technology, which is often thought of as only useful in rural areas. In many cases, Miami-area hospitals are acting as a resource for smaller, less centrally located hospitals in “hub and spoke” telemedicine networks. But there are also some local hospitals without on-call stroke teams using telestroke technology to treat patients faster.

The University of Miami, for one, provides telestroke consultations to Monroe County, where there are no stroke centers. Doctors at the university work with EMTs in the Keys to decide if the patient should be transported to the closest stroke center, Sacco said.

At Kendall Regional Medical Center, telestroke technology is used in a even broader capacity. Dr. Ricardo Garcia-Rivera, the founder and chief of the stroke center at Kendall Regional, started using telestroke in 2004 and now sees patients nearly exclusively through it. Now, when he’s on-call — often from his Redland home — he can see patients at more than 30 hospitals in 15 states, he said.

The consultation is just like having a doctor there in person, but faster, Garcia-Rivera said.

“It all takes maybe 10 minutes. Whereas by the time someone got there from their office or home, 10 minutes would have passed,” Garcia-Rivera said.

Kendall resident Alex Montero, 53, who had a stroke in mid-June, had a jarring initial introduction to the technology.

Montero first realized something was wrong when his head felt fuzzy while he was in the shower — then he couldn’t move his right leg or get out of the tub. Paralyzed and unable to speak, he was transported to Kendall Regional, fortuitously located close to home.

But instead of a doctor walking in, the hospital staff rolled in a screen and Garcia-Rivera popped up on the screen.

“It was really weird. It felt like I was in a sci-fi movie,” Montero said. Surprised and stressed out, his daughter asked for a “live doctor” instead. And hearing that death numbered among the risks of tPA through a computer screen rather than a live person was off-putting, Montero said.

But now, having made nearly a full recovery from the stroke except for some lingering tingling and numbness in his feet and hands, Montero said he wouldn’t have had it any other way.

“It was a tremendous blessing,” Montero said.

But even advances in stroke technology and treatment can only do so much, doctors say.

Calling 911 upon suspicion of a stroke is of the greatest importance, as is being aware of what stroke symptoms are, they say, something Florida and national campaigns are aiming to spread by promoting messages like “act FAST” —standing for face, arms, speech and time.

Also crucial is not waiting for the stroke to pass, or waiting for one’s primary care office to open, something doctors say they frequently hear and see patients doing.

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