When Stroke Strikes
Wednesday, September 19, 2012 • 9:14pm
The message is simple, and worth repeating: When it comes to stroke, time is brain.
Here's why: In an ischemic stroke (the most common form of stroke), an arterial blockage causes blood flow in the brain to stop. The absence of normal blood flow results in an absence of oxygen—and without oxygen, healthy brain cells begin to die, one after another. Without medical intervention, a person can be left with severe disabilities and impairments.
"Stroke is a race against time," says Robert Felberg, MD, the new Medical Director of the Comprehensive Stroke Center at Overlook Medical Center's Atlantic Neuroscience Institute. "There is never any time to waste."
Recognizing the signs of stroke is essential (see the "Act FAST" information, at right), as is receiving quality care—preferably at a designated Stroke Center. The Stroke Center at Overlook, awarded the Gold Seal of Approval from The Joint Commission for Primary Stroke Centers, was the first site in the state to be designated a Comprehensive Stroke Center by the New Jersey Department of Health and Senior Services. The designation is a reflection of Overlook's ability to diagnose and treat stroke at the highest levels. "We have the technologies and the skill to use the most up-to-date and aggressive treatments to manage stroke," says Felberg. "We have the ability to do whatever is medically possible to bring a patient out of danger. We also have physicians and nurses with special training in neuro-critical care. Almost every hospital has a critical care unit, as we do, but we also have an additional ten beds dedicated to neuro-critical care for the management of stroke, aneurysm, and brain tumors. Very few hospitals have this."
The power to intervene
The standard course of treatment for ischemic stroke is tPA (tissue plasminogen activator), a powerful thrombolytic (clot-busting) drug that is administered intravenously. But tPA can be administered only within 4.5 hours of an ischemic stroke, which serves to reinforce the importance of recognizing symptoms, noting their time of onset, and calling 911 to be transported to a Stroke Center immediately.
Beyond the 4.5-hour window for tPA, or in instances when the onset of stroke symptoms is unknown, certain patients who have had an ischemic stroke are candidates for endovascular interventions. These catheter-based procedures, in which clots are removed mechanically, sometimes in conjunction with injections of tPA directly into the blockage, expand the window of time for treating stroke.
Overlook's specialized stroke team includes four doctors who are available 24/7 to perform these life-saving interventions. "We partner with Overlook's impressive group of neuro-interventionalists to extend the window for treatment to 8 hours and beyond," says Felberg. "Patients who may not qualify for IV-based thrombolytic therapy can often be considered for intra-arterial and catheter-based therapies."
Ronald Benitez, MD, Director of Endovascular and Cerebrovascular Neurosurgery for Atlantic NeuroSurgical Specialists, explains that one such method of intervention is the Merci Retrieval System, which was introduced at Overlook in 2005. Once the location of a clot has been identified through angiography (an imaging technique used to visualize the inside of blood vessels), a balloon guide is inserted through a small incision in the femoral artery in the groin. Using X-ray images as a digital roadmap, the guide is maneuvered through blood vessels and into the brain. A guide-wire and micro-catheter are deployed through the balloon guide and placed just beyond the clot. The physician then deploys the Merci Retriever—a flexible wire that curls into a corkscrew—to ensnare the clot. When the clot is captured, the balloon guide is inflated to temporarily stop blood from moving forward while the clot is being withdrawn. The balloon is then deflated, and blood flow is restored. Penumbra, another device for removing clots mechanically, works similarly to the Merci Retrieval System but utilizes suction to remove a clot.
"Sometimes you can actually see the difference in a patient right away, as blood flow is restored in the brain," says neurosurgeon and neuro-interventionalist David Wells-Roth, MD, of Atlantic NeuroSurgical Specialists. "The use of tPA is still the first line of treatment for ischemic stroke, but these interventions have the ability to save lives when tPA cannot be administered."
In August, reports Benitez, Atlantic NeuroSurgical Specialists' endovascular neurosurgeons became the first group of doctors in the country trained on a new device, called a stentriever, following its FDA approval. It works much like the Merci Retrieval System, but uses a stent instead of the corkscrew-like wire and restores blood flow immediately. "We know with stroke that every second counts," says Benitez, "so being able to restore blood flow sooner is significant."With this, we are literally at the forefront of stroke treatment," he adds.
Diagnosing stroke from a distance—but not at a disadvantage
As a Comprehensive Stroke Center, Overlook helps to anchor a regional network of more than a dozen Primary Stroke Center hospitals in New Jersey. This allows Overlook physicians to share state-of-the-art stroke-related diagnostic and treatment technologies with physicians at other institutions, ensuring that stroke patients across the state receive the best possible medical care.
Through the introduction of its new Telestroke Program, Overlook's reach will be even greater. Telestroke utilizes state-of-the-art video communications, so that a patient at an outlying hospital can be evaluated for stroke by an Overlook physician. "We see patients on a computer monitor that's so powerful, I can differentiate eyelashes across a room," Felberg says of the "stroke robot" that houses the monitor and other necessary equipment. "The doctors and patients see me, and I see them; they hear me, and I hear them. It's like I'm in the room with them, but actually I'm across town or even across the state."
Currently, Telestroke is in place at Overlook Medical Center and at its satellite Emergency Department in Union. (In coming months, Overlook expects to enlarge the Telestroke treatment area by enrolling a number of referring hospitals.) Union patients who may qualify for intervention are evaluated through the Telestroke Program. If the patient then needs intervention, he or she is transferred to Overlook for management after receiving IV tPA, or transferred for mechanical intervention in Overlook's Catheterization Lab. "It's been shown that people who receive Telestroke evaluations get treated as quickly as or quicker than those who don't," says Felberg. "What we're doing with Telestroke is leveraging technology so people can get high-level evaluations quickly and at their local emergency center."
The most important thing, Felberg reminds, is to be able to recognize the signs of stroke and seek help quickly. "The best thing is to call 911 and go to an E.R. by ambulance" he says. "Once you're here, we'll take care of the rest."
Atlantic Health System is on the forefront of medicine, setting standards for quality health care in New Jersey and the New York metropolitan area.
Renowned for its breadth of cardiac services, including bypass surgery, angioplasty, and implantable pacemakers, Morristown Medical Center performs the second most heart surgeries in the New York metropolitan area. Overlook Medical Center, the regional leader in comprehensive stroke care and neuroscience services, was the first hospital in the Northeast to utilize the revolutionary CyberKnife robotic, image-guided technology. In addition, Newton Medical Center offers a variety of inpatient and outpatient programs and services in a state-of-the-art environment. Our nationally recognized medical doctors, experienced nurses and skilled staff provide outstanding and compassionate health care.
In all our specialties, such as pediatrics, orthopedics, cancer care, rehabilitation medicine, women's health, cardiovascular care and neuroscience, Atlantic Health System physicians are leaders in their fields, always searching for the most effective diagnosis and treatment options for each patient.
Our world-class facilities feature state-of-the-art equipment in a comfortable, family-friendly environment that puts patients first. Atlantic Health System is the primary academic and clinical affiliate in New Jersey of Mount Sinai School of Medicine and The Mount Sinai Hospital. Pursuing the leading medical technologies and treatments to continuously improve our medical services and provide you with the best health care is Atlantic Health System's goal; our programs are consistently lauded for their excellence by physicians and patients alike.
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