Opening the Time Window Wider for Better Stroke Treatment
When it comes to stroke, where you go for treatment can make the difference between going home afterward with good function or being sent to a nursing home with severe disability.
The statement seems harsh, but it’s reality.
Research and treatment protocols for stroke being developed at Barnes-Jewish Hospital and Washington University are giving patients better outcomes and more options than ever for a healthier, more fully functioning quality of life.
Time is Brain
The Stroke and Cerebrovascular Disease Center at Barnes-Jewish Hospital and Washington University is a comprehensive stroke center, meaning the multidisciplinary team has the ability to deal with all facets of stroke treatment. The team, which includes neurologists, neurosurgeons, neuroradiologists and rehabilitation specialists, is activated by the emergency medical services (EMS) crew in the field and is ready and waiting when the patient arrives by ambulance.
“We say that ‘Time is Brain’ during a stroke,” explains Jin-Moo Lee, MD, PhD, Washington University neurologist and Head of the Cerebrovascular Disease Section. “We apply that to our patients, which is the reason our outcomes are so good. The time factor is also why it’s critical to recognize the symptoms of stroke and to get immediate medical attention.”
It Starts with tPA
Most successful treatment for an ischemic stroke, an attack occurring when an artery to the brain is blocked, relies on the use of tPA (tissue plasminogen activator). tPA is a clot-busting drug used for acute stroke that can significantly reduce long-term disability if given within a specific three-hour treatment window. If treatment isn’t received in time, part of the brain dies due to the clot blocking blood flow to the brain. Paralysis, slurred speech, and other impairments can follow.
The first use of tPA happened at the former Barnes Hospital in the 1980s and that research helped pave the way for the treatment of patients today. The Barnes-Jewish stroke team also has one of the best “door-to-needle” times – the time between a stroke patient’s arrival at the hospital and administration of tPA – in the country.
Pushing the Time Envelope
However, some patients who miss the three-hour treatment window still have hope, thanks to investigative treatments at Barnes-Jewish and Washington University.
“With some ischemic strokes we’re finding we can still treat patients up to four and a half hours after stroke, rather than the traditional three hours,” Lee says.
“We’re leading the way in this treatment, by developing protocols for this extended therapeutic window.”
The National Institutes of Health (NIH) recently provided an $11 million grant to establish the Specialized Program for Translational Research in Acute Stroke (SPOTRIAS) Center – one of only eight throughout the country, headed by Colin Derdeyn, MD, in Neuroradiology. One of the studies at the SPOTRIAS Center includes testing a theory that strokes in blood vessels that supply the back of the brain may be treatable with tPA for a longer time period.
Lee is excited about pushing the envelope in stroke treatment.
“In patients with a specific type of stroke that affects the back of the brain, we’re exploring the possibility that the brain stem can live up to 24 hours after a stroke,” Lee explains. “So we believe that the therapeutic window for the brainstem may be longer than the rest of the brain.”
Lee says symptoms are different for a brain stem stroke than other types of strokes. Brain stem strokes result in double vision, a spinning feeling, uncoordinated gait, and slurred speech. Other types of stroke generally cause facial droop and arm weakness.
“We have a lot of educating to do with emergency workers, especially since brain stem strokes comprise 20 to 25 percent of all strokes,” Lee says.
He and his colleagues are developing a specific testing scale for EMS crews to use to determine which type of attack the patient is having.
One Size Treatment Does Not Fit All
Since tPA treatment is not an option for some patients, Lee believes in five years there will be many more interventions and treatment modalities for stroke. Currently, he and his colleagues are researching other options, including catheterization interventions up to 12 hours after a stroke that improve blood flow to the brain.
The future of stroke treatment also may hold ultrasound or lasers to dissolve clots, as they are used now to dissolve kidney stones. Or a catheter device to retrieve the clots from the blood vessels. “We’re realizing one size doesn’t fit all in stroke treatment,” Lee says.
Barnes-Jewish outcomes at discharge after stroke are significantly better than the national averages, Lee points out. “At Barnes-Jewish, one in four patients are able to go straight home after a stroke compared to one in eight nationally. Typically, 25 to 30 percent of patients nationwide end up in a nursing home after a stroke. But at Barnes-Jewish, we reduce that to 15 percent, while another 53 percent go to rehab and then home.”
He counts the rehabilitation facility at Barnes-Jewish Hospital as an important component in successful outcomes. “Our comprehensive stroke center truly offers 360-degree, comprehensive care, from the emergency department to the hospital to rehabilitation to our outpatient clinic,” Lee says.
Lee’s goal is to share the Stroke Center team’s knowledge and protocols with other hospitals in the St. Louis metropolitan area and surrounding counties. “There are 18,000 strokes every year in the metro area,” he says. “We can’t care for all of these patients alone so we hope to share our expertise by partnering with hospitals to help more patients have better outcomes after stroke.”