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The Battle for Your Brain

The word “stroke” used to trigger images of hopelessness, brain damage and people struggling to speak intelligibly or feed themselves. The outlook was bleak, not only for patients and families but also for the health care providers struggling to treat them.

Stroke was almost always a nursing home diagnosis. “Years ago, there was nothing you could do,” says Abdullah Nassief, MD, Washington University neurologist and director of the clinical stroke service at Barnes-Jewish Hospital. “You gave patients aspirin and oxygen and sent them to a chronic floor.” In just the past dozen years though, stroke treatment has experienced a turnaround. Thanks largely to the discovery of the clot-busting drug tissue plasminogen activator, or tPA, medical teams are able, in some cases, to completely reverse the effects of the most common type of stroke. Patients who once died or suffered disabling paralysis are going home within days and resuming normal lives.

Nowhere has the transformation been as dramatic as at Barnes- Jewish Hospital, where the rise to the top in stroke treatment and research has been deliberate and painstaking. A key has been the hospital’s ability to dramatically reduce what is called “door-to-needle time,” the time that passes from when a new stroke patient rolls through the hospital doors until receiving the clot-busting tPA.

“Reducing that time is critical in order to give the drug the best chance of working,” says Jin-Moo Lee, MD, PhD, Washington University neurologist at Barnes-Jewish. Research has shown that in order for the tPA treatment to be effective, it should be administered within three hours of stroke onset.

Decreasing the time it takes to begin treatment for stroke patients has been a top priority for hospital staff. Outreach workers have immersed themselves in the community, teaching emergency medical personnel and nursing home caregivers to identify the symptoms of stroke and stressing the importance of getting the victim to a qualified stroke center as quickly as possible.

Where elapsed time translates to decreasing chance for recovery, every minute counts. “Time is brain,” Nassief says. “No other hospital in the United States does it faster.” As a result, he believes that no other hospital offers a better chance for recovery.

Barnes-Jewish is set up to provide treatment within minutes to patients who might benefit. Lee believes there is room to save even more time and help even more patients. Currently, he says, only 4 to 5 percent of stroke victims who come to the hospital are eligible for the treatment. That number could increase dramatically if care were sought earlier.

The hospital sees some 1,000 stroke patients each year. Most arrive beyond the critical three-hour time window. But the hospital’s stroke team treats anywhere from 40 to 50 patients per year with tPA, by far the most in the area, making it uniquely qualified in the St. Louis region to treat more serious and complicated cases.

“In the wrong hands, tPA can be deadly,” Lee says. “Studies have shown that hospitals without a lot of experience actually end up causing more harm than good.”

Barnes-Jewish also has an advantage over other hospitals because it has the staff and equipment needed to handle particularly difficult cases and a specific inpatient unit dedicated to stroke patients as well as a specialized intensive-care unit and a rehabilitation unit that focuses exclusively on recovery after a stroke.

“Diagnosing a stroke is not that complex,” Nassief says, “but caring for a stroke patient is very difficult. We exceed at everything that has to do with treating a stroke. We’re better at reducing swelling, at preventing infection, at preventing clots to the lung and at predicting complications. And we’re better at initiating therapy early.”

“There are some phenomenal hospitals around the country,” says Colin Derdeyn, MD,Washington University radiologist who specializes in the brain and nervous system. “And there are some tremendous research medical schools. But it is very unusual to have a top-tier, full-service hospital like Barnes-Jewish paired with a world-class research institution like Washington University. I don’t think any place compares.”

Written by Bill Smith

3 Hours Can Make the Difference: tPA Effectiveness

A stroke is the sudden loss of blood flow to a region of the brain caused either by the blockage of an artery (ischemic stroke) or bleeding into or around the brain from the rupture or weakness of a blood vessel (hemorrhagic stroke).Only a small percentage of ischemic stroke patients are eligible for tPA, usually because they do not seek immediate emergency help or because of delays in obtaining treatment at a hospital.

From 2005 to 2007, the average “door-to-needle time” at Barnes-Jewish has dropped 23 percent.

tPA, or clot-busting drug tissue plasminogen activator, allows medical teams, in some cases, to completely reverse the effects of ischemic stroke.

Check for Symptoms of a stroke

1. Feel
Sudden severe headache with no known cause

 2. See
Sudden trouble seeing in one or both eyes

3. Talk
Sudden confusion, trouble speaking or understanding

4. Walk
Sudden trouble walking, dizziness, loss of balance or coordination

5. Reach
Sudden numbness or weakness of the face, arm or leg, especially on one side of the body  

Fact:
Stroke is the third leading cause of death, killing 170,000 Americans each year.

Improving Stroke Treatment

A team of stroke clinicians and emergency department staff at Barnes-Jewish Hospital borrowed techniques from the auto industry to give ischemic stroke patients a chance at better outcomes by reducing door-to-needle time for patients receiving tPA to 30 minutes.

 

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