BE FAST to spot a stroke

Every 40 seconds—that’s how often someone has a stroke in the United States. It’s the fifth leading cause of death among Americans, with someone dying of a stroke every 3.5 minutes.

Although these statistics are alarming, the experts in the Petznick Stroke Center at Barrow Neurological Institute want to remind the public that strokes are often preventable. Additionally, thanks to advancements in diagnostic imaging and the increasing ubiquity of telemedicine, more patients are able to access stroke treatments.

Dani VanBrabant, Barrow Neurological Institute.

‘The Best Treatment of Stroke is Prevention’

Strokes caused by a clot, also known as ischemic strokes, represent about 87 percent of all strokes. The remaining 13 percent are hemorrhagic strokes, which occur when a weakened blood vessel in the brain ruptures and bleeds into surrounding brain tissue.

The American Stroke Association estimates that up to 80 percent of ischemic strokes may be preventable. While we can’t alter risk factors like age, sex, race-ethnicity, and genetics, we can control several others through lifestyle changes and medication.

Modifiable risk factors include high blood pressure, high cholesterol, smoking, diabetes, physical inactivity, and poor diet. Generally, the first four of these have the most significant impact on stroke prevention and can usually be managed with a primary care physician.

However, individuals with more complex risk factors may benefit from consulting with a vascular neurologist. This might include a patient who has carotid artery blockages or certain cardiac conditions in addition to high blood pressure and diabetes.

“We need to do a thorough evaluation first on a patient to see what interventions we should perform first in order to bring the best benefit and least risk or complications,” said David Wang, DO, a vascular neurologist at Barrow. “I’m not sure other non-stroke neurologists can adjudicate that way, because it takes the knowledge of intracranial circulation, the degree of the blockage, and other coexisting conditions in that patient.”

A vascular neurologist is also more likely to be up to date on the latest guidelines in clinical practice for stroke care, Dr. Wang said. For example, aspirin is no longer routinely recommended for preventing an initial stroke due to the increased risk of hemorrhage.

“Our literature evolves,” he said. “The way we’re managing strokes changes rapidly.”

Recommendations can also differ based on whether someone is trying to prevent an initial stroke or a recurrent stroke, also known as primary versus secondary prevention.

Because managing multiple risk factors can be daunting, the Petznick Stroke Center offers a Stroke Prevention Clinic to help. Each patient in the clinic receives an in-depth assessment from specialists and individualized education for how best to manage their stroke risk.

The Clinic recently began offering transcranial Doppler ultrasound, a noninvasive test which uses high-frequency sound waves to evaluate blood flow in and around the brain. It can be a valuable tool in assessing intracranial circulation abnormalities and monitoring stroke risk factors, such as sickle cell disease and patent foramen ovale.

“The best treatment of stroke is prevention, and there is a lot you can do,” Dr. Wang said.

A Patient-Centered Approach to Diagnosis, Treatment

If a stroke does occur, it matters where you get your care.

The Petznick Stroke Center has met the rigorous standards for designation as a Comprehensive Stroke Center by The Joint Commission. Offered in collaboration with the American Heart Association and the American Stroke Association, this certification is the highest level a hospital can receive for the care of complex stroke patients. It recognizes the dedication of Barrow and St. Joseph’s Hospital and Medical Center to providing the highest quality of stroke care across the continuum—from the pre-hospital setting through neuro-rehabilitation.

Michael Waters, MD, PhD, director of the Petznick Stroke Center, said Barrow offers a unique combination of dedicated specialists and cutting-edge resources—available no matter what time of day a stroke happens.

“You want to be in a center that has the right expertise, and you want that expertise to be available to you or your loved one 24 hours a day,” he said. “Stroke care is not shift work, and patients don’t only come in on banker’s hours.”

Barrow patients always have access to vascular neurology expertise, whether they are evaluated in the hospital’s emergency department, via teleneurology stroke coverage, or aboard the mobile stroke unit.

Established in partnership with the Phoenix Fire Department, the Barrow Emergency Stroke Treatment Unit was the first mobile stroke unit in the country to operate around the clock in a city with a population greater than 1 million. Equipped with a portable computed tomography (CT) scanner, telemedicine capabilities, and CT technologists and stroke-certified nurses, the unit functions as a stroke-specific emergency room on wheels.

In the emergency department at Barrow, patients have immediate access to the latest diagnostic imaging technologies for stroke. This means they can be evaluated for treatments beyond the traditional time window guidelines.

The American Stroke Association recommends that tissue plasminogen activator (tPA), or alteplase, be administered within 4.5 hours following symptom onset. This timeframe eliminates many patients who wake up from sleep with stroke symptoms, since they are unsure when their symptoms began. These “wake-up strokes” account for about one in every five ischemic strokes.

Emergency departments that aren’t able to provide immediate access to magnetic resonance imaging (MRI) are unlikely to consider patients with wake-up strokes for clot-busting medication, Dr. Waters said.

“We have the advantage of having emergent MRI available,” he added. “That means that a patient can be in the emergency room and get an MRI within minutes of arrival.”

If a patient arrives at Barrow with a wake-up stroke, MRI images are gathered and evaluated in a sequence to show any mismatch in the results. A mismatch indicates a penumbra, or the area of stunned but salvageable brain tissue surrounding the irreversibly damaged ischemic core, and may warrant a more aggressive treatment approach.

Another tool for differentiating the penumbra from the ischemic core is real-time perfusion technology, which Barrow offers for both MRI and CT scans.

“This allows us to get rid of the clock and focus on brain physiology,” Dr. Waters said. “So we’re moving away from time windows and more toward brain functional windows.”

Not only do these tests expand the number of patients who may be eligible for tPA, and a modified form of the drug known as tenecteplase, but it also allows Barrow to consider more patients for endovascular thrombectomy.

This procedure involves passing a small catheter through a large blood vessel and navigating it to the site of the blockage with the help of imaging guidance. Once the catheter reaches the blockage, the neurosurgeon can insert specializes devices and manually remove the clot.

“Endovascular thrombectomy for large vessel occlusion stroke is one of the most powerful therapies in all of medicine in terms of improving outcomes for stroke patients,” said Andrew Ducruet, MD, an endovascular neurosurgeon at Barrow. “Our team has developed cutting-edge strategies to improve treatment times, including the use of artificial intelligence, direct transfer from an outside hospital to our angiography suite, radial access approaches, and patient-tailored endovascular device selection.”

Telestroke: Expanding Access to Specialized Stroke Care

It’s not only patients who present to Barrow who can benefit from the Institute’s advanced treatment options including neuroendovascular expertise.

“Our growing stroke telemedicine network allows us to identify stroke patients more rapidly in outside hospital emergency rooms to facilitate their transfer to Barrow for thrombectomy,” Dr. Ducruet said.

Through the Barrow Telestroke Program, partnering facilities can connect with an on-call vascular neurologist at Barrow any time of day. The Barrow neurologist can perform physical and neurological examinations via video and review medical imaging remotely. The neurologist can then assist with treatment planning and transferring the individual to a higher level of care, like the Petznick Stroke Center, when appropriate.

“We can employ all of our resources and expertise before a patient even gets here,” Dr. Waters said. “I’ll already have a plan mapped out that I’m conveying to my in-house team.”

‘BE FAST’ to Spot a Stroke

Although specialized centers like the Petnzick Stroke Center are equipped to push the boundaries of traditional time windows, experts want to reiterate that “time is brain.”

“The sooner you get here, the more I can help you,” Dr. Waters said. “It may not influence what I can offer you in terms of treatment, but it absolutely influences the likelihood of a good outcome. Even if you have a large area of the brain that I can ultimately save, that area is getting smaller by the minute.”

To bridge the gap between stroke prevention and treatment, it’s important to know the signs and symptoms of a stroke:

B: Balance problems
E: Eye/vision problems
F: Facial drooping
A: Arm weakness or numbness
S: Speech problems
T: Time to call 911

R: Rostro caído
A: Alteración del equilibrio
P: Pérdida de fuerza
I: Impedimento visual
D: Dificultad para hablar
O: Obtenga ayuda rápido

From Stroke Treatment to Secondary Prevention

It’s also important to remember that stroke care doesn’t end with removing the clot.

Stroke is a leading cause of serious disability for adults, and many people with stroke are referred to neuro-rehabilitation. A combination of physical, occupational, speech, cognitive, and recreational therapies can help patients improve function and maximize their independence following a stroke.

“We have a full complement of rehabilitation, including inpatient, outpatient, and the Center for Transitional Neuro-Rehabilitation—whose principal objective is to get people back to work and home with family,” Dr. Waters said.

Stroke care also circles back to stroke prevention, because one in four survivors of a stroke will have another.

“We like to prevent the primary stroke, but secondary prevention is huge,” Dr. Waters said. “We’re going to help you recover from your first stroke, but just as importantly, we want to prevent you from having another one.”