05:29am Friday 20 October 2017

Quick thinking, efficient communication and intervention lead to improved outcome for Stroke patient

Quick thinking, efficient communication and intervention lead to improved outcome for Stroke patient click to enlarge Sylvia and Patrick Pope/Photo courtesy of the Pope Family Quick thinking, efficient communication and intervention lead to improved outcome for Stroke patient click to enlarge Patrick Pope having a little fun on a recent cruise/photo courtesy of the Pope family

“I worked in a nursing home when I was younger,” Sylvia Pope said. “I dealt with stroke patients there and knew what was happening.”

She called 911 immediately.

“Had it not been for my quick thinking, he might not be with us today,” Sylvia said.

Patrick was rushed to Sampson Regional Medical Center in Clinton, where providers quickly recognized that Pope was having a major stroke. When dealing with a stroke patient, efficiency is vital. So, they called David Huang, MD, PhD, director of the UNC Comprehensive Stroke Center.

During that conversation, Huang asked the providers in Clinton several detailed questions and began making plans to transfer Pope to Chapel Hill. The first step, Huang advised them, was to administer Tissue Plasminogen Activator (TPA). Received intravenously, TPA helps dissolve the patient’s blood clot and improve blood flow to the affected part of the brain, but it must be administered within three hours of the patient’s stroke to be effective, and even then, effectiveness varies widely.

“If TPA is administered within the appropriate window of time after experiencing a stroke, the percentage of patients who can function independently within three months or so can get into the upper 30s,” Huang said. “But that also means there are a lot of people who don’t get better, and many more people who don’t even receive this treatment because they don’t get to the hospital in time.”

According to the North Carolina Stroke Collaborative, 75 percent of stroke patients eligible for TPA in the past two years received it.

In the past, Huang said, TPA would have been the best option available to Pope. But, in his conversation with Sampson Regional, Huang decided he needed to initiate transfer to UNC Hospitals for a more specialized intervention using a retrievable catheter-based device. There are only a handful of hospitals in North Carolina capable of providing this intervention, and none east of I-95.

To perform this procedure, Huang and his colleagues use the Solitaire device, made by Covidien. Huang explained how it works.

“It’s basically a big stent tethered to a wire. You push it in past the patient’s clot, pull the guide wire out and deploy the stent. The stent opens up blood flow, and the wire is used to actually pull out the clot,” Huang said.

This procedure will always be a second step after TPA and is only available to patients with a clot that is accessible to the device. Huang said this will most often be the case with more severe strokes, such as Pope’s. And, as with TPA, timely intervention is critical.

“The benefit clearly goes down over time,” Huang said. “Statistics suggest that if you don’t deploy the device within six hours of the patient experiencing a stroke it becomes drastically less effective.”

Due to the small window of time and lack of hospitals in the state equipped to perform this procedure, Huang anticipates that he and his colleagues will treat many patients from the Eastern part of the state and even patients from South Carolina and southern Virginia. That’s why nailing down the process like the one that got Pope from Clinton to Chapel Hill is critical.

“In that case, within 10 minutes of me speaking with my counterparts in Clinton, UNC Carolina Air Care was wheels-up. We had the patient in Chapel Hill within an hour. Once we got him here, we were ready to do the procedure within 40 minutes.”

The results were seen quickly as well.

“He literally started talking on the table,” Huang said. “A few days later, he walked out of the hospital and you’d be hard-pressed to know he even had a stroke.”

This is not a new procedure, but it fell out of favor for a few years when initial studies did not comprehensively prove its effectiveness. Huang said the rates of catheter-based stroke interventions fell into the single digits over a two-year period.

That changed late last year, Huang said, when the results of a trial conducted in the Netherlands, using a more comprehensive methodology than previous studies, confirmed that patients who receive this treatment do indeed see better outcomes.

Huang said that with this procedure now being considered the standard of care, education is necessary so that emergency room physicians can identify when it is appropriate to get the patient to a Comprehensive Stroke Center like UNC Hospitals. UNC was the first medical center in the Southeast to be designated as a Comprehensive Stroke Center by the Joint Commission.

“In the last few months, the landscape of stroke care has shifted and there really is a need for comprehensive stroke centers. So, we need to really refine the procedure for getting patients to us sooner. And for us, this will probably mean a lot more patients, many coming from places that may not have sent them to us before,” Huang said.

Education will be vital.

“I anticipate spending some time traveling the state, meeting with Emergency Department directors in our referring hospitals so that they know what to look for. It’s important to raise everyone’s level of comfort in dealing with strokes,” Huang said.

“But, this really is a game changer. Even if we only do 100 or so of these in a year, that’s a big deal for those patients and a big deal for those families who no longer will be faced with caring for someone who is severely disabled.”

The Popes, who recently returned from a cruise vacation, certainly agree.

“I’m pretty much back to normal. I haven’t had any problems and am just trying to enjoy life and get out of the house as much as I can.” Patrick Pope said.

University of North Carolina at Chapel Hill School of Medicine


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