Ischemic Stroke - Hennepin County Medical Center

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Profiles in Critical Care You are the Executive Director of the Minnesota Stroke Initiative. What is this initiative? The Minnesota Stroke Initiative is one of the largest stroke initiatives in the United States. There are three components. The first is education. Through the initiative, we’ve worked with several media sources like the American Heart Association (AHA) to provide educational materials in different forms to the public. The second aspect is clinical services and training. Clinical services include endovascular treatment, neurocritical care, stroke units, and stroke clinics. In terms of training, we now have one of the largest training programs in the United States in the subspecialties of stroke. A third very important component is research. We work with the National Institutes of Health (NIH) on research on the epidemiology of stroke, which will help identify new risk factors and methods of prevention. We also work with NIH and AHA to do clinical and basic research, developing new therapies for stroke. “It’s true that people don’t come to the hospital in time, but also hospitals don’t react to the need on time...recent studies have shed light on those deficits in the medical system, so we can’t just say it’s about patients not getting to the hospital on time.” When it comes to stroke care, what does Minnesota do well? What could we do better? Minnesota now has more specialized stroke centers than we used to have. Also, while in the past there was somewhat of a shortage of teaching programs that provide specialized stroke care, now there’s been a realization that we need to keep up with the rest of the country. As a program [at Hennepin County Medical Center and the University of Minnesota Medical Center, Fairview], we now would be rated in the top ten in the country, and that comes from having some of the largest training programs and clinical programs. As a state, we need to do more work on public education. We haven’t done as well as states like Florida, New Jersey, and Massachusetts. Those states also have defined standards of what they want to see in comprehensive and primary stroke centers, and here we have none of that. It’s a matter of funding at a state level, and the state getting behind it legislatively. In twenty years, what will stroke care in Minnesota look like? There will be evolution in three frontiers: First, evolution in patients recognizing a stroke earlier and coming to the hospital in time. Right now, we still have a lack of public recognition of what a stroke feels like, that stroke is treatable, and you need to go to the hospital as soon as possible and not wait until the next morning. Second, prevention. We will see programs trying to detect high-risk groups in the population and finding interventions that can target those groups and yield the best results. Third, treatment. There will be new treatments and the treatments will be applicable to a broader population. Right now, we have treatments only offered to 4% of the population. It’s true that people don’t come to the hospital in time, but also hospitals don’t react to the need on time. Hospitals aren’t currently ready to react in an expedient way, 24 hours per day. Recent studies have shed light on those deficits in the medical system, so we can’t just say it’s about patients not getting to the hospital on time. 12 | Approaches in Critical Care | December 2008
EMS Perspectives __________________________________ EMS Perspectives: Acute Stroke Paramedics from Hennepin County Medical Center transport a potential stroke patient. _____________________________________________ by Robert Ball, EMT-P, Hennepin Emergency Medical Services, Hennepin County Medical Center Acute stroke, or cerebral vascular accident (CVA), is the third leading cause of death in the U.S. Only heart disease and cancer (all types combined) have a higher mortality. Over 780,000 new or recurrent strokes occur each year or roughly one every 40 seconds. Stroke is the single largest cause of disability with over 4 million survivors; about 90 percent of those have at least some neurological deficit. History: Stroke treatment and EMS Historically, emergency medical services (EMS) has considered stroke to be a “life-threatening condition” but in the past it has been a threat that could not be mitigated. This tended to leave EMS at odds with other health care disciplines, as we would often find ourselves responding emergently to a patient who had an onset of stroke symptoms up to 24 hours earlier. The concept of stroke as a “brain attack” with definitive methods of treatment began in the mid-1990s, as ischemic stroke patients were treated with tPA and other “clot-busting” drugs. The limitations were great, however; patients with a symptom onset of greater than three hours were not good candidates for thrombolytics because necrotic areas had a higher risk of hemorrhage after this point. Also, guidelines dictated that treatment could not begin without ensuring the patient was indeed having an ischemic stroke and not a cerebral hemorrhage, which could be worsened by thrombolytic drugs like tPA. The narrow window of opportunity to provide an effective treatment made EMS a key stakeholder in reducing symptom onset to treatment time. Even so, the assessment necessary in the emergency department to ensure the patient was a suitable candidate for treatment resulted in a daunting challenge for providers, as some assessments were time-consuming. Since then, treatment for acute stroke has become more refined, including the use of intra-arterial administration of tPA at the site of the thrombus and mechanical clot retrieval devices. Such refinements in treatment have increased the window of treatment Approaches in Critical Care | December 2008 | 13
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