June 2009
By Julie Budnik
Stroke was first recognized over 2,400 years ago by Hippocrates and labeled as “apoplexy,” meaning “struck down by violence.” An apt description given that the victim had sudden onset of paralysis and dramatic physical changes. Early Greek physicians had very few ideas about the cause of apoplexy, let alone how to treat it. Stroke is the third leading cause of death in the United States today behind heart disease and cancer. In Georgia, which is located in the center of the “stroke belt,” the stroke death rate is twice that when compared with the rest of the nation. Luckily, today’s stroke patients have a much better chance of survival and positive outcomes when treated at a stroke center.
North Fulton Regional Hospital is a premier leader in stroke medicine in the north Georgia area. In 2005, North Fulton Regional Hospital was awarded the Gold Seal of Approval for stroke care when the Joint Commission on Accreditation of Healthcare Organizations named the hospital as a Primary Stroke Center after an extensive on-site review. Emergency room practices, inpatient care, appropriate use of medications and rehabilitation facilities are just a few of the factors that came in to play in the evaluation.
The highly skilled team of health care professionals at North Fulton Regional Hospital Stroke Center realize that time is of the essence when dealing with a stroke victim. The center is supported by over 100 nurses and therapists trained in advanced stroke life support as well as five board-certified neurologists available 24 hours a day, seven days a week. A coordinated multifaceted approach is used to ensure that patients are given the best possible chance for a successful recovery.
When the initial EMS call comes in from the field, the ER team, led by Dr. Michael Lipscomb, Medical Director of the emergency department, is alerted that a potential stroke case is en route. The North Fulton Regional Hospital team uses the trauma approach to treat strokes by activating multiple areas including radiology, laboratory and the hospital’s rapid response team. “The stroke coordinator oversees the stroke program and ensures that the overall process runs smoothly,” says Dr. Lipscomb.
The ER physicians will be waiting for the patient to confirm the field diagnosis with blood work, EKG and CT. North Fulton Regional Hospital has preloaded orders for CT scans in the system for ER physicians to easily access. Patients are immediately sent to one of two dedicated CT scanners to determine the type of stroke-ischemic or hemorrhagic.
While the workup is in progress, a neurologist will be on the way to assess the patient as a candidate for treatment with tissue plasminogen activator (tPA).
tPA is a fibrinolytic agent involved in the breakdown of blood clots but is approved for use in patients who present within three hours of the initial onset of symptoms. Newly published data from the ECASS III trial in The New England Journal of Medicine suggests that the time period may be extended by 1½ hours and still be effective.
“Out of a group of 100 stroke patients that present to the ER, it is likely that only four or five will be considered eligible to receive tPA,” says Dr. Lipscomb. “It is important to know the potential complications and risks inherent with the medication. Families should be consulted and fully informed on the benefits and risks of tPA. “There is a 6-7% increased risk of intracranial hemorrhage with tPA administration. Gastrointestinal and retroperitoneal hemorrhage may also occur.
In some cases, tPA can be a wonder drug. Dr. Frank Puhalovich, Director of the Stroke Program at North Fulton Regional Hospital, points to the case of an 89-yearold man brought in by EMS within one hour of exhibiting stroke symptoms. “His stroke was massive and would have meant substantial neurological deficit,” says Dr. Puhalovich. “He was given tPA and had a remarkable response to the medication and today has only minor issues on his left side.”
Subacute strokes are treated entirely differently because the time factor does not come into play. “Patients come in with a focal deficit, which indicates stroke,” says Dr. Puhalovich. If a patient is not tPA eligible, they are admitted to the hospital and begin pharmacological treatment as well as receive physical, occupational and speech therapy.
As a neurologist, it is Dr. Puhalovich’s responsibility to evaluate patients for the best treatment option. Although the assessment process for stroke is virtually unchanged from past years, treatment is much broader in terms of options. “In some cases, intra-arterial tPA and mechanical manipulation of the clot is being used to clear blockages. Most recently there is a trend toward using tPA and other modalities such as transcranial ultrasound to break up and agitate the clot. This is less invasive and does not require a specialist,” says Dr. Puhalovich. Dextrans are still used in some patients and statin drugs are starting to show promise in terms of preventing stroke recurrence. “Neuroprotective medications like calcium channel blockers are not as effective as we had hoped they would be, perhaps because they are lowering blood pressure at a time when we need increased pressure,” says Dr. Puhalovich.
Approximately 20% of stroke patients are admitted with a hemorrhagic stroke. A small percentage of these may require surgical intervention. Of the few studies that have been performed, there are mixed results as to the benefits of surgery.
“The indications for surgery in intracranial hemorrhage are a bit of a controversial subject,” say Dr. Charles Weaver Jr., M viagraindian.com.D., Ph.D. “Neuroimaging capabilities including conventional angiogram, CT angiogram and the North Fulton Regional Hospital’s 3-tesla MRI have improved our ability to identify underlying lesions that increase a patient’s risk for further bleeding.” The hospital’s 3-tesla MRI is one of only a few in the state and provides the highest imaging resolution and anatomic detail available.
In hemorrhages with no underlying lesion, the decision to operate is individualized and dependent on the patient’s neurologic symptoms, the location and size of the hemorrhage, patient age and other medical conditions.
“You have to take into account the family’s wishes regarding surgical intervention for hemorrhagic stroke,” says Dr. Weaver. “In some cases, surgery is considered a ‘heroic’ intervention in the case of a potentially devastating illness.”
In order to receive and maintain Primary Stroke Center Certification, a neurosurgeon must be available within two hours of initial notification. Dr. Weaver and his partner, Dr. Steven Disch, actively practice at North Fulton Regional Hospital.
Once the patient is diagnosed, stabilized and treated, the rehabilitation process begins. Usually within a 24- to 72-hour period, patients will have some type of intervention by the rehab team. “The Critical Care and Medical Telemetry Units have physical, occupational and speech therapists assigned directly to their acute areas,” says Dr. Alan Harben, who serves as the Medical Director for the Department of Rehabilitation Medicine at North Fulton Regional Hospital. Some patients will be transferred to the 33-bed Comprehensive Acute Rehabilitation Unit and have a nurse assigned to them to manage pulmonary, swallowing, bowel and bladder and skin health issues.
Dr. Harben, who is board certified in physical medicine and rehabilitation and pain management, works in close collaboration with the neurologists and neurosurgeons to develop a treatment strategy specific to each patient’s need. “With a team approach, it is possible to streamline the whole hospital process so the patients can move more quickly from the acute care areas to rehab,” says Dr. Harben.
The rehabilitation team is striving to maximize recovery from stroke while minimizing complications. There is a whole host of rehab options that are available to stroke patients at North Fulton Regional Hospital. In the early days of stroke rehab, choices were limited to splinting, casting and alcohol blocks. Today, pharmacologic and surgical options are on the table as well. With the advent of botulinum toxin or Botox for spasticity and pain relief, patients can experience the benefit of spasticity reduction without the side effects of alcohol blocks. Most recently, intrathecal baclofen implanted pumps have been introduced as a programmable way to manage pain. The catheter is placed into the spinal column and baclofen is delivered directly to the area where spasticity originates.
Spasticity management is just one area that the rehab team evaluates. Pharmacologic management of patients involves a combination therapy of antidepressants and stimulant medications that promote arousal and attention to help with recovery. “We work in conjunction with neurology to select medications that will help with arousal and memory,” says Dr. Harben. Different unique combinations of medications are explored to improve arousal and awareness. “Some intervention begins even in ICU with stimulant medications. If there is severe spasticity, we may use Botox injection therapy.” In addition, surgical intervention may be necessary to control spasticity for a better patient outcome.
Dr. Harben and his staff conduct rounds on a daily basis to monitor patients for behavior, motor and cognitive changes. Each patient has a case manager to establish a care plan for rehabilitation. Once patients are discharged, Dr. Harben continues to monitor their progress and will follow them in his office to adjust medications and spasticity or for pain management. If late complications develop in terms of pain issues, patients may be referred to North Fulton Regional Hospital’s pain management group.
The stroke care team at North Fulton Regional Hospital reports all of its stroke data to the Coverdell Stroke Registry, which was named after longtime Georgia Sen. Paul Coverdell, who died in 2000 from a cerebral hemorrhage.
Well-known risk factors for stroke include hypertension, diabetes, hyperlipidemia, smoking, obesity, physical inactivity, atrial fibrillation and carotid disease. North Fulton Regional Hospital’s dedicated team is focused on the future and trying to educate the community about the dangers and prevention of stroke. Community health events are offered periodically and include cholesterol and carotid bruit screenings. In addition, the community education team provides stroke lectures for varying local organizations and first responders such as EMS and fire departments. “We are trying to reverse, minimize and prevent future stroke,” says Dr. Lipscomb.
North Fulton Regional Hospital’s stroke team is dedicated to providing full-service quality care for patients and their families. “North Fulton has a really good interdisciplinary approach to stroke care with a full spectrum of services,” says Dr. Harben. Capable of treating patients from the time they enter the emergency department through the acute care process, potential surgical intervention and rehabilitation, North Fulton Regional Hospital offers a continuum of care for stroke patients that is unique in Metro Atlanta.
