In September, Willie Frank Blackburn of Washington, Ga., a rural city of 5,000 people, had just left his auto shop when his tow truck slid off the road. Police officers who happened to be nearby found him slurring his speech and acting unlike the person they knew. His daughter, the director of nursing at Wills Memorial Hospital, a 25-bed acute care facility, knew he was showing signs of a stroke.
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Blackburn was brought to the hospital by paramedics who called ahead because they understood that time plays an important role in the recovery of stroke victims. The telemedicine stroke team was ready for his arrival. Within minutes he’d had a CT scan. A cart with a mobile two-way camera that enables observation and has the ability to transmit scans was set up between Wills and Augusta University Medical Center, a major stroke facility where highly trained neurologists, usually not found at rural hospitals, are always on duty.
After looking at the scan and the patient, the experts at Augusta determined that Blackburn had had an ischemic stroke and instructed the Wills staff to inject tPA (tissue plasminogen activator), the only FDA-approved treatment for ischemic strokes. It dissolves clots and allows blood to flow to a brain that is being deprived of oxygen.
Once his condition stabilized, Blackburn was transferred for further care to Augusta.
“The neurologist there told me that, had my father not received tPA so quickly, the damage from his stroke would have been devastating and irreversible,” says Angie Vickery.
Timely treatment is critical to limiting damage from a stroke. If Blackburn had needed to be transported to a major stroke center, lack of oxygen would have had several more hours to destroy brain cells and wreak havoc. Telestroke systems allow patients in rural and other remote areas to be assessed and receive treatment quickly.
A stroke occurs when a blood vessel that carries oxygen and blood to the brain is blocked. An ischemic stroke occurs when a clot obstructs the flow of blood to the brain; a hemorrhagic stroke occurs when a blood vessel ruptures and prevents blood flow to the brain; and a transient ischemic attack (TIA) or ministroke, occurs when blood flow is temporarily obstructed.
According to the American Stroke Association, symptoms of stroke include sudden numbness in the face, arms or legs or on one side of the body, sudden confusion and trouble speaking, sudden trouble seeing, sudden trouble walking or symptoms of dizziness or loss of balance and coordination, and sudden severe headaches with no known cause.
The Centers for Disease Control and Prevention says stroke is the fifth leading cause of death for Americans and the leading cause of long-term disability. Every year, almost 800,000 Americans have a stroke and 130,000 of those people die. One out of every 20 deaths in the U.S. is the result of a stroke. Of total yearly strokes, the CDC says 87 percent are ischemic strokes that can be treated by injecting tPA.
The American Stroke Association says that, if administered within three to four hours, tPA can improve the chances of recovery. That’s one reason it’s important to identify the signs of stroke quickly and get a patient to a hospital in time. With the advent of telestroke systems, more people than ever have access to quick treatment that would otherwise not be available.
At Augusta University, Dr. David Hess is the chairman of the department of neurology at the Medical College of Georgia and a designer of a telestroke system known as REACH, a platform that reaches out to rural and underserved Georgian hospitals without stroke specialists.
Doctors can log on to a secure system from anywhere and connect directly to a rural hospital for a videoconference. If appropriate, depending on what the imaging shows, experts determine a tPA dose, which works only if the stroke is ischemic and if the drug is injected intravenously within three hours of the onset of symptoms.
“Two million brain cells die every minute during a stroke,” warns Hess, stressing the urgency of time.
Telestroke was conceived in 1999 and is now part of mainstream care for patients with acute stroke. Hess says the main push for the use of telestroke was and is to increase the appropriate injection of tPA in patients with acute ischemic stroke. Hospitals with fewer than 100 beds usually don’t have a neurologist on staff or the proper intensive care capabilities. Often, patients are treated with tPA and then transferred to a larger “hub” hospital.
Dr. Michael Mullen, director of the telestroke program at the University of Pennsylvania’s Penn Neuroscience Center, a facility known as a “hub” hospital, says that, although stroke is common, there is a limited amount of expertise in the area.
Stroke experts — those trained in neurology and vascular neurology — tend to be clustered at large medical institutions. He says his program works best with smaller hospitals that do not have local stroke expertise and where Penn’s neurological specialists can help ensure that the highest possible care is available 24/7.
Mullen’s colleague Christopher Ware is the medical director who oversees the telestroke program at Chester County Hospital, one of the University of Pennsylvania’s smaller “spoke” community hospitals. He says that a National Institute of Neurological Disorders and Stroke study, published in 1995, showed tPA improved outcomes for stroke victims; before that, doctors would only learn the outcome of a stroke by watching and waiting.
Now, for patients who are appropriately identified and who reach treating physicians within a three- to four-hour window, tPA can reverse clotting and lessen potential damage.
“Effective therapies do exist for stroke, but they are time-dependent,” says Mullen. “Patients need to recognize the symptoms and quickly call 911, while providers need to facilitate the best possible outcomes.”
Barbara Sadick is a freelancer.
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