Health Care: Innovations in Stroke Care

When the brain is under attack by a stroke, a team assembles ready for battle, says Dr. Kerri Remmel.

“The patient is at the center of the team and all of us work to improve the patient’s wellness and brain health,” she said. “We want to prevent future strokes and enhance overarching wellness for those patients.”

Today’s stroke care teams are armed with increasingly effective medications, surgical interventions, communication and diagnostic tools to achieve greater rates of victory over this potentially debilitating and deadly vascular incident.

Remmel is professor and chair for the Department of Neurology at the University of Louisville and director of the UofL Hospital Stroke Center. New treatments are in development and those already in use are being refined to be less invasive, she said. Imaging capabilities, too, continue to advance, along with endovascular treatments used by neurologists and neurosurgeons.

Stroke is a vascular condition—or more simply put, a blood vessel problem. There are 400 miles of vessels inside the brain supporting brain function so issues can be caused by small vessel disease, clotting disorders, genetic factors, large vessel atherosclerosis and even unknown causes. Ischemic strokes are the most common type. Hemorrhagic strokes involve bleeding in the brain and comprise 13% of cases, Remmel said.

Now there are treatments that can completely reverse symptoms of strokes, like IV thrombolytics. Given within a four-hour window from the last known time a patient felt well, these drugs serve as “clot busters” and can minimize or eliminate the aftereffects of a stroke.

Other endovascular surgery treatments can be performed if patients are deemed suitable candidates and if it’s within a 24-hour window from their last known well time, Remmel said.

Christina Brady, the stroke program manager for Saint Joseph Hospital and Saint Joseph East in Lexington, said stroke is the No. 4 cause of death in women and can affect anyone at different ages, with major risk factors including smoking, aFib (irregular heartbeat), obesity or having had a previous stroke.

Though some patients delay treatment hoping symptoms will go away, clot-busting medications need to be administered quickly to restore blood flow back to the brain and surgery can be scheduled for some hemorrhagic stroke patients.

“That’s why we want everyone to get into a certified stroke center,” she said.

On the national stage, a new medication called TNK (Tenecteplase) has emerged. Though not yet approved, TNK is showing encouraging early results as a future alternative clot-busting medication, Brady said.

Anticoagulants, statins and antithrombotic medications are prescribed to help manage risk factors like blood clotting and cholesterol, Brady said, and the latest CTA (computed tomography angiography) and CT perfusion equipment gives medical personnel clear pictures of what’s going on in the brain during a stroke.

“These images help us know exactly where the stroke is occurring and what tissue can be saved in the brain,” she said.

During the early days of the pandemic, fewer patients sought care in the emergency department for stroke, some out of fear of contracting COVID-19 during a medical visit or because family and friends weren’t around as much to notice obvious symptoms, she said.

Studies are now emerging that show the decrease of stroke reporting may have led to higher morbidity and mortality in these patients, Brady said. However, lately patients have been returning as before to emergency departments when concerned about possible stroke symptoms.
Coordinated efforts at the local, state and national levels are also helping fine-tune stroke care for all.

Dr. Larry Goldstein is chair of the UK HealthCare Department of Neurology and co-director of the Kentucky Neuroscience Institute, as well as an associate dean for clinical research.

Goldstein said hospitals in Kentucky are categorized in terms of where a stroke patient will be sent by emergency medical services: the closest hospital, a primary stroke care hospital, a comprehensive stroke care hospital or acute stroke-ready hospital. The patient may be sent to one hospital for immediate treatment then transferred if needed to a more advanced center elsewhere.

To better engage hospitals and improve levels of stroke care across the board, UK teamed with Louisville-based Norton Healthcare to form the UK Norton Healthcare Stroke Care Network. The network is comprised of 37 hospitals throughout Kentucky, southern Indiana and West Virginia, Goldstein said.

Network officials work with hospitals’ stroke programs, protocols and education, collecting performance metrics to help provide the best possible stroke care. With a bit of a different reach, he said, a program called SEQIP—Stroke Encounter Quality Improvement Project—is conducted in conjunction with the Kentucky Heart Disease and Stroke Prevention Task Force.

In 2021, after the University of Kentucky’s first-time proposal to join was accepted, Kentucky became part of the Paul Coverdell National Acute Stroke Program. The program was founded in 2001 and named for U.S. Sen. Paul Coverdell, who passed away from a stroke.

As part of this designation, the Kentucky Department of Health and others are working to coordinate different stroke-related programs statewide, and to fulfill goals outlined by the Centers for Disease Control. They’re also working to address unmet needs and build on existing strategies.

Goldstein said the strategy was to identify the counties in Kentucky with the highest stroke mortality rates, understand what resources for stroke patients are available, then work with hospitals and providers in those counties to try and address stroke risk factors and improve care.

Lea Anne Edwards is a PCCN (progressive care certified nurse) unit facilitator and a cardiovascular unit/critical care unit stroke program coordinator for Ephraim McDowell Regional Medical Center in Danville. She said patients and their families who are concerned a stroke is occurring shouldn’t try to drive themselves to a medical facility but instead call 911, as ambulance personnel can evaluate the condition, call ahead to the hospital best suited to treat the severity of the symptoms, and facilitate faster treatment.

Ephraim McDowell RMC doesn’t have clot-busting drugs onsite, Edwards said, but can further evaluate via CT scan or other means to diagnose and treat patients until, if needed, they can be transferred to a facility that does have these drugs. Scans collected here are sent to cloud storage so even if transferred, patients’ eventual treating physicians can easily retrieve them.

Programs like Viz AI allow practitioners in different facilities to communicate about a patient’s needs and diagnosis and any needed interventions like surgical clot removal, Edwards said. In the end, patients may be able to remain in Danville for treatment.

Raising awareness, encouraging prevention
In any case, people need to know the symptoms of a stroke and that people’s symptoms can differ from person to person. Some may be dizzy or lightheaded, others may have numbness in their hand or trouble walking, Edwards said.

“These are all signs of a stroke, and they should come in and have it looked at,” she said. “It’s always better to overreact than underreact.”
The southern United States has the highest rates and mortality rates for stroke, Remmel said. In 2007-09 in Kentucky, the western and easternmost parts of the state were most affected. But as more stroke centers have opened up across the state, by 2017-2019 these areas’ stroke and stroke mortality numbers have decreased somewhat, though stubborn pockets of higher rates remain.

West Louisville has been designated as a food desert, where it’s more difficult to access fresh produce that’s a cornerstone of a healthy diet. Other socioeconomic factors like housing insecurity and transportation difficulties are also more common here, elevating cardiovascular disease and stroke risks.

Remmel said UofL facilities “are juxtaposed very conveniently.”

“The UofL hospitals are very close to the west end of Louisville and can conveniently serve our patients of greatest need,” Remmel said.
They also educate people about symptoms and risk factors and provide other support via a cardiovascular risk clinic established in west Louisville to provide prevention education and continuity of care via telemedicine, medication management and more.

Innovations aside, it’s obviously better to not have a stroke at all, leading those in the medical community to advocate for greater public education.

“We want to prevent the first-ever stroke, so how are we going to do that?” Remmel said. “Education and aggressive management of risk factors.”

People can start by knowing their numbers for blood pressure, blood glucose levels and cholesterol and keeping those well-managed with the help of their primary physicians. Eliminating risk factors like smoking and a sedentary lifestyle also help. Even small improvements can have marked impacts on stroke prevention, Remmel said.

UK HealthCare’s Goldstein said from the early 2000s through around 2012, there were statistical declines in stroke-related deaths nationwide. However, around 2013-14 the curve started to flatten and eventually increase. Kentucky has also followed this trend; in 2015 stroke numbers started to climb here too.

“That can come from a variety of different possible causes,” he said. “We think that a good portion of that is poor risk-factor control. The best way to treat a stroke is never to have it to begin with so prevention is paramount.”

He says research shows about 80% of strokes could be prevented with simple risk factor avoidance but failing that, more strokes occur and those tend to be more severe and more fatal. Social stressors are a factor, as are lifestyle choices such as smoking and alcohol use. Kentucky barely lags behind West Virginia in smoking rates nationally.

Link to COVID?
One area sparking a bit of controversy in medical circles is the potential relationship between patients who’ve had COVID-19 or its variants and an increased risk of clotting that could lead to stroke or other issues.

Goldstein said despite early research indicating this may be the case, during the pandemic’s peak fewer patients were transported with acute strokes to hospitals in Kentucky, nationwide and even worldwide.

“This was a general phenomenon that we don’t completely understand,” he said, adding that someone with COVID-19 or variants who experiences any signs consistent with stroke needs to be rapidly evaluated and may possibly receive different treatment than a regular stroke patient.

Support following a stroke is also important for an improved outcome, Remmel said. At UofL Healthcare, nurse advocates and stroke social workers team up to support patients after discharge in hopes of reducing recurrence rates. They provide wellness information and depression screenings, explain the importance of adhering to discharge instructions, and help patients better understand risk factors and symptoms so that they can quickly recognize signs of a future stroke.

Outpatient rehabilitation and home health services are also discussed, as are any barriers to attending future appointments.

Remmel said the program has been successful and UofL is continuing to expand on it.

Education-based stroke support groups in Louisville and surrounding areas—which include virtual options—cover educational topics like nutrition, exercise, smoking cessation and more. Pharmacists-turned-guest-speakers talk about stroke prevention medications, and group members can even suggest topics of interest to be addressed by specialists.

As treatments continue to improve, Edwards said with prompt treatment the outlook and outcomes generally are much better for stroke patients now than in years past.

“If they have a clot, they can go in and retrieve that clot and in two or three days they’re good to go,” she said.

Shannon Clinton is a correspondent for The Lane Report. She can be reached at editorial@lanereport.

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