Clinician-to-Clinician Update Clinician-to-Clinician Update

Connecting Acute Stroke Patients to Advanced Care

January 2017

Each year approximately 795,000 people experience some form of stroke, with ischemic strokes representing 87% of all strokes.1 While the rate of stroke mortality has fallen, in 2013, approximately 1 in 20 deaths were attributable to stroke.1 Rapid restoration of blood flow is central to limiting tissue damage and reducing the rate of morbidity among ischemic stroke patients, and intravenous recombinant tissue-type plasminogen activator (r-tPA) remains the standard-of-care initial treatment for ischemic strokes.2 Improved patient outcomes, however, remain relatively low when clot-dissolving therapies are the sole treatment approach, a reported 33%.3 Recanalization rates associated with the approach are 46%.4

January-2017-Stroke-Consult-Feature-Article-Main-Article-Image-MH Loc UMMC EastBank 3271-4
— University of Minnesota Medical Center, the medical center within University of Minnesota Health. M Health received accreditation as a comprehensive stroke center in early June 2016.

Endovascular procedures for ischemic stroke have received research attention, and recent findings suggest improved outcomes when endovascular therapy is used as an adjunct to intravenous r-tPA. For a subset of ischemic stroke patients, endovascular therapy via stent retrieval and as a following treatment to intravenous r-tPA has been reported to achieve better functional outcomes in patients than does treatment with r-tPA alone.2, 3 Updated treatment guidelines from the American Heart Association Stroke Council indicate endovascular therapy with stent retriever as an adjunct to r-tPA for a select group of stroke patients 18 years of age or older. Effectiveness of the approach, however, is less certain 6 hours or more after onset of symptoms.2 For patients with chronic cerebrovascular disease, in whom stent retrieval poses a high risk, endovascular catheterization enables site-directed thrombolysis with intra-arterial r-tPA.

Endovascular procedures, to be effective, must be initiated rapidly, and they require the support of advanced imaging and specialized care teams. To meet the challenge of providing a full range of endovascular therapies and advanced care to stroke patients, the AHA Stroke Council has recommended the establishment of stroke networks. The proposed regional networks would link healthcare providers to facilitate rapid consultation and transport of patients to advanced care facilities.2 Comprehensive stroke centers serve as a regional hub in these networks, providing advanced endovascular treatment and periprocedural care and collaborating with health systems on medical training.

In 2016, University of Minnesota Health received accreditation as a comprehensive stroke center, becoming one of approximately 100 such specialized care facilities in the country.5 Comprehensive Stroke Centers maintain advanced stroke imaging capabilities, dedicated neurointensive care units and rehabilitation services, and care teams trained in acute stroke protocols and the evidence-based surgical, endovascular, and medical interventions addressing cerebrovascular disease.6

References

  1. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2015;133 :e38-360. doi: 10.1161/CIR.0000000000000350
  2. Powers WJ, Derdeyn CP, Biller J, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:3020–3035. doi.org/10.1161/STR.0000000000000074
  3. Rodrigues FB, Neves JB, Caldeira D, et al. Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and metaanalysis. BMJ. 2016;353:i1754.
  4. Rha J-H and Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 2007;38:967-973.
  5. University of Minnesota Medical Center, Fairview, Quality Report. The Joint Commission Quality Check website. www.qualitycheck.org/certificationhistory/?bsnId=2908. September 30, 2016. Accessed November 29, 2016.
  6. The Joint Commission. Facts about advanced certification for comprehensive stroke centers. Joint Commission website. www.jointcommission.org/certification/certification_main.aspx. July 15, 2014. Accessed November 29, 2016.

When to refer

The University of Minnesota Health Stroke Center provides preventive care, treatment, and recovery services for full range of cerebrovascular diseases, such as ischemic stroke, cerebral aneurysms, arteriovenous malformations, and carotid disease. Certified as a comprehensive stroke center by the Joint Commission, our center serves as the top regional center for acute stroke care and partners with dozens of local hospitals in Minnesota and the upper Midwest. We offer 24/7 consultation and arrange emergency care and transport for patients experiencing stroke or other cerebrovascular emergencies. The referring physician is an essential member of our team.

Multidisciplinary, Collaborative Care

The Stroke Center is home to complete care services for patients with cerebrovascular disease. Our stroke neurologists provide emergency consultation to outside providers and direct the inpatient stroke service and outpatient stroke specialty clinic. The neurointerventionalist team works within our dedicated angiography suite to provide endovascular treatments for acute stroke, cerebral aneurysms, arteriovenous malformations, and carotid stenosis. They also direct the outpatient neurointervention clinic for patients who elect for treatment. Our vascular neurosurgeons specialize in surgical repair of vascular malformations and aneurysms. Patients with cerebrovascular diseases, seizure disorders, or traumatic brain or spinal cord injuries receive full-time neurocritical care in our dedicated Neurointensive Care Unit.

Stroke Center clinicians work closely with emergency medicine physicians during patient intake and diagnosis, and with physical medicine and rehabilitation specialists during patient recovery. Our goals at the Stroke Center are to identify stroke emergencies quickly and to provide full-spectrum, around-the-clock care for every patient.

For additional information, contact Stroke Program Coordinator Angi Heyer, RN, CNRN at 612-273-4102, aheyer1@fairview.org.

For opportunities to partner with the M Health Stroke Center in clinical staff stroke education, contact Kristen Purtell at 612-672-2868, kpurtel1@fairview.org.

To find current clinical trials available through M Health providers: studyfinder.umn.edu

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