When every minute counts
Posted on: June 3, 2014; Updated on: June 3, 2014
By Steven Powell, spowell2@mailbox.sc.edu, 803-777-1923
Staving off the long-term effects of a stroke is a time-sensitive undertaking that can mean the difference between a crippling disability and walking out of the hospital with no lingering effects.
The School of Medicine and Palmetto Health Richland are helping S.C. stroke sufferers beat the clock — and the odds — with telemedicine, a potent tool that greatly expands the geographic range of rapid stroke assessment and treatment.
Using a technology system produced by the company REACH Health, Columbia-based specialists are able to use a laptop computer to consult with six remote hospitals throughout South Carolina.
The technology package has just what a physician needs to make a diagnosis quickly and effectively, according to Dr. Souvik Sen, professor and chair of the School of Medicine's neurology department and endowed chair of the SmartState Stroke Center of Economic Excellence.
"The Internet connection is secure, so there are no privacy issues. Not only can you see the patient, you can look at the scan and the blood work," Sen says. "You're able to do the whole consultation on the system itself."
Being able to do stroke assessments remotely is crucial in rural areas that make up a large part of the S.C. landscape. Transportation to a specialist can cost time, which is a particularly precious commodity in the early stages of a clot-based stroke.
A blood clot in the brain is the cause of ischemic strokes, which constitute about 80 percent of all strokes. The clot restricts blood flow to a portion of the brain, depriving it of oxygen and typically causing one or more of the five common symptoms of stroke — weakness or numbness of the face, arms or legs (usually on one side of the body); difficulty speaking; trouble seeing; difficulty walking or dizziness; or sudden severe headache with no other apparent cause. Any of the symptoms is cause for calling 911 or visiting the emergency room immediately.
Swift action is called for partly because one of the common medical treatments of ischemic stroke — a drug called tissue plasminogen activator (TPA) — has a very quick-to-close time window of effectiveness. Oxygen deprivation in the brain caused by a blood clot will kill brain cells if blood flow isn't restored. TPA can dissolve the clot quickly and, if administered soon enough, even eliminate symptoms altogether in the space of a few hours.
But "soon" is soon indeed, with every minute that passes potentially representing millions of cells dying. Getting the medication into a stroke patient in less than three hours is the FDA-approved indication, and every minute under that goal enhances a patient's long-term outlook.
"We had a patient who came to Lake City hospital, and within an hour and 10 minutes from symptom onset, we had TPA infusing," Sen says. "If we had not had the system in place, that patient would essentially have had to wait until they got shipped by ambulance here or to a hospital in Florence. If you delay another hour to an hour and a half, sometimes TPA doesn't even work.
"By the time the ambulance got them here, the patient was completely back to normal with no stroke symptom. To me, we had already saved the brain, we were just following up on the TPA treatment with monitoring here."
But TPA is decidedly not called for with hemorrhagic (or bleeding) stroke, which accounts for the other 20 percent of stroke incidents. That's one reason it's so important to quickly get patients in contact with neurological experts at Palmetto Health Richland, the only Joint Commission-certified stroke center in the Midlands, for a thorough assessment.
Other treatments are also available at the stroke center. One is interventional stroke management, involving a catheter inserted in an artery at the groin and threaded all the way to the brain, where the clot might be found and removed. Another is an experimental stem cell trial — the only one of its kind in South Carolina — in which researchers are trying to use stem cells to repair the brain.
Both techniques also have short time frames before they are deemed no longer effective: eight hours and 48 hours, respectively. Rapid assessment through the REACH system, Sen says, is invaluable at each step of possible treatment that might diminish the need for later rehabilitation.
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