Transcription:
Advanced Stroke Care at Memorial Hospital

Bill Klaproth (Host): Stroke is the fifth leading cause of death in the United States and the leading cause of disability. So, what do you need to know about early detection and treatment through endovascular thrombectomy, or EVT? Here to talk to us about thrombectomy and the stroke center at Memorial Hospital is Dr. Kiron Thomas, director of stroke and neuro-interventional services at Dignity Health Bakersfield Memorial Hospital. Dr. Thomas, thank you so much for your time. So, what are the two different types of strokes we should know about?

Kiron Thomas, MD (Guest): Good morning Bill. Thanks for having me here. So, the stroke means injury to the brain, or more or less irreversible injury to the brain because of a blood vessel related problem. So that is what the term means. There are two types of injuries that can arise from vascular problems. One is ischemic, meaning there’s a blocked blood vessel. Or the second is a hemorrhagic where there’s a leaky blood vessel. So, it is essential a dry problem, meaning injury to the brain because there’s not enough blood getting there. Or hemorrhagic or wet problem where there’s a puddle of blood that’s leaked out from a blood vessel causing injury to the brain just because of the pressure or the mass effect of the hematoma or the blood puddle. Also, this blood was supposed to reach somewhere, which it did not. So, you can have injury arising from that too. So ischemic and hemorrhagic stoke to answer your question are the two types of stroke that you come across.

Host: With ischemic strokes, those are largely treatable. Is that correct?

Dr. Thomas: Now the term stroke itself means irreversible injury. So, when injury to the brain occurs, it’s essentially considered irreversible. There is no going back on that. However, during the evolving phase of the injury, there may be steps we can take to either halt the progression of injury or maybe even reverse some of the effects by restoring the blood flow if it’s an ischemic type of stroke or stopping the hemorrhage or the potential for the hemorrhage if it’s the hemorrhagic kind. So, to answer your question, yes. Despite the term meaning irreversible injury, during the hyperacute phase or the acute phase, the first few hours of the process, there may be steps we can take to reverse the problem or limit the problem.

Host: So, it’s important to get the patient to the right hospital for the right treatment. Is that correct?

Dr. Thomas: Absolutely. So many of the advancements in treatment of ischemic stroke, for one, even hemorrhagic stroke. The advancements that have been made in the last 10 or 15 years, some of those advancements are still not available in many of the centers in the country. So, in the ischemic stroke on the other hand, most of the advances have been made in the last four or five years, the path breaking advancements. So, it is very important to identify stroke. For one, to make sure we get the patient to the right place and in the right time. Two, the right place is very important because many of these capabilities, many of these advancements are pretty sophisticated and it may not be available across the time that you're living in. There may be only one center in town that has it, or sometimes it may not be even available in town. You may have to be airlifted or transported to a different city to have this done at. So, identification of the place to go through when you have symptoms of an ischemic stroke or hemorrhagic stroke for that matter, it’s very crucial.

Host: You just mentioned advancements. Can you tell us about advancements in early detection and treatment or large ischemic strokes, and how that’s improving patient outcomes?

Dr. Thomas: Sure. So, the two key words that you used, large and ischemic. Ischemic means there’s a lack of blood flow. Large, it’s a larger territory of the brain involved as opposed to a small region. How is that relevant? Because the brain’s not just supplied by one vessel. There are four major vessels supplying the brain. Also, those four vessels, the numerous branches or small branches that arise of it. So, the smaller the vessel involved, the smaller territory of brain that will be affected. On the other hand, if it’s a larger vessel that goes to one side of the brain and gets blocked before it branches out, then obviously going to be a larger area of the brain that’s going to be affected. Thereby a larger deficit that the patient would be left with.

In larger vessel strokes, because the stakes are really high because it’s a much bigger territory of brain that’s involved here. It is important that we do everything possible to try to limit the progression of the injury or reverse it. How do we do that? A large vessel stroke is passed by obstruction or reclusion of a large blood vessel. We can try the clot dissolving medicine just as we used in small strokes. We can use the same one if the patient is a candidate. So, there are time limits or patient characteristic limits and criteria that applies here. So, we can try the medication, but many times know that in a large vessel stroke, the chance of that clot dissolving medicine working and opening up the vessel is not that high. So, there is a great proportion, great number of people who may not derive complete or good benefit from that clot dissolving medicine.

So, in those cases, it may be reasonable if, again, for the right patient with the right characteristics and the right time frame, if we can go up and somehow mechanically open the vessel. Either sucking the clot out or dissolving injecting medication directly to it or using devices called stint retrievers to pull the clot out. If we can open up that vessel, we can limit the actual amount of injury that otherwise would have happened. That would make a huge difference. That would determine if the patient is going to be independent or completely dependent for the rest of its life.

Host: Well that’s really good to know Dr. Thomas. Can you tell us about the endovascular thrombectomy? What is that and what kind of stroke needs a thrombectomy?

Dr. Thomas: So endovascular pertains to the inside of a blood vessel. So, what is means is we are actually going through the blood vessel. The most common site of entry’s in the groin. We get into the blood vessel with a series of tubes, slender hallow tubes called catheters. We navigate through the blood vessel using an arthroscopy or x-ray to get the point of occlusion. And we deliver devices called stint retrievers or use suction or use medication to open that vessel up. Either by pulling the clot out of maybe disintegrating or dissolving the clot with medication. So that procedure of opening up a vessel which was previously occluded by a blood clot is called thrombectomy. Thrombus refers to clot. Thrombectomy means removal of that blood clot. So, it is very important to see if a patient would be a candidate, would meet the criteria for thrombectomy in a large vessel occlusion.

Host: Dr. Thomas, I just quickly want to ask you. What are the symptoms of both ischemic and hemorrhagic stroke?

Dr. Thomas: So, again, the symptoms of a stroke whether it’s hemorrhagic or ischemic are all related to the area of the brain that’s involved. The only additional symptoms that you can expect with hemorrhagic stroke is symptoms related to increased pressure inside the skull. Those symptoms are depressed consciousness or headaches. Someone who all of a sudden becomes very drowsy and lethargic or has a massive headache. These are symptoms of a hemorrhage in addition to those symptoms related to dysfunction of that part of the brain.

The most common symptoms, which are most easily noticed, are what are described by the acronym FAST. So facial asymmetry because there’s weakness of the facial muscles. Loss of strength in the arms, and speech because your speech is either slurred because of loss of motor tone of the facial muscles or tongue. Or an impairment of language. So, the ability to understand and produce language or spoken language or written language. So, these are the most commonly and easily noticed in acute stroke. It doesn’t mean that these need to be the only symptoms. Sometimes strokes can be pretty hard to diagnose or discern even for a neurologist. So, some of these strokes, depending on the area of the brain that’s involved, can have different symptoms. The face and speech are the most common and easily noticed ones.

Host: Okay very good to know. Memorial Hospital has achieved national recognition for excellence in stroke care. What standards must the hospital meet to achieve this certification?

Dr. Thomas: That is true. So, memorial was recently designated as a thrombectomy capable center by the Joint Commission. What that means, or any certification means, is that we have standardized care. So, it is not a one-off thing for one patient who’s lucky enough to get the procedure. We standardize the availability of the procedure, the availability of the facility. The way we do this so we can optimize outcomes to aim for the best outcome for every one of the patients who comes to the ER or being transferred to that hospital for any reason. Any patient that comes to the hospital will be met with and will receive the same standard of care, which is comparable and at par with anything that you can receive from any advanced centers in the country.

Host: How is the Sarvanand Heart and Brain center at Memorial Hospital uniquely qualified for this distinction?

Dr. Thomas: So just like what I mentioned before, the certification entails a lot of things. So, making sure that we adhere to all the protocols, all the guidelines that have been enunciated by the certifying bodies or the boards that govern or that research the problem. So that is one thing. So how long do we take to get a cat scan. How long do we take to get a blood draw after the patient hits the ER door or comes to the facility? It’s important that we try to shave off every minute possible in trying to get the patient to the right treatment. Whether it’s the clot dissolving medication called alteplase, or a lifesaving or quality of life saving or altering procedure like thrombectomy.

So, one thing, the most important thing about certification and what’s unique about the Sarvanand Heart and Brain center is that we constantly strive to meet those guidelines, to meet with the parameters that have been enunciated by the body. Or even try to better them whenever possible. The second is the facility. So, we have a biplane unit, which is the gold standard for imaging in neurovascular procedures. We have a neurological critical care unit that is dedicated to care of patients with very critical conditions involving the brain and the spine. So, all of these factors into the ultimate outcome that a patient will experience or will have when they suffer, when they experience the life changing condition like a neurological problem.

Host: Well Dr. Thomas, this has been very informative and thank you for your time. For more information about thrombectomy and the stroke center at Memorial Hospital, please visit dignityhealth.org. That’s dignityhealth.org. This is Hello Healthy, a Dignity Health podcast. I’m Bill Klaproth. Thanks for listening.