GW Hospital has received the 2020 American Heart Association®/American Stroke Association's® Get With The Guidelines®-Stroke Gold Plus, Target: Stroke Elite, and Target: Type 2 Diabetes Honor Roll award. The award is the highest stroke recognition possible.
Wayne Olan, MD discusses treatment of stroke with mechanical thrombectomy. He highlights the latest clinical indications for use, the importance of patient selection criteria and the expertise of the medical professionals at the Comprehensive Stroke Center at GW Hospital that provides fast and efficient stroke care to help patients reach a better outcome after suffering a stroke emergency.
Selected Podcast
Mechanical Thrombectomy
Featuring:
Learn more about Wayne Olan, MD
Wayne Olan, MD,
Wayne Olan, MD, serves as the Director of Interventional and Endovascular Neurosurgery at the GW Medical Faculty Associates/The George Washington University Hospital and is an associate professor at The George Washington University School of Medicine & Health Sciences.Learn more about Wayne Olan, MD
Transcription:
Melanie Cole (Host): You're listening to GW Doc Pod, a peer-to-peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole and joining me today to discuss mechanical thrombectomy is Dr. Wayne Olan. He's the director of minimally invasive and endovascular neurosurgery at The George Washington University School of Medicine & Health Sciences. And he's affiliated with The George Washington University Hospital. Dr. Olan, it's a pleasure to have you join us again today. I'd like you to start as we get into the topic of mechanical thrombectomy to discuss the chain of events that favor good functional outcome from an acute ischemic stroke beginning with the recognition of stroke when it occurs. And including the importance of a designated stroke center and stroke care in the quality improvement process, and including pre-hospital management and field treatment as that can speed the clinical assessment, emergency evaluation and diagnosis of acute ischemic stroke.
Dr. Wayne Olan: Well, first and foremost again, thank you so much for having me. It's absolutely my privilege. With respect to stroke, it is the ultimate sort of team sport in healthcare. Everybody's input can improve the outcome and a failure anywhere along the line can also greatly change what the potential outcome may be. So you need everybody kind of to be on board, starting the community, really starting with the patient, their family, the people they're around, strangers on the street, whoever may be there or around to witness the initial event to recognize that this person needs care needs help. Don't go take a nap on the couch.
Don't see if it'll shake off, get to an emergency room, get in an ambulance. As quickly as you can, to a place that can provide care for you if you need it. Trust me, we would all rather nothing greater than false alarms. But the worst thing we hear is, well, we took, it, went back to bed or, they thought it was something different. They didn't send them to the right facility. Well, we didn't call 911. Patient wouldn't let us, they didn't want us to call an ambulance, things like that. So it really starts out in the community. You have to recognize what they're doing and then make sure now that you have a patient you think is having a stroke, contact the EMS, or get them to the hospital.
EMS can really decide now where to send a patient if they have the diagnosis of a stroke. So more often than not, they're trying their best to send the patient to a facility that can treat that patient because all transferring a patient, sending them to the wrong facility, all that does is prolong the interval from the time that they experience their symptoms to the time that you may be able to do restore flow. And by increasing that interval, you decrease the chance that their outcome is as good.
So the quicker we can reestablish flow from the time that the flow stopped, which is the time that that patient experienced their symptoms, that gives us the best opportunity for the best possible outcome. And as I said, you need everybody on board from whoever recognizes the issue or the patient to the EMS, to the emergency room, to people in cat scan, moving the patient quickly from place to place, to a team of people ready to respond, meaning they know they need to come in and getting on their horse and getting here.
To getting the patient very efficiently onto the table, getting the breathing tube in, intubating them, and then subsequently getting the thrombus out and restoring the flow back to their brain. So there's a bunch of people involved in assuring that you're gonna be successful, but when you could do it correctly, there really is no greater team sport in all medicine.
Melanie Cole (Host): Wow. That was such an excellent description and such great points that you made Dr. Olan. Now let's talk about endovascular interventions, such as mechanical thrombectomy. How have the devices themselves evolved over the years, our higher rates of recanalization associated with these newer generation thrombectomy devices compared with the first generation devices? And how does the George Washington University Hospital approach this very important part of management?
Dr. Wayne Olan: Well, without question and we're nowhere near the final iteration of what devices we may be using for this entity. If you came to us five years, even three years from now, the devices are changing. The gold standard for stroke intervention is clearly still not written, but the first device was something called the mercy retriever, which was essentially a string on a wire that you've helped to wrap into the clot. And then over time aspiration devices. which are basically like little vacuums. And then we have what we call stent retrievers, which everybody's familiar with stents that they use in people's hearts or in your carotid arteries or in legs.
But it's a stent retriever, meaning I can not only put the stent up, but I can also take the stent out and we open the stent into the clot. There are very special, parameters that the stent has to make the clot more likely to interdigitate or get stuck in it. And then we could remove that. So you basically today, the devices that we use are really twofold, are either aspiration or what we call the stent retriever or a combination of both. On top of all that, you remember, early, early, early stroke treatment were medications. There's an IV medication called TPA.
You can still also inject that medicine directly into the thrombus, what we would call intra arterial. And before that, even many, many years ago, there was a medication called urokinase, which was sort of the first clot busting medicine that we used. As we said, there's a consistent evolution, the gold standard still hasn't been written. But no question. When we now go after an occlusion, our goal is to open it and the rates of opening these occlusions are very, very high. Now, the question comes in is, again, all the things we talked about earlier, the sooner we can get a patient on the table, the sooner we can get that clot removed, gives them the best opportunity for outcome.
Just restoring flow doesn't necessarily do that because if cells have died, they've died, and we want to get there before they do that before the cells die and give this patient a chance to recover as best as possible.
Melanie Cole (Host): So please speak about the latest clinical practice guidelines for indication for use. I assume that patient selection is just so important here. So speak about the indications for mechanical thrombectomy and patient selection.
Dr. Wayne Olan: Interestingly, almost all the indications are based on trying to avoid disaster, as opposed to predicting success. So there are guidelines for the patient that they would have to fit into. And now there's some really interesting, not just procedural technologies, but imaging technologies that we use to make sure that these procedures and this revascularization that we are doing, is gonna be safe. Because If we revascularize or open the vessel up into dead tissue, the patient would have a very high likelihood potentially of hemorrhaging, which could end up being a catastrophic event.
So we're trying really to avoid that, but we have what we call perfusion imaging that we use that shows not only the tissue that may not be Recoverable, but also shows us the tissue that is recoverable. So going in, we know if we restore flow, we have a very high chance of the volume of tissue that we're trying to recover. And then on top of that, we use some, artificial intelligence to help use, to notify our team that does some of those calculations for us as well.
So it makes it much more streamlined when we're looking at imaging to decide who's a case and who isn't. The other things that we're trying to look at is the patients function prior to having this episode, we're trying to look at their vasculature. Is this a chronic or an acute problem? And then have they had old strokes prior? If they haven't, it makes them a better candidate for treatment and obviously their age. and different things like that. Other medical issues they may have, which may preclude them from having treatment.
But there are certainly really good and defined guidelines that we use now to make us not only the most potentially efficacious or effective, but also the safest in doing these procedures. Because at the end of the day, these patients are in a bad way when we start, and to be able to go in there and make a difference is really one of the great privileges in medicine.
Melanie Cole (Host): So it never used as a first line therapy? And while you're telling us that. There issues that you can see around the country that may limit the widespread clinical use of this procedure? Any challenges, complications, technical, things that you would like other providers to know about?
Dr. Wayne Olan: Well, first and foremost, it's become the go first line, when someone had a stroke, people used to sit around and go, well, let's wait and see. We don't have wait and see anymore. We have get this patient to a facility and get this clot out. So it is the first line now. It's an aggressive line, but it is the first line because the outcome associated with a large vessel occlusion and the stroke that would be associated with that is devastating. Not just to the individual, but to their entire family unit, their community, so to speak.
So this is the first line now, if this patient's a candidate, they are going for what we call a thrombectomy. The problem is that not everybody provides it. Not every center provides it. If you're living in an urban community where there are universities, yes. Chances are, they're gonna be a, comprehensive stroke center in your community, but patients live in a more rural community to get to a facility that does provide this, might take some time. And we've already talked about the more time that you spend the potentially diminishing returns with respect to the outcome.
But on the flip side of that, the people who are trained now in stroke are continuing to grow and more community hospitals are starting to offer this treatment because people have a stroke five minutes from where they work five minutes from where they live. And not everybody has one on the door of a university center. So, again, as we said, if we sit down, two, three years, five years from now, you're gonna find that this is gonna be more routine care in most community hospitals, than it is currently today.
So the press is sort of on to make this treatment much more widespread. than it is now, not just for facilities, but physicians who do provide this type of treatment. It's a highly specialized physician who can go in and be the one to take this clot outta someone's head, without making things kind of worse.
Melanie Cole (Host): 100%. So as we wrap up, I'd like you to speak about the unique areas that set you apart and why it's important to refer to the specialists, set the George Washington University Hospital? If someone wants to refer a patient, what would you like to tell them about the importance of early referral? And certainly for stroke, there's a time factor. And as you say, an expertise factor. We're not just given TPA and sitting around waiting anymore. So please tell other providers what you would like them to know about mechanical thrombectomy and the expertise at the George Washington University Hospital.
Dr. Wayne Olan: Well without, even knowing the provider's names, knowing that this institution is a comprehensive stroke center means we are committed to 24/7, 365 response to your patient and being able to get that clot out within an hour from the time they enter the facility. Regardless of where we are, and that's a big commitment for an institution and not every institution in the area. In fact, most institutions in the area and some that you'd be surprised to know, don't have that level of certification, aren't what we would call comprehensive.
Stroke certifications can be a little bit misleading because primary stroke certification, that sounds great. Right. I'm Primary. Who could be better than that, doesn't necessarily provide this service. With a comprehensive center, we're committed to providing it. A primary center could transfer a patient out. We can't. A thrombectomy capable center also may be able to provide this type of care, but there are gonna be times that we don't have anybody available. So we're gonna transfer that patient out as well.
So there is a little bit of murky water with respect. To these certifications. But what you wanna know is where is the comprehensive stroke center in your region, closest to where you live closest to where you work? Because if God forbid somebody somebody, you love somebody you work with needs to be somewhere. You wanna know where to send them. And that's probably the most important thing. You're gonna hear a lot about stroke certifications, but the one that's in interest, everybody the most is a comprehensive center. Because even if it's nine o'clock on Christmas Eve, we are here, we're waiting, and we're ready to take care of the people that you care about.
Melanie Cole (Host): Beautifully said, and thank you so much, Dr. Olan, what a great guest you are and such an educational podcast. Thank you so much. To refer your patient, please call 1-888-4GW-DOCS, or if you have a question for one of our specialists, please email physician relations@gwuhospital.com.
That concludes this episode of GW Doc Pod, a peer-to-peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole. Thanks so much for tuning in.
Physicians are independent practitioners who are not employees or agents of the George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians.
Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if minimally invasive surgery is right for you.
Melanie Cole (Host): You're listening to GW Doc Pod, a peer-to-peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole and joining me today to discuss mechanical thrombectomy is Dr. Wayne Olan. He's the director of minimally invasive and endovascular neurosurgery at The George Washington University School of Medicine & Health Sciences. And he's affiliated with The George Washington University Hospital. Dr. Olan, it's a pleasure to have you join us again today. I'd like you to start as we get into the topic of mechanical thrombectomy to discuss the chain of events that favor good functional outcome from an acute ischemic stroke beginning with the recognition of stroke when it occurs. And including the importance of a designated stroke center and stroke care in the quality improvement process, and including pre-hospital management and field treatment as that can speed the clinical assessment, emergency evaluation and diagnosis of acute ischemic stroke.
Dr. Wayne Olan: Well, first and foremost again, thank you so much for having me. It's absolutely my privilege. With respect to stroke, it is the ultimate sort of team sport in healthcare. Everybody's input can improve the outcome and a failure anywhere along the line can also greatly change what the potential outcome may be. So you need everybody kind of to be on board, starting the community, really starting with the patient, their family, the people they're around, strangers on the street, whoever may be there or around to witness the initial event to recognize that this person needs care needs help. Don't go take a nap on the couch.
Don't see if it'll shake off, get to an emergency room, get in an ambulance. As quickly as you can, to a place that can provide care for you if you need it. Trust me, we would all rather nothing greater than false alarms. But the worst thing we hear is, well, we took, it, went back to bed or, they thought it was something different. They didn't send them to the right facility. Well, we didn't call 911. Patient wouldn't let us, they didn't want us to call an ambulance, things like that. So it really starts out in the community. You have to recognize what they're doing and then make sure now that you have a patient you think is having a stroke, contact the EMS, or get them to the hospital.
EMS can really decide now where to send a patient if they have the diagnosis of a stroke. So more often than not, they're trying their best to send the patient to a facility that can treat that patient because all transferring a patient, sending them to the wrong facility, all that does is prolong the interval from the time that they experience their symptoms to the time that you may be able to do restore flow. And by increasing that interval, you decrease the chance that their outcome is as good.
So the quicker we can reestablish flow from the time that the flow stopped, which is the time that that patient experienced their symptoms, that gives us the best opportunity for the best possible outcome. And as I said, you need everybody on board from whoever recognizes the issue or the patient to the EMS, to the emergency room, to people in cat scan, moving the patient quickly from place to place, to a team of people ready to respond, meaning they know they need to come in and getting on their horse and getting here.
To getting the patient very efficiently onto the table, getting the breathing tube in, intubating them, and then subsequently getting the thrombus out and restoring the flow back to their brain. So there's a bunch of people involved in assuring that you're gonna be successful, but when you could do it correctly, there really is no greater team sport in all medicine.
Melanie Cole (Host): Wow. That was such an excellent description and such great points that you made Dr. Olan. Now let's talk about endovascular interventions, such as mechanical thrombectomy. How have the devices themselves evolved over the years, our higher rates of recanalization associated with these newer generation thrombectomy devices compared with the first generation devices? And how does the George Washington University Hospital approach this very important part of management?
Dr. Wayne Olan: Well, without question and we're nowhere near the final iteration of what devices we may be using for this entity. If you came to us five years, even three years from now, the devices are changing. The gold standard for stroke intervention is clearly still not written, but the first device was something called the mercy retriever, which was essentially a string on a wire that you've helped to wrap into the clot. And then over time aspiration devices. which are basically like little vacuums. And then we have what we call stent retrievers, which everybody's familiar with stents that they use in people's hearts or in your carotid arteries or in legs.
But it's a stent retriever, meaning I can not only put the stent up, but I can also take the stent out and we open the stent into the clot. There are very special, parameters that the stent has to make the clot more likely to interdigitate or get stuck in it. And then we could remove that. So you basically today, the devices that we use are really twofold, are either aspiration or what we call the stent retriever or a combination of both. On top of all that, you remember, early, early, early stroke treatment were medications. There's an IV medication called TPA.
You can still also inject that medicine directly into the thrombus, what we would call intra arterial. And before that, even many, many years ago, there was a medication called urokinase, which was sort of the first clot busting medicine that we used. As we said, there's a consistent evolution, the gold standard still hasn't been written. But no question. When we now go after an occlusion, our goal is to open it and the rates of opening these occlusions are very, very high. Now, the question comes in is, again, all the things we talked about earlier, the sooner we can get a patient on the table, the sooner we can get that clot removed, gives them the best opportunity for outcome.
Just restoring flow doesn't necessarily do that because if cells have died, they've died, and we want to get there before they do that before the cells die and give this patient a chance to recover as best as possible.
Melanie Cole (Host): So please speak about the latest clinical practice guidelines for indication for use. I assume that patient selection is just so important here. So speak about the indications for mechanical thrombectomy and patient selection.
Dr. Wayne Olan: Interestingly, almost all the indications are based on trying to avoid disaster, as opposed to predicting success. So there are guidelines for the patient that they would have to fit into. And now there's some really interesting, not just procedural technologies, but imaging technologies that we use to make sure that these procedures and this revascularization that we are doing, is gonna be safe. Because If we revascularize or open the vessel up into dead tissue, the patient would have a very high likelihood potentially of hemorrhaging, which could end up being a catastrophic event.
So we're trying really to avoid that, but we have what we call perfusion imaging that we use that shows not only the tissue that may not be Recoverable, but also shows us the tissue that is recoverable. So going in, we know if we restore flow, we have a very high chance of the volume of tissue that we're trying to recover. And then on top of that, we use some, artificial intelligence to help use, to notify our team that does some of those calculations for us as well.
So it makes it much more streamlined when we're looking at imaging to decide who's a case and who isn't. The other things that we're trying to look at is the patients function prior to having this episode, we're trying to look at their vasculature. Is this a chronic or an acute problem? And then have they had old strokes prior? If they haven't, it makes them a better candidate for treatment and obviously their age. and different things like that. Other medical issues they may have, which may preclude them from having treatment.
But there are certainly really good and defined guidelines that we use now to make us not only the most potentially efficacious or effective, but also the safest in doing these procedures. Because at the end of the day, these patients are in a bad way when we start, and to be able to go in there and make a difference is really one of the great privileges in medicine.
Melanie Cole (Host): So it never used as a first line therapy? And while you're telling us that. There issues that you can see around the country that may limit the widespread clinical use of this procedure? Any challenges, complications, technical, things that you would like other providers to know about?
Dr. Wayne Olan: Well, first and foremost, it's become the go first line, when someone had a stroke, people used to sit around and go, well, let's wait and see. We don't have wait and see anymore. We have get this patient to a facility and get this clot out. So it is the first line now. It's an aggressive line, but it is the first line because the outcome associated with a large vessel occlusion and the stroke that would be associated with that is devastating. Not just to the individual, but to their entire family unit, their community, so to speak.
So this is the first line now, if this patient's a candidate, they are going for what we call a thrombectomy. The problem is that not everybody provides it. Not every center provides it. If you're living in an urban community where there are universities, yes. Chances are, they're gonna be a, comprehensive stroke center in your community, but patients live in a more rural community to get to a facility that does provide this, might take some time. And we've already talked about the more time that you spend the potentially diminishing returns with respect to the outcome.
But on the flip side of that, the people who are trained now in stroke are continuing to grow and more community hospitals are starting to offer this treatment because people have a stroke five minutes from where they work five minutes from where they live. And not everybody has one on the door of a university center. So, again, as we said, if we sit down, two, three years, five years from now, you're gonna find that this is gonna be more routine care in most community hospitals, than it is currently today.
So the press is sort of on to make this treatment much more widespread. than it is now, not just for facilities, but physicians who do provide this type of treatment. It's a highly specialized physician who can go in and be the one to take this clot outta someone's head, without making things kind of worse.
Melanie Cole (Host): 100%. So as we wrap up, I'd like you to speak about the unique areas that set you apart and why it's important to refer to the specialists, set the George Washington University Hospital? If someone wants to refer a patient, what would you like to tell them about the importance of early referral? And certainly for stroke, there's a time factor. And as you say, an expertise factor. We're not just given TPA and sitting around waiting anymore. So please tell other providers what you would like them to know about mechanical thrombectomy and the expertise at the George Washington University Hospital.
Dr. Wayne Olan: Well without, even knowing the provider's names, knowing that this institution is a comprehensive stroke center means we are committed to 24/7, 365 response to your patient and being able to get that clot out within an hour from the time they enter the facility. Regardless of where we are, and that's a big commitment for an institution and not every institution in the area. In fact, most institutions in the area and some that you'd be surprised to know, don't have that level of certification, aren't what we would call comprehensive.
Stroke certifications can be a little bit misleading because primary stroke certification, that sounds great. Right. I'm Primary. Who could be better than that, doesn't necessarily provide this service. With a comprehensive center, we're committed to providing it. A primary center could transfer a patient out. We can't. A thrombectomy capable center also may be able to provide this type of care, but there are gonna be times that we don't have anybody available. So we're gonna transfer that patient out as well.
So there is a little bit of murky water with respect. To these certifications. But what you wanna know is where is the comprehensive stroke center in your region, closest to where you live closest to where you work? Because if God forbid somebody somebody, you love somebody you work with needs to be somewhere. You wanna know where to send them. And that's probably the most important thing. You're gonna hear a lot about stroke certifications, but the one that's in interest, everybody the most is a comprehensive center. Because even if it's nine o'clock on Christmas Eve, we are here, we're waiting, and we're ready to take care of the people that you care about.
Melanie Cole (Host): Beautifully said, and thank you so much, Dr. Olan, what a great guest you are and such an educational podcast. Thank you so much. To refer your patient, please call 1-888-4GW-DOCS, or if you have a question for one of our specialists, please email physician relations@gwuhospital.com.
That concludes this episode of GW Doc Pod, a peer-to-peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole. Thanks so much for tuning in.
Physicians are independent practitioners who are not employees or agents of the George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians.
Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if minimally invasive surgery is right for you.