According to the Stroke Center, stroke is the leading cause of serious, long-term disability in the United States. Approximately 795,000 people suffer a stroke each year.
Three out of four stroke patients don't receive treatment fast enough for the best chance of a full recovery.
Listen as Dr. John Cullen discusses the life-saving stroke care provided at Rochester Regional Health.
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The Importance of FAST Stroke Treatment
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Learn more about Dr. John Cullen
John Cullen, MD
Dr. John Cullen is a key member of the Rochester Regional Health stroke team. He received his Medical degree from SUNY at Syracuse College of Medicine Office of the Registrar.Learn more about Dr. John Cullen
Transcription:
The Importance of FAST Stroke Treatment
Bill Klaproth (Host): Three out of every four stroke patients don't receive treatment fast enough for the best chance of a full recovery, so how are health professionals addressing this need for speed? Here to tell us about that and the life-saving stroke care at Rochester Regional Health is Dr. John Cullen, a key member of the Rochester Regional Health Stroke Team. Dr. Cullen, thank you for your time today. Can you first tell us why timing is so critical when it comes to stroke victims?
Dr. John Cullen (Guest): Yeah, timing is such a critical aspect of it because there is a medication that we can give called TPA that's given intravenously, and the issue with this medication is it has to be given within a certain time window in order for it to be both safe and effective. Generally, we try to give this medication within four and a half hours of when the symptoms onset began, and one of the first questions we typically ask a patient when they’re coming in with signs and symptoms of a stroke is when they were last seen normal because that helps us determine when that clock starts for the timing aspect of this medication.
Bill: So within four and a half hours of the onset of the symptoms and then tell me about the efficacy of this drug if it's caught within that four and a half hour window?
Dr. Cullen: So, within the four and a half hour window, it is pretty efficacious. The one factor to keep in mind is that four and a half window is the window to where we give this medication, but the earlier you give it, the better it works. So, you know, the thing that we like to say is "time is brain." Every minute that you wait -- delay to give this medication -- vital neurons in the brain can die and then you can lose more function, so, you know, when symptoms are first discovered it's important for families to immediately call 911 to get to the hospital as soon as possible because every minute is precious to try to give this medication.
Bill: So "time is brain." That's what you said, and every minute counts it sounds like, so this is really important the first time you notice any symptoms or something out of the ordinary, speed counts in this situation, like you say, "time is brain." Every minute counts. So, can you tell us what happens then during stroke treatment?
Dr. Cullen: Yeah, so the first thing you do when you arrive to the emergency room is you'll be triaged by the nurses, and they will assess you as an acute stroke alert and that rings off a bunch of different protocols. It gets the neurologist in the emergency room involved with your care very quickly. Usually the first thing when you do when you arrive is the nurse will quickly assess you, then check your blood pressure, then the emergency room physician will see you and do something called a NIH Stroke Scale, which is a measurement of how severe the potential stroke could be and then almost immediately after that, you usually get a non-contrast head CT and this is important to make sure that you're not having a hemorrhage or something else that could be making it so you cannot get that IV TPA medicine. Strokes come in a couple different forms, but the two main categories are either ischemic strokes which means a clot forms and blocks one of the arteries, not letting blood flow go to the brain or hemorrhagic stroke which means an artery or something else in the brain then bleeds and then that causes that kind of stroke symptoms so the head CT will help determine which type of stroke that you've had a stroke – if you’ve had a stroke. After the head CT's done, usually by that time, you'll be reevaluated, the neurologist usually at bedside at the time, and determination between the patient, the family, and the neurologist and the emergency room physician will often determine whether or not someone is an IV TPA candidate. If they are, then we try giving the medication, again, as possible.
There's another further intervention that can be done acutely where a neuroendovascular physician can actually do one of two things. They can actually go in with a device and retrieve a clot if it's within the arteries in the brain, or they can go in there to the arteries and give another medication called interarterial TPA which will then help resolve the clot. There’s the time component to that as well -- it's a little longer than the typical four and a half hours, but, again, it’s important to do it as soon as possible to help preserve the normal functioning of the brain.
Bill: Right, as soon as possible that time is brain again. So, you talked about the acute stroke alert, so this involves a whole team at Rochester Regional Health and time is of the essence. Can you tell us, then, about the intensive stroke training and some of the advanced technology you use at Rochester Regional Health to incorporate that speed of diagnosis and assessment?
Dr. Cullen: Yeah so we have different imaging modalities. We have, you know, the CTs – the scan I was talking about -- and doing other scans called a CT angiogram that looks specifically at the arteries within the head and the neck to look for any blockage. Other imaging modalities that we have available is we do something called a CT perfusion, that sometimes helps us determine the number or the size of the stroke and that there is tissue that can be preserved by doing the interventions as soon as possible. An MRI of the brain is also possible, though, usually in the acute phase that isn’t something that we do because that takes a little bit more time and again, time is of the essence here. At Rochester Regional Health, we have neuroendovascular-trained physicians that can perform these more advanced procedures that are used to take out the clots with different devices. Currently, that physician that we use is at Rochester General Hospital, and if a patient were to present to any of the other hospitals, we are able to quickly transfer them over to Rochester General so that they can receive this procedure.
Bill: And, Dr. Cullen, how about after a person suffers a stroke, can you tell us about the rehabilitation services and post-discharge follow-up?
Dr. Cullen: Yeah, so that's a very important factor of stroke care because the recovery is a vital component, and physical and occupational and speech therapy are keys to that. At all the Rochester Regional Hospitals, we have specifically trained physical, occupational, and speech therapists that are well-trained to be able to deal with neurological diseases, particularly stroke. Here at Unity Hospital, we have the Rochester -- we have the Golisano Rehab Center and most of our stroke patients go there after their stroke to receive their post-stroke care. This is staffed by PM&R physicians who are specifically trained in dealing with these kind of neurological injuries, and they have a dedicated team on multiple therapies that help get them through and help them recover after the stroke. In addition, at both Unity and Rochester General Hospital, we have TIA and stroke clinics that are set up in order to get patients quick post-hospitalization follow-up to make sure that all the treatment recommendations and therapies that were recommended during the hospitalization are being followed through with and make sure that nothing’s left that can help prevent future strokes from occurring.
Bill: Okay, well that's really good to know, and I know we are talking about stroke treatment, but can you quickly talk with us about stroke prevention such as stroke risk factors and how to lower them quickly?
Dr. Cullen: Yeah, so, when you talk about treating strokes, there's two main factors, there’s the treatment of the acute stroke which is what we talked about and then there's the secondary stroke prevention, which is just as important. The mainstays of stroke prevention are anti-platelet medications, such as aspirin and Plavix. There’s another medication called Aggrenox that we use sometimes, just is a blood thinner that helps prevent future strokes from forming. Other types of strokes are caused by irregular heart rates, typically something called atrial fibrillation and those type of strokes are best treated with anticoagulation medication. So, that's why it's usually very important to determine what caused someone's stroke so that we can properly and most effectively treat it going forward.
Other things and other factors that put you at risk for strokes are smoking, high blood pressure, high cholesterol, and diabetes, and that's why when anyone presents with signs or symptoms of stroke, we always try to best treat and evaluate for those conditions. If someone is a smoker, we strongly encourage smoking cessation and work hard with them to quit. After a stroke, it's very important to get the blood pressure well-controlled and for a new diabetic it's very important to get that well controlled. If someone has high cholesterol, we usually start them on cholesterol medication. One of the better cholesterol medications is one called atorvastatin, or Lipitor. Studies have shown that that medication has stroke reduction benefits irrespective of your cholesterol level, so typically we place patients on that medication for secondary stroke prevention. Other things that we look for is the arteries in your neck. We typically image those with either cardiac ultrasound, a CT angiogram of the head and neck or an MRA angiogram of the head and neck. Often, we'll get an echocardiogram of your heart, and we place patients on telemetry to monitor the heart rate. If we're strongly suspicious of an irregular heart rate as the cause of stroke, we will often recommend prolonged monitoring of the heart with something that could be additionally called a Holter monitor, the event monitor, or a loop recorder.
Bill: Okay, so lifestyle modifications, medication and testing all very important in helping to prevent stroke, and if you could wrap it up for us Dr. Cullen, what else should someone know about Rochester Regional’s Stroke Centers?
Dr. Cullen: So, this is a very important thing that at Rochester Regional Health that we want to deal with and make sure that we do our best to prevent strokes from occurring, and the disability that comes with strokes, we want to try to limit that. So, between the acute interventions of getting to the hospital as soon as possible, seeing if you are a TPA candidate; while in the hospital, receiving a thorough workup to try to determine the etiology or the cause of your stroke and then afterwards receiving the proper post-stroke care whether it's going to rehab or just seeing us in the TIA or stroke clinics, we’re able to help prevent and treat the disease that is potentially very devastating but sometimes preventable.
Bill: Right, well, thank you for sharing that with us Dr. Cullen, and thank you for your time today. You are listening to Rock Your Health Radio with Rochester Regional Health. For more information, you can go to rochesterregional.org. That's rochesterregional.org. I'm Bill Klaproth. Thanks for listening.
The Importance of FAST Stroke Treatment
Bill Klaproth (Host): Three out of every four stroke patients don't receive treatment fast enough for the best chance of a full recovery, so how are health professionals addressing this need for speed? Here to tell us about that and the life-saving stroke care at Rochester Regional Health is Dr. John Cullen, a key member of the Rochester Regional Health Stroke Team. Dr. Cullen, thank you for your time today. Can you first tell us why timing is so critical when it comes to stroke victims?
Dr. John Cullen (Guest): Yeah, timing is such a critical aspect of it because there is a medication that we can give called TPA that's given intravenously, and the issue with this medication is it has to be given within a certain time window in order for it to be both safe and effective. Generally, we try to give this medication within four and a half hours of when the symptoms onset began, and one of the first questions we typically ask a patient when they’re coming in with signs and symptoms of a stroke is when they were last seen normal because that helps us determine when that clock starts for the timing aspect of this medication.
Bill: So within four and a half hours of the onset of the symptoms and then tell me about the efficacy of this drug if it's caught within that four and a half hour window?
Dr. Cullen: So, within the four and a half hour window, it is pretty efficacious. The one factor to keep in mind is that four and a half window is the window to where we give this medication, but the earlier you give it, the better it works. So, you know, the thing that we like to say is "time is brain." Every minute that you wait -- delay to give this medication -- vital neurons in the brain can die and then you can lose more function, so, you know, when symptoms are first discovered it's important for families to immediately call 911 to get to the hospital as soon as possible because every minute is precious to try to give this medication.
Bill: So "time is brain." That's what you said, and every minute counts it sounds like, so this is really important the first time you notice any symptoms or something out of the ordinary, speed counts in this situation, like you say, "time is brain." Every minute counts. So, can you tell us what happens then during stroke treatment?
Dr. Cullen: Yeah, so the first thing you do when you arrive to the emergency room is you'll be triaged by the nurses, and they will assess you as an acute stroke alert and that rings off a bunch of different protocols. It gets the neurologist in the emergency room involved with your care very quickly. Usually the first thing when you do when you arrive is the nurse will quickly assess you, then check your blood pressure, then the emergency room physician will see you and do something called a NIH Stroke Scale, which is a measurement of how severe the potential stroke could be and then almost immediately after that, you usually get a non-contrast head CT and this is important to make sure that you're not having a hemorrhage or something else that could be making it so you cannot get that IV TPA medicine. Strokes come in a couple different forms, but the two main categories are either ischemic strokes which means a clot forms and blocks one of the arteries, not letting blood flow go to the brain or hemorrhagic stroke which means an artery or something else in the brain then bleeds and then that causes that kind of stroke symptoms so the head CT will help determine which type of stroke that you've had a stroke – if you’ve had a stroke. After the head CT's done, usually by that time, you'll be reevaluated, the neurologist usually at bedside at the time, and determination between the patient, the family, and the neurologist and the emergency room physician will often determine whether or not someone is an IV TPA candidate. If they are, then we try giving the medication, again, as possible.
There's another further intervention that can be done acutely where a neuroendovascular physician can actually do one of two things. They can actually go in with a device and retrieve a clot if it's within the arteries in the brain, or they can go in there to the arteries and give another medication called interarterial TPA which will then help resolve the clot. There’s the time component to that as well -- it's a little longer than the typical four and a half hours, but, again, it’s important to do it as soon as possible to help preserve the normal functioning of the brain.
Bill: Right, as soon as possible that time is brain again. So, you talked about the acute stroke alert, so this involves a whole team at Rochester Regional Health and time is of the essence. Can you tell us, then, about the intensive stroke training and some of the advanced technology you use at Rochester Regional Health to incorporate that speed of diagnosis and assessment?
Dr. Cullen: Yeah so we have different imaging modalities. We have, you know, the CTs – the scan I was talking about -- and doing other scans called a CT angiogram that looks specifically at the arteries within the head and the neck to look for any blockage. Other imaging modalities that we have available is we do something called a CT perfusion, that sometimes helps us determine the number or the size of the stroke and that there is tissue that can be preserved by doing the interventions as soon as possible. An MRI of the brain is also possible, though, usually in the acute phase that isn’t something that we do because that takes a little bit more time and again, time is of the essence here. At Rochester Regional Health, we have neuroendovascular-trained physicians that can perform these more advanced procedures that are used to take out the clots with different devices. Currently, that physician that we use is at Rochester General Hospital, and if a patient were to present to any of the other hospitals, we are able to quickly transfer them over to Rochester General so that they can receive this procedure.
Bill: And, Dr. Cullen, how about after a person suffers a stroke, can you tell us about the rehabilitation services and post-discharge follow-up?
Dr. Cullen: Yeah, so that's a very important factor of stroke care because the recovery is a vital component, and physical and occupational and speech therapy are keys to that. At all the Rochester Regional Hospitals, we have specifically trained physical, occupational, and speech therapists that are well-trained to be able to deal with neurological diseases, particularly stroke. Here at Unity Hospital, we have the Rochester -- we have the Golisano Rehab Center and most of our stroke patients go there after their stroke to receive their post-stroke care. This is staffed by PM&R physicians who are specifically trained in dealing with these kind of neurological injuries, and they have a dedicated team on multiple therapies that help get them through and help them recover after the stroke. In addition, at both Unity and Rochester General Hospital, we have TIA and stroke clinics that are set up in order to get patients quick post-hospitalization follow-up to make sure that all the treatment recommendations and therapies that were recommended during the hospitalization are being followed through with and make sure that nothing’s left that can help prevent future strokes from occurring.
Bill: Okay, well that's really good to know, and I know we are talking about stroke treatment, but can you quickly talk with us about stroke prevention such as stroke risk factors and how to lower them quickly?
Dr. Cullen: Yeah, so, when you talk about treating strokes, there's two main factors, there’s the treatment of the acute stroke which is what we talked about and then there's the secondary stroke prevention, which is just as important. The mainstays of stroke prevention are anti-platelet medications, such as aspirin and Plavix. There’s another medication called Aggrenox that we use sometimes, just is a blood thinner that helps prevent future strokes from forming. Other types of strokes are caused by irregular heart rates, typically something called atrial fibrillation and those type of strokes are best treated with anticoagulation medication. So, that's why it's usually very important to determine what caused someone's stroke so that we can properly and most effectively treat it going forward.
Other things and other factors that put you at risk for strokes are smoking, high blood pressure, high cholesterol, and diabetes, and that's why when anyone presents with signs or symptoms of stroke, we always try to best treat and evaluate for those conditions. If someone is a smoker, we strongly encourage smoking cessation and work hard with them to quit. After a stroke, it's very important to get the blood pressure well-controlled and for a new diabetic it's very important to get that well controlled. If someone has high cholesterol, we usually start them on cholesterol medication. One of the better cholesterol medications is one called atorvastatin, or Lipitor. Studies have shown that that medication has stroke reduction benefits irrespective of your cholesterol level, so typically we place patients on that medication for secondary stroke prevention. Other things that we look for is the arteries in your neck. We typically image those with either cardiac ultrasound, a CT angiogram of the head and neck or an MRA angiogram of the head and neck. Often, we'll get an echocardiogram of your heart, and we place patients on telemetry to monitor the heart rate. If we're strongly suspicious of an irregular heart rate as the cause of stroke, we will often recommend prolonged monitoring of the heart with something that could be additionally called a Holter monitor, the event monitor, or a loop recorder.
Bill: Okay, so lifestyle modifications, medication and testing all very important in helping to prevent stroke, and if you could wrap it up for us Dr. Cullen, what else should someone know about Rochester Regional’s Stroke Centers?
Dr. Cullen: So, this is a very important thing that at Rochester Regional Health that we want to deal with and make sure that we do our best to prevent strokes from occurring, and the disability that comes with strokes, we want to try to limit that. So, between the acute interventions of getting to the hospital as soon as possible, seeing if you are a TPA candidate; while in the hospital, receiving a thorough workup to try to determine the etiology or the cause of your stroke and then afterwards receiving the proper post-stroke care whether it's going to rehab or just seeing us in the TIA or stroke clinics, we’re able to help prevent and treat the disease that is potentially very devastating but sometimes preventable.
Bill: Right, well, thank you for sharing that with us Dr. Cullen, and thank you for your time today. You are listening to Rock Your Health Radio with Rochester Regional Health. For more information, you can go to rochesterregional.org. That's rochesterregional.org. I'm Bill Klaproth. Thanks for listening.