Anna Khanna MD.and Brian Hoh MD, MBA, FACS, FAHA, FAANS describe treatment options and the importance of timely treatment for acute ischemic stroke.
In this podcast, they outline the benefits of mobile stroke units. Additionally, they explain the research that has been conducted surrounding MSTU’s across the country how they can decrease stroke related disability and improve outcomes for stroke patients.
Selected Podcast
Mobile Stroke Treatment Unit
Featuring:
Brian Hoh, MD, MBA, FACS, FAHA, FAANS | Anna Khanna, M.D.
My name is Brian Hoh, MD, MBA, and I am chair of the UF Department of Neurosurgery. I specialize in the treatment of brain aneurysms, arteriovenous malformations, ischemic and hemorrhagic stroke, cavernous malformations, carotid stenosis, moyamoya disease, hydrocephalus, Chiari malformation, brain cysts and brain tumors, including meningiomas, glioblastoma and astrocytomas.
I joined the UF Department of Neurosurgery in 2006. Before that, I graduated with a bachelor’s degree from Stanford University and a medical degree from Columbia University. I completed my internship in surgery, residency in neurosurgery, and fellowship in endovascular neurosurgery and interventional neuroradiology at Harvard University’s teaching hospital, Massachusetts General Hospital. I later attended UF business school and graduated with an MBA in 2019.
In addition to taking care of patients, I conduct NIH-funded laboratory and clinical research to improve biomedical advances in care. My laboratory investigates the biological mechanisms of brain aneurysm formation and rupture, innovative tissue engineering technology to improve the treatment of brain aneurysms, and the pathophysiology of acute neural injury and delayed cerebral ischemia after subarachnoid hemorrhage.
The NIH awarded me a $38 million grant to lead a large national clinical trial, Comparison of Anticoagulation and anti-Platelet Therapies for Intracranial Vascular Atherostenosis (CAPTIVA). With CAPTIVA, we are investigating rivaroxaban or ticagrelor versus clopidogrel for preventing stroke in patients with symptomatic 70% or greater intracranial atherosclerotic stenosis.
As a national leader in neurosurgery, I have served as president of the Congress of Neurological Surgeons, chair of the Joint American Association of Neurological Surgeons/Congress of Neurosurgical Surgeons Cerebrovascular Section, co-chair of the editorial board of the Journal of Neurosurgery and a past member of the editorial board of World Neurosurgery.
In my free time, I enjoy spending time with my family, rooting for the Gators and playing golf.
Anna Khanna, MD, an assistant professor of neurology at the University of Florida College of Medicine and is a key member of the only comprehensive stroke program in north central Florida.
Dr. Khanna earned her B.A. in biological sciences from Rutgers University and her MD at Ross University School of Medicine. She completed her preliminary internal medicine residency year at the University of Medicine and Dentistry of New Jersey in 1999 and remained there to complete her neurology residency in 2002. Dr. Khanna became a stroke fellow there, and through its active vascular program, used both medical and endovascular therapies for the treatment of stroke. She completed her fellowship in 2003. She remained on faculty as an assistant professor, stroke program director and a mentor to medical students and residents. Dr. Khanna played an integral role in the community outreach for stroke education and traveled extensively to educate the public. As director of the outpatient stroke clinic and the resident clinic, Dr. Khanna introduced a comprehensive vascular ultrasound examination in the outpatient setting.
Transcription:
Dr. Brian Hoh: The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And joining me, we have a panel today with Dr. Brian Hoh, he's Chair of the Department of Neurosurgery at the University of Florida College of Medicine and UF Health Shands Hospital; and Dr. Anna Khanna, she's an Assistant Professor of Neurology at the University of Florida College of Medicine and the Medical Director of the Joint Commission Comprehensive Stroke Center at UF Health Shands Hospital, and they're here to highlight the Mobile Stroke Treatment Unit.
Melanie Cole, MS: Doctors, thank you so much for joining us today. And Dr. Khanna, I'd like to start with you, set the table a little bit for other providers with the prevalence of stroke, what you've seen in the trends and what populations you see this affecting most.
Anna Khanna, MD: Stroke in general is the fifth leading cause of death in the United States. It's actually second worldwide. But unfortunately, stroke is the highest reason why patients and stroke survivors live with disability. The earlier we treat patients with stroke, the better functional outcomes. And in fact, what we've seen with prior research is the highest correlate of a good or independent functional outcome is treating stroke victims within the first 60 minutes. Most stroke patients do come into the emergency department late. And in fact, 15 to 60% of patients arrive within that first three hours, which the treatment window for stroke patients is usually within four and a half hours of an ischemic stroke. We're able to deliver thrombolytic therapy, which includes either alteplase or tenecteplase. But in reality, within that golden hour, only 1.4% of patients are treated.
So in order to improve treatment times and deliver treatment earlier, we've conceptualized, something called the Mobile Stroke Treatment Unit. The concept was actually developed in Germany with a unit that was called a STEMO, which stands for Stroke Emergency Mobile. And the unit was launched in 2008. The first unit here in the United States was pioneered by Dr. James Grotta in UT Houston. And since then, there's been various numerous research projects demonstrating the benefit of the service in treating patients within an earlier time window.
Melanie Cole, MS: Well, thank you so much, Dr. Khanna, for telling us the importance of timely treatment for acute ischemic stroke. Now, Dr. Hoh, tell us about your mobile stroke unit. What are you seeing as the largest benefits and including how they'll decrease stroke-related disability, improve outcomes, decrease death? Tell us a little bit about this mobile stroke unit.
Dr. Brian Hoh: Thank you for that question. So, a mobile stroke unit quite simply is an ambulance equipped with a CT scanner to diagnose stroke and with the capability to provide timely treatment for stroke, which in many cases might be IV thrombolytic therapy, such as tPA or tenecteplase. Really, multiple studies, clinical trials have demonstrated the quicker the treatment for stroke, the better the functional outcome for the patient. Unfortunately, for many patients, particularly in our area where UF Health Shands Hospital is located, there are many patients who are located or live in rural areas, in far outlying regions where it may take time for them to get to a stroke center, a hospital where they're diagnosed with stroke and then receive treatment for their strokes. So, the benefit or the critical importance of a mobile stroke unit is that this ambulance can go out to the field where the patient is, stroke can be diagnosed by CT scan and by neurological assessment, examination and history-taking by a neurologist who is doing this either who travels out there on the ambulance or through telemedicine, can diagnose the stroke and then, timely treatment for the stroke can be delivered directly to the patient out in the field or while they're traveling by the mobile stroke unit ambulance to the stroke center hospital.
Melanie Cole, MS: What an amazing program this is. So, Dr. Khanna, when we talk about stroke and that time window, we always hear about where EMS fits into the picture, how they are alerting the trauma center of an incoming stroke, and how that affects treatment decisions and modalities and things. So, tell us a little bit about how EMS is involved in this, how they're trained with this mobile stroke unit, if they're involved. Expand a little bit for us.
Anna Khanna, MD: Well, in simple terms, really what a mobile stroke unit is an ambulance with several features. One would be a CT scan on board. And it has full capabilities of doing a full non-contrast CT of the brain. But also, we will have capabilities of doing a CT angiogram of the brain. And where this becomes helpful is when we're diagnosing patients with large vessel occlusions in those that come in with an ischemic stroke.
In addition, the unit will be staffed by EMTs and paramedics with expertise in stroke care. In addition, there will be a CT technologist on the unit, plus a stroke expert nurse who has undergone extensive training in stroke diagnosis, various stroke scales, and also in the mixing of pertinent medications. So with a compliment of all of this personnel, in addition, the vascular neurologist will either travel directly on the unit or will be available entirely via telemedicine in order to render immediate care. And the benefit is for patients that present with ischemic stroke, we will have a capability of administering early thrombolytics. And in patients that present with hemorrhagic stroke, we'll be able to diagnose that immediately via CT scan and administer hemostatic therapy or reversal medications if they are on anticoagulants, in addition to aggressive blood pressure control and possibly seizure control if needed. The unit will also have a ventilator on board and all full ALS equipment. Therefore, patients will have full emergency care. So, what we're basically doing is bringing the emergency room to the patient directly wherever they are. And it could be in their home, in front of their house, or even in places where sometimes we would have to park and rendezvous with a regular EMS agency, such as in a store parking lot.
Melanie Cole, MS: Well then, Dr. Hoh, speak a little bit about outcomes, what you've heard as far as research that's been conducted surrounding these mobile stroke treatment units across the country.
Dr. Brian Hoh: So, there have been a number of studies that have looked at health systems and regions where a mobile stroke unit have been instituted and they have been able to demonstrate that outcomes from stroke have been significantly better once a mobile stroke unit system has been in place. And that just makes sense. We know that the quicker, the timelier the treatment for stroke, the better patient outcomes. And in places where mobile stroke units are in use, that allows for timelier and faster, quicker treatment for stroke patients.
Anna Khanna, MD: I would just like to add and highlight one of these particular research projects. This was called the BEST-MSU trial, fully conducted in Texas University of Houston. And in this trial, what they did was, on alternating days, they sent out either an mobile stroke treatment unit truck or a regular, what they called, standard management EMS vehicle. And what they found is 33% of patients on the mobile stroke unit were treated within that golden hour, that key timeframe, which is associated with functional independence compared to only 3% of patients treated within that golden hour with standard medical care or the regular EMS vehicle. And this was also associated with a significant improvement in functional outcome. And what they showed that for every 100 patients treated in the mobile stroke unit, 27 had less disability and, in fact, 11 went home after hospitalization, fully independent. So, those rates are pretty significant and impressive.
Melanie Cole, MS: They certainly are, and it's such an exciting time. I'd like to give you each a chance for a final thought. And Dr. Hoh, tell us about anything exciting in the stroke world, anything coming on the horizon, research, clinical trials, anything you'd like other providers to take away from this episode.
Dr. Brian Hoh: Well, I think that the important message is perhaps in the past many providers and people who took care of patients with stroke felt there was nothing really that could be done, that the patient was doomed to living the rest of their life with disability. We know now that that's not true. We have treatments for stroke. We have thrombolytic therapy, but we also have mechanical thrombectomy for patients with large vessel occlusion. And we are seeing patients have better outcomes and patients surviving without disability and being able to live independent and functional lives. So, the introduction of mobile stroke units is a great advance in our treatment for stroke. It's something that will improve population health and improve outcomes for our stroke patients with timelier quicker treatment.
I'd also like to mention the incredible importance of stroke patients being taken to comprehensive stroke centers. It is so important for stroke patients to be taken to a hospital that has the multidisciplinary specialty expertise in taking care of stroke, where the patient will be eligible to receive whatever treatments are necessary for that patient, whether it be thrombolytic therapy or mechanical thrombectomy and endovascular procedure to remove the clot that's occluding the large vessel at the base of the brain. And for that patient to be taken care of in a specialized neurointensive care unit or stroke unit, it's incredibly important. And when mobile stroke units are part of that stroke system of care, there are protocols in place that enable patients to be taken to these comprehensive stroke centers where they're going to get the best specialized stroke care.
Melanie Cole, MS: Thank you for that. And Dr. Khanna, last word to you. What would you like other providers to know about the mobile stroke treatment Unit at UF Health Shands Hospital in the University of Florida College of Medicine. When is this initiative going to start? Just summarize it for us.
Anna Khanna, MD: The University of Florida Mobile Stroke Treatment Unit is scheduled to arrive at the end of May, and the program will officially launch roughly end of July. And what the mobile stroke unit will do, it will shorten time to treatment. It will also increase overall rates of thrombolysis. It will be a vehicle that can treat acute hemorrhages and possibly with reversal or hemostatic agents. And also, it will improve pre-hospital triage and getting patients to the right facility, especially patients with large vessel occlusions that could benefit from immediate transfer to the operating room for surgical mechanical thrombectomy.
Melanie Cole, MS: Thank you both so much for joining us today and sharing your expertise and telling us about the mobile stroke treatment units at UF Health Shands Hospital. Thank you again. And to learn more, please visit innovation.ufhealth.org. And to listen to more podcasts from our experts, you can always visit uhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today.