While strokes and other neurological disorders can be seriously debilitating, in recent years an array of surgical and minimally invasive treatments have led to significant advances in neurological health at Christiana Care, an accomplishment highlighted at the 5th annual Neurovascular Symposium in April at the John H. Ammon Medical Education Center.
Barbara J. Albani, M.D., chair of Neuro-Interventional Surgery, noted that July marks the 10-year anniversary of the launch of the Neuro-Interventional Program. From that initiative grew a state-of-the-science treatment facility.
“We are recognized as a Comprehensive Stroke Center with one of the highest volumes of patients in the nation and an outstanding record of care,” said program chair Gregg H. Zoarski, M.D., attending physician in Neuro-Interventional Surgery. “We provide a full-range of neuro-interventional treatments for brain aneurysms, carotid disease and intracranial hemorrhage as well as vascular malformations, and in 2017 there is no reason for patients to look outside Delaware for cutting-edge medicine.”
Broad goals for the symposium included:
• Explaining the evaluation and treatment plan for carotid and vertebral artery injuries.
• Describing research on image-guided treatment for cerebral hemorrhage.
• Identifying new approaches in the treatment of intracranial venous pathology, including clots in the dural venous sinuses which drain blood from the brain.
• Describing the risk assessment, genetics and surveillance of brain aneurysms, as well as endovascular treatment options.
Early presentations to the 175 attendees by four Christiana Care physicians dealt with acute ischemic stroke, the type of stroke that impacts the vast majority of stroke patients. “Our goal in treatment is to get to a vessel as fast, as safely and as quickly as possible and to get the vessel open in order to restore perfusion to the brain at risk,” said neuro-interventionalist Thinesh Sivapatham, M.D.
Mary Kobak, M.D., a Christiana Care family physician, said the conference provided a great deal of valuable information about strokes, a disease that results in significant morbidity and mortality among her patients. “We have a high-risk population in Delaware, with lots of high blood pressure, high cholesterol, diabetes and smoking,” said Dr. Kobak. “In listening to the speakers, I heard about helpful new technologies and preventive strategies.”
For instance, neurologist Anthony Munson, M.D., suggested that primary care physicians put up American Heart Association posters in exam rooms to explain stroke symptoms and the importance of calling immediately for an ambulance. “Patients spend time alone in the exam room, and I know when I am there, I read what’s on the wall,” Dr. Munson said.
Christiana Care ran an extensive public communications campaign in May and June, with messages on social media and billboards across New Castle County highlighting the symptoms of stroke and the importance of calling 911 fast.
Over the years Christiana Care has treated severe stroke patients faster and faster, which is effective in preventing the neuronal loss in acute stroke which occurs at the rate of 2 million neurons a minute until revascularization is achieved, said Jonathan Raser-Schramm, M.D., Ph.D., medical director of the Stroke Program and attending physician in Inpatient Neurology. However, there is evidence from national studies that one in five patients presenting to emergency departments with mild stroke symptoms are not always diagnosed and treated in prompt fashion, even though mild strokes can be extremely life-altering, and tPA is often indicated.
“Mild stroke is really not a benign condition and can be very disabling. Patients may not be able to go home or resume their previous activities,” said Dr. Raser-Schramm.
Mary E. Jensen, M.D., professor of radiology, neurology and neurosurgery and vice chair for operations in the Department of Radiology in the University of Virginia Health System, described procedures for evaluation, treatment and clinical cases on dural venous sinus thrombosis and idiopathic intracranial hypertension, which is sometimes called “pseudotumor cerebri” (false brain tumor). The latter involves an increase in pressure around the brain, leading to headaches and vision problems.
“When it comes to the veins, this is one of the forgotten topics, but I think you will be hearing more about them in the near future,” said Dr. Jensen. A leader in neurointerventional radiology, Dr. Jensen has pioneered treatments for cerebral aneurysms, including endovascular coiling techniques.
Leif-Erik Bohman, M.D., neurosurgeon, talked about image-guided treatment of cerebral hemorrhage. Such hemorrhages are fairly common, representing 10 to 15 percent of all strokes. Until recently there has been no efficacious treatment and studies have shown patient outcomes to be poor, with only 20 percent of patients being functionally independent after six months. However, a minimally-invasive surgical procedure targeting small clots has shown promise in China, and this had led to the MISTIE trials in the U.S., using a stereotactic insertion of a catheter directly through the skull to withdraw a blood clot with a subsequent infusion of alteplace (tPA) for up to four days.
While there have been few published results of the trials, the procedure seems to help patients, and there are now two FDA-approved mechanical devices to remove the clots. Christiana Care will begin offering this endoscopic surgery procedure this year, said Dr. Bohman.
Randy Gaboriault, MS, chief information officer and senior vice president of innovation and strategic development, spoke about approaches to innovation in health care that will one day involve the widespread use of data-driven health algorithms assisting clinicians to provide effective, timely, low-cost care. Peer-reviewed literature on this topic is growing exponentially, from 400,000 articles published annually 15 years ago to 900,000 in 2016. And with so much information to absorb, the medical establishment has a significant lag time between the distribution of valuable new research and its adoption.
Using today’s medical records, computer algorithms can factor in diagnostic data, demographic data and environmental data to offer care teams real-time patient analytics. In fact, elements of this model are already in place in the CareVio service, which offers intensive engagement — and virtual monitoring — for the 5 percent of Christiana Care patients at risk for hospital readmission. Gaboriault speculated that one day the hospital system will provide similar digitized medicine for every patient and every intervention to maximize the patient experience and deliver customized care.