Five takeaways from the 6th Annual Neurovascular Symposium

Five takeaways from the 6th Annual Neurovascular Symposium

Experts gather at Christiana Care to take a closer look at the role of time in stroke care

Gregg H. Zoarski, M.D.

Every 40 seconds, someone in the United States suffers a stroke, which kills about 140,000 Americans each year.

Seeking immediate medical attention can boost the odds of meaningful survival, which is why time was key among the many topics discussed during the 6th Annual Neurovascular Symposium, hosted by Christiana Care Health System.

About 130 participants attended the April 20 event, held at the John H. Ammon Medical Education Center at Christiana Care — the only Joint Commission-designated comprehensive stroke center in the region outside of Baltimore and Philadelphia.

Program Chair Gregg H. Zoarski, M.D., an attending physician in NeuroInterventional Surgery and symposium chair, highlighted his top five takeaways from the symposium:

1. Effective communication between EMS and the emergency department can save lives

When a stroke happens, every second counts. To save precious time in the emergency department, the emergency medical services (EMS) team can begin sharing information before they arrive. An EMS team can use the rapid arterial occlusion evaluation scale (RACE) to identify symptoms — such as facial palsy, or arm or leg motor impairments — and call the Emergency Department while still in the field.

Once alerted that a possible stroke patient is en route, the hospital team can prepare IV-administered tissue plasminogen activator (Alteplase IV r-tPA) and assemble diagnostic equipment.

Stroke team members, vascular specialists and the imaging team are made aware of the patient’s arrival along with the Emergency Department staff.

An ischemic stroke occurs when blood flow to the brain is blocked. The tPA treatment, which dissolves the blood clot causing an ischemic stroke, must be given within four-and-a-half hours of the stroke’s onset in most cases.

“Shaving 10 minutes here and 10 minutes there makes a big difference,” Dr. Zoarski said.

2. The ‘Golden Window’ is wider

During a stroke, a patient can lose up to 2 million brain cells a minute. The golden window for thrombectomy, a catheter procedure to remove a large blood clot blocking a vessel to the brain, has traditionally been up to six hours from the time of the stroke.

For certain patients, that’s changed. Two recent trials, DAWN and DEFUSE 3, have shown that qualifying patients may benefit from the procedure up to 16 or 24 hours after the onset of stroke symptoms.

In addition to clinical examination, these patients first undergo a non-contrast CAT scan to look for a hemorrhage or large completed stroke and a CT angiogram with contrast to evaluate the blood vessels.

3. Posterior circulation strokes can mimic other conditions

A posterior circulation stroke occurs in the back of the brain in such areas as the cerebellum, which affects balance and coordination.

Unlike an anterior circulation stroke, which may cause obvious concerning neurological symptoms such as paralysis and the inability to speak, the symptoms of posterior circulation stroke may be less obvious, even to Emergency Department physicians.

Patients might act drowsy, experience double vision or feel dizzy. Symptoms may resemble a metabolic problem, a viral illness or an overdose.

“Doctors need to remember to consider posterior circulation strokes when patients are admitted to the Emergency Department with these symptoms,” Dr. Zoarski said.

Similarly, friends and family who see loved ones with these symptoms should still call 911.

4. Risk factors are not always obvious

Risk factors for stroke include high blood pressure, smoking, diabetes, high blood cholesterol, atrial fibrillation, sickle cell disease and obesity.

Heart disease is another factor. At the symposium, speakers discussed endocarditis, a heart valve infection.

Drug users and other individuals with severe infections can develop endocarditis when bacteria enter their blood through a needle. The infection may break free from the valve and be carried to the brain, where critical vessels become blocked and cause a stroke.

“Your heart is the pipeline to the brain,” Dr. Zoarski said.

About 30 percent of ischemic strokes in the United States are cryptogenic, meaning the cause is unknown.

Some possible causes include paradoxical embolism — a blood clot that travels through a patent foramen ovale, a hole in the heart that did not close after birth — and antiphospholipid antibodies, a disorder in which the immune system mistakenly attacks normal proteins in the blood.

5. Know your risk. Know the signs.

Dr. Zoarski underscored the continued need for public awareness, particularly since the clock is ticking from the moment the patient experiences symptoms.

Studies have found that patients who arrive at the Emergency Department within three hours of the first symptoms of stroke suffer from fewer disabilities three months after a stroke than those who delay care.