Every year, more than 795,000 people in the United States have a stroke, according to the CDC. That’s 90 people each hour of every day of the year.
Stroke is the third leading cause of death and the top cause of disability in the country. So identifying a stroke quickly and getting immediate treatment both saves lives and can help limit long-term damage.
Early recognition of stroke warning signs is the key to better outcomes. Another critical component is having a well-coordinated team of neurologists, neurosurgeons, neuro-intensivists, radiologists, therapists, nurses, physiatrists, pharmacists and other healthcare professionals committed to and focused on the care of stroke patients. The Jefferson Acute Stroke Center is the largest facility dedicated to the care of acute stroke in the Delaware Valley and nationally acclaimed for the prevention, diagnosis, treatment and research of stroke.
Here’s a look at what happens when a stroke patient arrives in the Emergency Department (ED) at Jefferson Hospital for Neuroscience and the continuum of care from initial diagnosis to treatment to follow-up care.
The Stroke Alert
As soon as someone experiencing symptoms that suggest a stroke arrives at the emergency room – whether transported by EMS or a “walk-in” brought by friends or family – they are assessed by an experienced nurse in the ER waiting area.
“Then the patient is moved to the triage area and is seen by an attending physician,” explains Jeannee Birch, RN, a neurovascular coordinator at Jefferson. “The ED physician will determine whether to initiate Jefferson’s Stroke Alert.”
The Stroke Alert notifies a response team that consists of:
- An On-Call Neurologist
- Endovascular Neurosurgeons
- The CAT Scan Unit
- The Clinical Lab
- An ED Charge Nurse
- An ED Clinical Educator
- A Neurovascular Coordinator
- The Pharmacy
“At this point, everyone is working as a team. One nurse is drawing the lab, another is doing intake history and collecting required information,” Jeannee says.
Then the patient moves to a room with a nurse for monitoring.
“A neurologist is at the bedside assessing the patient within 10 minutes,” Jeannee notes.
From Assessment to Treatment in Minutes
If the neurologist determines a stroke has likely occurred, a CT scan is ordered. This helps to identify abnormalities in the brain and to determine if blood flow has been blocked (known as an ischemic stroke, accounting for 87 percent of cases) or a blood vessel has ruptured (a hemorrhagic stroke).
Based on the results of the scan and other factors, the neurologist may order intravenous (IV) or intra-arterial (IA) tPA – strong clot-busting medications.
“This medication offers a 30 to 50 percent better chance of cure from stroke disability,” says vascular neurologist Maria Carissa C. Pineda, MD. “As one of the few hospitals in the region to offer IA tPA, many patients are transferred to Jefferson to receive this lifesaving treatment.”
In strokes, similar to heart attacks, time is a critical factor.
If the patient is not eligible for tPA, the patient is quickly moved to one of the interventional neuroradiology laboratories. An experienced endovascular neurosurgeon performs a CT angiogram to determine narrowing or obstruction of the arteries and a CT perfusion to evaluate brain tissue. This process enables the team to determine if the patient is eligible for endovascular procedures, such as intra-arterial thrombolysis or stenting.
“Vascular neurologists work closely with endovascular neurosurgeons to find the right next step. We have a short window for treatment,” says Dr. Pineda.
Minimally Invasive Neurosurgery for Stroke
Intra-arterial thrombolysis is a technique used to break up a blood clot located within a blood vessel and may be effective in reversing a stroke. This involves the minimally invasive insertion of mechanical devices through the patient’s blood vessels through the groin and up to the brain to open the blocked vessels.
Another way neurosurgeons can restore blood flow to the brain is through a carotid angioplasty with stenting, which opens blockages and removes plaque deposits within the carotid artery.
After treatment, patients move to the Acute Care Stroke Unit or the Neuro-Intensive Care Unit, where nurses trained to care for stroke patients monitor them. The multidisciplinary team searches for other factors, such as atrial fibrillation, high blood pressure, high cholesterol and diabetes mellitus, that may have caused or played a role in the stroke. Once identified, treatment of these other health issues can decrease the risk of a second stroke.
Neuro-intensivists – doctors who specialize in life-threatening diseases of the nervous system – then join in to care for the patient. They will look for things like swelling of the brain and high intracranial pressure.
Rehabilitation and Recovery
Rehabilitation is very important to recovery after a stroke.
Physical therapists, occupational therapists and speech-language pathologists evaluate patients at the bedside. Our rehabilitation therapists look for difficulties that the patient may have with movement, walking, getting in and out of bed, dressing/bathing, swallowing, speaking and thinking clearly.
Physiatrists (physical and rehabilitation medicine physicians) meet with patients to determine functional deficits caused by the stroke, including issues with cognition, weakness, paralysis and other movement disorders in addition to looking at the prior level of function and social supports of the patient.
“Based on our rehabilitation team assessment of the patient and their functional capacity within the first few days, we can determine what kind of rehabilitation they need, if any,” says physiatrist Nethra Ankam, MD, director of the Rehabilitation Medicine Consult Service. “The earlier we mobilize the patient, the better it is for recovery.”
Rehabilitation begins with acute care services during hospitalization to re-learn the skills to live as independently as possible.
The 23-bed Comprehensive Acute Rehabilitation Unit at Jefferson is available to adult patients in need of continued intensive inpatient rehabilitation services following discharge from Jefferson Hospital for Neuroscience. Nationally accredited by the Commission on the Accreditation of Rehabilitation Facilities (CARF) for Stroke Specialty, the Unit’s goal is to maximize patients’ functional independence and to transition them back into the community.
The interdisciplinary rehabilitation team includes the physiatrist, rehabilitation nurses, case manager/social worker, physical therapists, occupational therapists, speech-language pathologists, psychologists and therapeutic recreation specialist working closely with the patient and family.
“Stroke rehabilitation is a marathon, not a sprint; it’s a long process,” Dr. Ankam comments. “It’s important to educate patients and their families during rehab and provide some guidance on how to live with this condition and what they can expect going forward.”
Outpatient rehabilitation therapies are available to patients of all ages through JeffFIT. Jefferson physiatrists work closely with our outpatient rehabilitation therapists to help minimize patients’ pain, promote wellness and regain their function. The rehabilitation therapists practice an interdisciplinary team approach, working with referring physicians, nurse practitioners and case managers to ensure the delivery of comprehensive quality services.
Guiding Individualized Care
Case managers play a vital role in caring for a stroke patient. What makes Jefferson Hospital for Neuroscience unique is that we have a dedicated case manager for stroke patients. Our case manager, Berlinda Mihaich, RN, is aware of every stroke patient at the Hospital. She educates patients and their families, coordinates the services associated with discharge or returning home, and ensures proper care and follow-up after discharge.
Dr. Pineda describes Berlinda as “the other arm,” meaning, the other helping hand to see a patient through all levels of care. Berlinda works closely with Case Management on the Comprehensive Acute Rehabilitation Unit to assist with this transition.
After Returning to the Community
Long-term complications of stroke, such as diminished cognitive ability and depression, may develop right away or months to years after a stroke. During follow-up visits, Jefferson outpatient nurse practitioners screen stroke patients for depression, and neuropsychologists assess a patient’s cognitive ability through tests, patient history, observations and neuroimaging findings.
To schedule an appointment with a Jefferson physician, call 1-800-JEFF-NOW or request an appointment online.