"Time is brain": Coordinated stroke care at Christiana Care saves time, lives
In stroke care, time is of the essence to prevent a patient from rapidly losing brain cells.
That’s why hospitals in the state coordinate to get patients to Christiana Care Health System in Newark — the only place in Delaware that can do a specialized procedure to surgically remove large blood clots.
If you had a stroke 30 years ago, doctors would monitor your blood pressure and probably give you an aspirin.
But in 1995, the U.S. Food & Drug Administration approved an IV drip medicine called tPA that doctors use to dissolve blood clots and return blood flow to the brain — and the game changed.
“Some of these patients can literally go home that would’ve been in a skilled nursing center the rest of their lives,” said Doug Huisenga, the program manager of Christiana Care Health System’s Comprehensive Stroke Program. He says tPA is just one option to improve a patient’s life.
Christiana Care is the only hospital in Delaware that offers a minimally invasive procedure called mechanical thrombectomy, where doctors surgically remove a large blood clot in more severe stroke cases. Christiana Care first started performing it in 2007 and studies validating its effectiveness started appearing in 2015.
Last year, Christiana Care doctors performed more than 80 mechanical thrombectomies on large vessel blockages, and offered tPA to more than 300 people.
Jonathan Raser-Schramm, the program’s medical director, says coordinating these procedures quickly and efficiently is important because a stroke patient can lose two million brain cells per minute. As Christiana Care doctors say, “time is brain.”
“As soon as a blockage occurs, part of the brain starts dying,” Raser-Schramm said. “And we know that the treatments are the most effective the sooner we’re able to restore blood flow, we’re able to prevent permanent death to that part of the brain.”
If a patient in Sussex County has a stroke, they go to their local hospital first. If their physician determines they need more intense treatment, they arrange for a helicopter to pick them up.
In 2017, Christiana Care performed more than 80 mechanical thrombectomies and offered tPA to more than 300 people.
When a patient arrives at the hospital, doctors hear this announcement play twice over the intercom:
“Attention please, attention please, stroke alert, emergency room one, patient is here.”
Once a patient is settled, doctors talk with them and try to figure out what happened.
Jason Nomura, an emergency medicine physician, monitors blood pressure, any sort of facial droop and breathing ability in the emergency department.
“We look at how they look facial wise, do they have a facial droop, are they awake, do they have trouble breathing,” Nomura said. “We’re looking for life threatening situations early on.”
Then they bring the patient to a CT scanner to look at pictures of their brain.
Barbara Albani and Thinesh Sivapatham are two of the doctors involved in this part. They look through a recent patient’s images.
THINESH: This is the right, the carotid artery. as it comes up, you see how it stops right here. You see all of these little blood vessels here, but there’s a lack of those blood vessels in this part of the brain. BARBARA: See that little cut-off right there. See this is a big trunk, major, major branch, major branch, see it looks like someone cut the limb off right there, it just abruptly stops.
Based on the size of the blockage, doctors determine whether the patient needs tPA or a thrombectomy, and they bring them to that procedure.
That usually happens about 35 minutes after a patient first enters the emergency room. The national average for this time is about 45 minutes.
Albani says to do a thrombectomy, she’ll make an incision in a patient’s leg, put an IV tube in and move long catheters to try to suck out that clot. And while she does that, an analogue clock on the wall shows them how much time has gone by, because “time is brain.”
Coordinated stroke care enables doctors to reduce permanent disabilities like vision or movement impairment.
“Time is always brain, right? You know we try very hard to minimize the variables we can control — that is to say the time the patient gets on the table, the time we make incision, that sort of thing," Albani said. "Beyond that, obviously we try to work as fast as we can.”
Then they take a patient to the Intensive Care Unit unit for special care, until they’re ready to move to a less-intensive unit for therapy.
Through this process, doctors reduce permanent disabilities like vision or movement impairment — and the patient can start the recovery process.
Middletown resident Kathi Brown is currently recovering from a stroke she had in January. While working out at her personal trainer’s house, she realized she was not able to communicate clearly, and had trouble climbing stairs.
“They put me in an ambulance and took me to Christiana Care,” Brown said. “I was not able to communicate clearly. I could answer simple questions, but I said a lot of weird things.”
The stroke team was ready for her before she even arrived at the hospital.
After receiving a thrombectomy and staying in the hospital for four days, Brown was discharged, and has been going to therapy for speech, language and memory. She says she has seen massive improvements since.
“I’ve resumed most of my normal activities,” Brown said. “I do get tired, and I have to think about that. I’ve starting back exercising. I am back now at work now full-time.”
Brown says she’s thankful for the rapid treatment and the kind and coordinated staff. Had it not been for either…
“I don’t know,” Brown said. “I might still be speaking like I spoke there the first few minutes —having the thoughts fairly clear in my head but not being able to communicate them.”
And as Brown continues to improve, Christiana Care says it hopes to improve its specialized stroke center as well.
Doctors say they’d like to see the hospitals across Delaware work more closely together in getting patients to the right hospital at the right time — as soon as stroke symptoms start.