CT scans like these — sometimes sent from remote places in the WWAMI region — form the basis of stroke diagnosis and care for the multidisciplinary stroke team at UW Medicine.

When Time is Brain: The UW Medicine Stroke Center

Police officer Phil Farr remembers the instructor, the track, the obstacles — all part of the high-speed driving course his unit took on a regular basis. But something was different in 2003. He left the track with a splitting headache.

Farr, a member of the Island County Sheriff’s Department in Oak Harbor, Wash., didn’t know that the strain of driving had torn his left carotid artery. Clots formed, and much of the blood flow to his brain simply stopped.

Farr — then 47 years old — was having a stroke.

When time is brain

Farr experienced the most common type of stroke — ischemic — which occurs when an artery is blocked by a clot. Another type, hemorrhagic stroke, occurs when blood vessels in the brain break. In both cases, brain cells deprived of oxygen and glucose die, and rapid treatment means better outcomes. In other words, time is brain.

Still, many things about stroke care remain uncertain. David Tirschwell, M.D., M.Sc., Res. ’93, UW associate professor of neurology and co-director of the UW Medicine Stroke Center at Harborview Medical Center, says stroke patients present with many different symptoms, including bad headaches, sudden weakness on one side of the body, or sudden language or vision problems. “The challenges are that every patient is different and there are only a few therapies proven to be effective,” he says.

One such evidence-based therapy is tissue plasminogen activator or tPA, a clot-busting blood-thinner that can be administered intravenously within 4½ hours of an ischemic stroke. But there are limits to its effectiveness. “If you treat too late [with tPA], you’ll have more bleeding than benefit, and that’s why there’s a limited treatment window,” says Tirschwell.

These and other high-tech therapies — as well as an expert team in stroke care based primarily at Harborview — can be found at UW Medicine.

“We have some of the most advanced equipment in the U.S., in the world, even, because we’ve had a collaborative effort with [Philips] over the years,” says Raj Ghodke. This partnership — Harborview is one of Philips’ national “show sites” — provides great benefits, like minimally invasive surgery for stroke patients. Pictured above: the angiography suite.

The Stroke Center and Telestroke: better care for the region

The UW Medicine Stroke Center at Harborview is unique to the Pacific Northwest; it includes six board-certified vascular neurologists, neuroradiologists, interventional neuroradiologists, neurosurgeons and rehabilitation specialists.

These individuals treat patients from the four-state WAMI region of Washington, Alaska, Montana and Idaho — in fact, they care for more than 700 patients hospitalized for stroke every year. Harborview has been recognized for this high level of care with certification as a Primary Stroke Center by The Joint Commission, stroke honor roll recognition by the American Heart Association/American Stroke Association and pending state certification as a level 1 stroke center.

Sharing this kind of medical expertise is part of UW Medicine’s mission and the purpose of the Telestroke Program, which began roughly a decade ago. “The stroke phone has been part of the UW Medicine neurology system since around 2001…initially, it was just for residents in our system to call when they had questions,” says Sandeep P. Khot, M.D., MPH, Res. ’06, Fel. ’07, a stroke specialist and director of Harborview’s Neurology Consult Service. Now doctors from the WWAMI region use the phone, too; it’s staffed, 24/7, by Khot and other vascular neurologists.

Telestroke faculty dispense advice, review images and help doctors decide if their patients should be transferred to Harborview for care. It’s a vital service for smaller hospitals in the WWAMI region that don’t have stroke experts, says Vicki Johnson, DNP, MHS Ed., ARNP, manager of the Stroke Center. Johnson helps educate staff at other institutions.

“We want to help our partners be better stroke providers,” she says.

When every minute counts

For far-flung and local patients alike, stroke care often starts en route to Harborview — with emergency services like Medic One and Airlift Northwest. Harborview’s ER is also on the alert for potential stroke patients. “The system automatically has a quick checklist, looking for red flags for stroke as it does for cardiac problems,” says Johnson.

Next comes a CT or MRI scan, which can help determine if the patient had a stroke. Then the team weighs the patient’s options, based on the type, size, severity and timing of the stroke. “You want fast, accurate evaluation and immediate access to treatment,” says Bruce R. Ransom, M.D., Ph.D., UW professor and chair of the Department of Neurology, and the Warren and Jermaine Magnuson Endowed Chair in Medicine for Neurosciences. “Access to this high level of care can be life-saving.”

“We want to help our partners be better stroke providers.”—Vicki Johnson

Some patients with hemorrhagic stroke are eligible for neurosurgery; others with ischemic stroke can receive intravenous (IV) tPA. “We can administer IV tPA to somebody within 30 minutes of presentation when all goes well,” says Kyra J. Becker, M.D., UW professor of neurology and neurological surgery and co-director of the Stroke Center.

Other ischemic stroke patients are candidates for angiographic interventions. These image-guided therapies are delivered by experts like Basavaraj (Raj) Ghodke, M.D., Fel. ’03, UW associate professor of radiology and neurological surgery, director of neuro-interventional radiology, and co-director of the UW Brain Aneurysm Center, and Danial K. Hallam, M.D., M.Sc., UW associate professor of radiology and neurological surgery.

Most patients arrive after the 4½- hour window required for intravenous tPA has closed, explains Ghodke. In those cases, interventional neuroradiologists may use sophisticated scanning and catheter-based techniques to deliver tPA directly to a clot. Or they may perform a mechanical thrombectomy, another catheter-based therapy in which doctors remove clots either by inserting a corkscrew-type coil through the neck to snag the obstruction, or by using a tiny vacuum.

“We’re fortunate to have the best diagnostic neuroradiology and therapeutic neurointerventional team in the country,” says Norman J. Beauchamp, M.D., MHS, UW professor and chair of the Department of Radiology. Their expertise, he says, pays dividends — such as the relationship they’ve developed with medical technology companies. Take Penumbra, Inc., for example, the company that developed the vacuum-based system.

“We’re the first center in the Seattle area to use Penumbra,” says Hallam, noting that he and his colleagues have helped the company develop better catheters. UW Medicine also partnered with Philips Healthcare to develop Harborview’s high-tech angiography suite. In other medical centers, patients would need a separate scan to measure perfusion — an indication of blood flow and blockage in the brain — at a time when every minute counts.

With Harborview’s one-stop angiography suite, no time is wasted, says Ghodke. “We can monitor our progress by doing these perfusion angiograms during the procedure itself,” he says.

After the stroke

Kyra Becker gives stroke patient Phil Farr a test to assess his coordination. “We do the same thing with drunk drivers,” says Farr, a police officer with 30 years’ experience.

For many patients, rehabilitation — physical, occupational and/or speech therapy — often follows acute care. “Rehabilitation is all about maximizing function and getting back to your previous activities,” says Peter C. Esselman, M.D. ’86, Res. ’87, ’90, UW professor and chair of the Department of Rehabilitation Medicine.

This was certainly the case for Phil Farr, who couldn’t speak after his stroke. After therapy at Harborview helped restore normal speech, he returned to work.

Approximately 120 stroke patients are admitted to Harborview’s inpatient rehabilitation unit every year; others, like Farr, use the hospital’s outpatient rehabilitation services. UW Medical Center also provides stroke rehabilitation — often for cases connected to complications from other conditions, like cardiac problems or cancer.

In addition to improving speech and cognition, the rehab team works to improve a patient’s basic mobility: often, stroke leaves a patient with weakness on one side of the body, which makes it difficult to walk. The progression, from parallel bars, to walker, to cane, for instance, “takes time and a lot of work,” says Esselman.

There’s another piece to stroke care, too, says Johnson: education. She and her colleagues teach patients about risks posed by hypertension, diabetes and cholesterol. “A big part of the work-up is digging deep to figure out why they had their stroke,” she says. “If we can identify the cause, we can come up with a better long-term plan to prevent future strokes.”

From robots to the immune system

Still, problems may persist. Five years after his stroke, Farr’s headaches returned, and he passed out during a visit to Becker’s clinic. “That bought me a 10-day stay in Harborview,” he says.

While Farr had not had a second stroke, his right carotid artery (like the left one a few years earlier) had torn.

His case is a textbook example of the importance of research in advancing patient care. This time, Ghodke inserted a stent — a therapy that simply hadn’t existed five years earlier — in Farr’s carotid. The stent promotes blood flow in an effort to prevent strokes, and it eliminated Farr’s debilitating headaches.

“The demand for stroke specialists has really gone up.”—David Tirschwell

Many research questions remain, however, because existing therapies don’t work for everyone. Becker and her colleagues are searching for answers — collecting data on how best to prevent secondary strokes, for instance, and on how the immune system responds to stroke. “There’s a possibility that the immune system actually can contribute to brain injury following stroke,” she says.

Other studies at UW Medicine — involving robots, video games and re-training the brain — focus on rehabilitation for stroke patients.

Participating in stroke rounds is an important part of the learning experience for stroke fellows, residents and other medical professionals. With the aging of the baby boom generation, stroke specialists are in high demand. “We have great clinical material that the fellows can learn from, and our graduates have been very successful,” says David Tirschwell.

Keeping up with quality of life

Anthony M. Avellino, M.D., Res. ’00, FACS, MBA, UW professor in the Department of Neurological Surgery and director of the multidisciplinary UW Medicine Neurosciences Institute, recently evaluated the institute’s programs, placing them into tiers of importance. Given our aging population, he and his colleagues put stroke management in the top tier.

“If we don’t focus on heart disease, joints, stroke, and aging and neurodegenerative disorders, we’re going to be way, way behind,” says Avellino. The medical marketplace proves the point. “The demand for stroke specialists has really gone up,” says Tirschwell, who directs the stroke fellowship at UW Medicine.

Stroke education, research, care: it’s all done to save and improve lives. And watching patients’ progress is rewarding for providers, who see patients in clinic three, four, 12 months after their stroke. Some show so much improvement, says Johnson, “you wouldn’t even believe it’s the same person.”

Phil Farr can attest to that. In 2008, he was on a morphine drip for intense pain. In 2010, he and his Jack Russell terrier headed out on a motorcycle trip to visit a friend in Missouri.

This is life after stroke, Farr says. “I try to take more opportunities to find things to enjoy.”

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