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Comprehensive Stroke Services: Saving Time, Saving Brain

June 22, 2015

No one knows when Eileen Engels’ symptoms began, but around 2 p.m. on October 31, her husband Paul returned home to find her lying helpless. The left side of Eileen’s face was drooping, and she had no movement in her left arm and leg. Her speech was slurred.

Saving a life

Paul called an ambulance, and immediately, the stroke services team at Baystate Medical Center thrummed into action and were ready to perform scan and other diagnostics when the Engels arrived.

Neurosurgeon Dr. Farhad Bahrassa said it was clear she’d suffered a severe stroke. Engels was given an intravenous course of a clot-busting drug, Tissue Plasminogen Activator (TPA), and was evaluated by Bahrassa for further treatment.

Less than two hours after her husband found her, Bahrassa removed a one-inch clot blocking a critical artery in this 78-year-old woman’s brain. Two days later, Engels walked out of Baystate, virtually unaffected.

“It was a great, great save for her. She went home completely restored,” said Bahrassa, who removed the clot in Baystate’s new, state-of-the-art neurointerventional laboratory. “She could have been permanently disabled in a nursing home and unable to care for herself.”

Brain Attack Team

Bahrassa said the interventional procedure to remove the clot restored the flow of blood to the Engels’ brain. But key in this dramatic success story is the fact that Baystate has launched a comprehensive stroke services team that moves swiftly and collaboratively when a 911 call is received for someone suffering a stroke or a burst aneurysm.

Called the Brain Attack Team, this stroke-specific Rapid Response Team includes neurosurgeons who perform interventional and cranial surgeries, neurologists, emergency physicians, radiologists, physiatrists, and other support staff.

Fayla Anderson, BSN, CNRN, the coordinator for stroke services, oversees care for stroke patients from the time they enter the ED until they complete their care in the stroke clinic.

Training around swift response began by training area emergency medical service teams and community fire department ambulance services.

“Now if they pick up a patient with stroke symptoms and have an arrival time within four hours, they call ahead and tell us they have a stroke alert,” Anderson said.

This phone call triggers the group stroke page, which notifies the lab and scan departments that a patient is on the way.

“We all meet at the door,” she said, “and immediately upon a patient’s arrival, we do lab work, conduct an EKG and CT scan, and if the patient is not on a drug such as Coumadin and so qualifies for TPA, we begin intravenous treatment.”

“The goal is to get the TPA started in less than an hour from the time the patient arrives,” Anderson said, noting that two million neurons die per minute during a stroke. “Nationally, this has been a big struggle for hospitals. It’s hard to get a patient from one department to the next and get lab work done and drawn.”

At Baystate, the assessments are all done well within an hour, sometimes as quick as 45 minutes.

“This system serves stroke patients along the entire continuum of care at every possible level they might need it,” said Dr. Edward Feldmann, vice president and medical director of the Baystate Neurosciences Program. “This comprehensive level of care never existed in western Massachusetts before this.”

Expertise & Technology

In addition to having the right team in place, Baystate’s experts are supported by its new neurointerventional laboratory, available 24/7. The trend is to treat patients using the less invasive, interventional method which allows faster recovery time, less pain, and a shorter hospital stay.

But, Bahrassa said, “The determination depends on the location, the size of the aneurysm, and the relevant anatomy of vessels around it. Sometimes it’s not safe to go through the vessels – they’re either too small or winding – and then open brain surgery is a better option.”

In Engels’ case, Bahrassa determined clot removal would be performed in the neurointerventional laboratory using a metallic stent-like device that opens in the artery to immediately restore circulation.  

“When she woke up and we evaluated her, she could move her left arm and leg,” Bahrassa said.

While Eileen was conscious through the entire pre-procedure evaluation, she was only able to nod to communicate; she had trouble talking.

“She remembers everything,” Bahrassa said. “She told me afterwards. She appreciated it all.” 

In recovery, patients receive care in a Stroke Clinic that offers rehabilitation services to bring them back to optimal functioning. 

Time is Brain

“With any stroke, the optimal outcome depends on being evaluated and treated as quickly as possible,” said Dr. E. Jesús Duffis, a neurointerventional neurologist. “Time is brain. Our intent is to have a smoothly operating system that allows for quick mobilization to provide care in the timeliest fashion – very similar to what happens in cardiovascular care when a person is having a heart attack. The quicker this gets done, the better the outcome for the patient.”

Unfortunately, Bahrassa said, clot removals and occlusions do not always produce the dramatic results Engels experienced.

He explained that in the case of a clot, for instance, the procedure restores blood flow to the brain, but it does not reverse damage already done before blood flow is restored. The goal is to save undamaged but “at risk” areas of brain before they become damaged.

Bahrassa praised Engels’ husband for his quick response.

“Her husband Paul gets credit, too, for making the call that got her right to Baystate,” he said. “This is the only place in western Mass where she could have had this result.”