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Beating Stroke - Expanding Access to Effective Treatment and Perfecting Systems of Care Delivery
Guest Post Authors:
Deborah L. Benzil, MD, FAANS (left)
Chair, AANS/CNS Communications and Public Relations Committee
Mount Kismo Medical Group
Columbia University Medical Center
Mt Kisco, New York
Clemens M. Schirmer, MD, PhD, FAANS (right)
Vice-Chair, AANS/CNS Communications and Public Relations Committee
Geisinger Health System
Wilkes Barre, PA
Stroke is the fifth leading cause of death in the United States and the top cause of disability; thus representing a significant public health problem worldwide. According to the Centers for Disease Control and Prevention (CDC), each year, approximately 800,000 people in the U.S. suffer a stroke. Given that May was National Stroke Awareness Month, neurosurgeons believe individuals should take this opportunity to learn more about stroke care.
With stroke, the onset of symptoms is sudden and unpredictable, just like a heart attack. Aggravating this problem, many patients suffering from a stroke cannot voice their symptoms — letting valuable time go by until the stroke is recognized and critical intervention can be initiated.
Over the last few years, increased public awareness and enhanced pre-hospital triage systems have combined with hospital stroke certification programs to optimize stroke interventions. These efforts ensure that stroke providers — beginning with emergency medical services in the field and extending through the intensive care unit and rehabilitation after an acute episode — are appropriately trained and knowledgeable. Studies suggest that restoring blood flow after an acute ischemic stroke (called reperfusion) remains significantly under-utilized. In community settings, only five percent of acute stroke patients receive the mainstay of stroke interventions, which is intravenous (IV) recombinant tissue plasminogen activator (rtPA) therapy. Today, advanced stroke care goes beyond acute reperfusion with intravenous or intra-arterial techniques. For patients who develop significant infarcts, subsequent care may include:
- Dedicated neurointensive management;
- Intracranial pressure monitoring and management;
- Decompressive surgery; and
- Hemorrhage evacuation.
Each of these is a potentially critical aspect of managing stroke care. Large centers that specialize in comprehensive stroke services provide the full gamut of neurocritical care, neurovascular neurosurgery with experience in open and endovascular procedures, and dedicated rehabilitation capabilities in addition to medical stroke services.
Whether the stroke is hemorrhagic (bleeding into the brain) or ischemic (blockage of a vessel causing loss of oxygen to the brain), neurosurgeons play a central role in treating stroke patients. In most hospitals, neurosurgeons work collaboratively with a comprehensive team that meets a stroke patient at the moment he or she arrives at the hospital. As neurosurgeons, we provide the unique surgical skills often required as part of the treatment team. During neurosurgical training, the evaluation and treatment of stroke — both the acute treatment and secondary prevention — is an area of focus such that neurosurgeons become experts in stroke intervention. Some neurosurgeons also receive additional specialized training in cerebrovascular surgery, which includes highly technical expertise in endovascular (from within the blood stream), interventional or open surgical techniques uniquely geared towards the treatment of patients suffering the potential wreckage of a stroke.
Ischemic stroke, from blockage of major blood vessels, causes lasting brain damage and is devastating to patients. This type of stroke is a target for proven procedures that reopen the involved vessel, which restores blood flow. Cerebrovascular and endovascular neurosurgeons have long been at the forefront of developing the procedures and medical technology advances that have allowed for the efficient delivery of care. These include endovascular devices such as stent retrievers, suction aspiration devices, and clot retrieval devices, which allow rapid restoration of blood flow in blocked arteries in the brain.
Now that there is a significant and growing body of evidence that endovascular interventions offer significant advantages to those who suffer large vessel strokes, there is a need to optimize further the collaboration between services provided in the field with hospitals systems to improve patient access to these treatments. These efforts need to be free of insurance and network barriers and must be focused on the critical factor: “time is brain.” The goal must be to get a stroke patient to the most comprehensive center in the least amount of time. An essential component to ensuring that stroke patients receive this timely treatment is to compel insurers to remove the “experimental” designation for these proven interventions. While many have responded appropriately over the last year, some health insurers remain recalcitrant. To this end, neurosurgery will continue to advocate for our patients to help guarantee that they have access to all available treatment options.
Cerebrovascular neurosurgeons are thrilled to be part of this new and exciting era of stroke care. Given the aging population, in the coming years, the number of stroke patients per year will certainly rise. Primary and secondary prevention will have to become our focus to drive these numbers down. Therefore, resources and efforts must be directed toward creating regionalized stroke centers to bring high quality and comprehensive stroke care — including but certainly not limited to timely access to endovascular surgery — to these patients.