THE KAISER PERMANENTE TELESTROKE PROGRAM: 'Time Is Brain'

Jonathan Artz, MD

Stroke, the nation’s third-leading cause of death and a leading cause of serious long-term disability, is a condition often seen in emergency rooms. Acute ischemic stroke, the most common type of stroke mechanism, is caused by a clot obstructing the flow of blood and oxygen to the brain, which can result in the death of brain cells.

The motto of health care providers who evaluate and treat stroke patients is “Time Is Brain.” That is, every minute lost before the obstruction is cleared results in the oxygen-deprivation death of additional brain cells.

Thanks to telehealth equipment and techniques, including high-resolution video, providers can now gain precious time in evaluating and treating patients presenting with symptoms of stroke. In the Kaiser Permanente system in Northern California, we call this our Telestroke program.

The goal of a welldesigned stroke program is to quickly address the blockage, either by administering tPA (tissue plasminogen activator, which dissolves clots) or by physically removing it.

tPA is the only FDAapproved treatment for acute ischemic stroke, and the sooner it can be given to a patient, the better the outcome in terms of functional recovery and reduced morbidity and mortality. This medication must be administered in the hospital as it is a potent clot-busting drug given by intravenous infusion. Recent advances in acute stroke management help patients who do not improve after tPA administration by extracting their blood clot with newly developed clot retrieval devices.

Kaiser’s “Stroke Pathway of Care” involves Primary Stroke Centers (where tPA is administered) and Comprehensive Stroke Centers where medical personnel with advanced interventional radiology training are available to manage situations involving a large clot persisting in one of a few major arteries within the brain. Groundbreaking research in stroke management has made possible the introduction, in just the last two years, of several new clot retrieval systems. Thesethrombectomy studies1–4 showed that removal of certain large clots within welldefined regions of specific brain arteries within a defined time window from the onset of the stroke episode can be safely performed. Such clot removal reduces major disability and greatly improves functional outcomes.

Kaiser’s Telestroke program allows emergency physicians in any of 21 Kaiser hospitals in Northern California to alert a neurologist at a remote location—often before the patient suspected to be having a stroke arrives at the Emergency Department via ambulance. Diagnostic images of the patient’s brain are made instantly available to both the Emergency Department and remote physicians electronically, and the neurologist can assess the patient visually with the help of video technology. All this shaves precious minutes off the time it takes to determine if the patient is a candidate for tPA. That drug, to be effective, must be administered within 180 minutes of the onset of stroke symptoms (with an extended window of up to 270 minutes if the patient meets certain criteria), and it is more effective the sooner it is delivered.

Kaiser’s Northern California Stroke Express Program was established in 2015 and consists of a group of about 18 neurologists and neuro-critical care specialists from various facilities throughout Kaiser’s Northern California network. Each Stroke Express member rotates call coverage in a shift that typically lasts four to eight hours. The Telestroke neurologist on duty covers the entire Northern California hospital network and evaluates patients, both those being seen in a Kaiser ED and inpatients who suffer a stroke in any of these 21 Kaiser facilities. Some of the Stroke Express neurologists are part of a core group of six who spend over a third of their clinical time just performing Telestroke assessments. The other (noncore) members do fewer stroke “calls” per week.

The teleneurologist leads the way in ensuring the expedited evaluation of newly arrived patients in order to optimize the delivery of tPA in either the Emergency Room or an inpatient setting. The teleneurologist also communicates with the nearest Comprehensive Stroke Center when it is necessary to remove large clots using sophisticated mechanical clot retrieval systems.

Following is an example of a Telestroke team approach to evaluating and managing an acute ischemic stroke patient.

Patient Mr. B, age 62, with welldocumented hypertension and atrial fibrillation (on daily aspirin), was sitting watching TV with his wife at 6:30 p.m., just after finishing dinner. He got up to go the kitchen when his wife noticed he was staggering to the right. His walking remained impaired. He could not communicate his thoughts, and most words did not make sense. She called 911 at 6:32, and EMS arrived at 6:40 to find Mr. B with an expressive and receptive speech/language deficit and difficulty in lifting his right arm. EMS called in a “pre-notification stroke alert” to the local (South San Francisco) Kaiser facility, which immediately led to a stroke alert activation for the entire stroke team at the Primary Stroke Center, including the Telestroke neurologist (who was sitting at the computer at home in Sacramento), the local South San Francisco neurologist, the radiologist, the CT technologist and the Emergency Department staff.

he patient arrived at the Emergency Department at 6:52 p.m. and was immediately met by the virtual Telestroke neurologist who had already reviewed his health record on the computer and verified his outpatient medication list. The Telestroke neurologist, with the assistance of one of the Emergency Department nurses, performed the NIHSS (National Institute of Health Stroke Scale) evaluation over the next five minutes—the score was 12 (out of maximum 42 points). Blood pressure was recorded, weight entered in the computer and the decision made to mix tPA. Mr. B, with his wife walking next to him, was escorted to the CT scanner with the Cisco AVI Live Stream Camera alongside him on a cart pushed by the ED nurse. Once in the CT scanner area, the patient underwent a CT scan of the head, which the on-call radiologist read within two minutes and reviewed with the Telestroke neurologist.

The CT scan showed no evidence for intracranial hemorrhage (the presence of blood products would have been an absolute contrainidication to administering tPA) so the Telestroke neurologist led a “time-out” session where the patient was reassessed for the persistence of his neurological deficits and blood pressure was recorded (since hypertension over 185/110 is also considered a contraindication to tPA administration). The risks and benefits of tPA were reviewed with the patient’s wife, who was asked for consent or non-consent to tPA administration. (Mr. B could not understand or reliably express his wishes about accepting or refusing tPA therapy.) The pharmacist who had mixed the tPA was standing next to the ED nurse, holding the tPA bag. Once the Telestroke neurologist gave the verbal order to “Go ahead and give tPA,” the pharmacist, after verifying the appropriate patient identifiers, handed the tPA to the nurse.

After the initial bolus of tPA was administered, a one-hour infusion was begun. (The recommended dose of tPA [Activase®/alteplase] is 0.9 mg/kg, not to exceed a 90 mg total dose, infused over 60 minutes with 10% of the total dose administered as an initial bolus over one minute.) Immediately after the tPA infusion started, a CT-angiogram was performed over the next several minutes to view the blood vessels from the top of the aortic arch to within the brain, searching for a large vessel occlusion (LVO).

Because the CT angiogram showed a large clot in the Left Middle Cerebral Artery (M-1 segment), the Telestroke neurologist called for a Critical Care Transport vehicle to be ready to take Mr. B to the Comprehensive Stroke Center in Redwood City, about 20 minutes away, where a thrombectomy (clot removal) could be considered if the clot was still present and shown to be anatomically accessible on a catheter angiogram. Mr. B finished his one-hour tPA infusion, but his neu- rological deficits remained as he entered the angiogram suite at Kaiser Redwood City. Thrombectomy was attempted by a neuro-interventional radiologist, using a Solitaire Clot Retrieval System.

The patient was immediately taken to the ICU for post-tPA and thrombectomy nursing surveillance. One hour after the thrombectomy, Mr. B’s speech was coher- ent but slurred and his arm strength had improved as objectively verified by the modified NIHSS score of 4.

This sequence is a typical example of the work f low and team dynamics that occur nearly every day throughout Kaiser’s Northern California system in evaluating and treating patients with acute ischemic stroke.

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Dr. Artz, a neurologist, is medical director, Stroke Services, at Kaiser San Rafael Medical Center.
Email: jonathan.artz@kp.org

References

1. Pierot L, “Three positive thrombectomy trials presented at International Stroke Conference 2015 (Nashville, TN),” ESMINT (European Society of Mini- mally Invasive Neurological Therapy) www.esmint.eu/news/15071189/three- positive-thrombectomy-trials-presented- international-stroke-conference-2015- nash.
2. Berkhemer O, et al, “A Randomized Trial of Intraarterial Treatment for Acute Isch- emic Stroke,” NEJM 372:11-20 (2015).
3. Goyal M, et al, “Randomized Assess- ment of Rapid Endovascular Treatment of Ischemic Stroke,” NEJM 372:1019-1030 (2015).
4. Campbell B, et al, “Endovascular Therapy for Ischemic Stroke with Perfusion-Imag- ing Selection,” NEJM 372:1009-1018 (2015).