Hope for a devastating condition
Stroke (cerebrovascular accident or “CVA”) is the number one cause of disability in the U.S. and the fifth leading cause of death, according to neurologist Michael Markowski, DO, FAAN, who has been the stroke director at Cape Cod Hospital for over a decade. A stroke is brain damage caused by an abnormality of brain blood vessels, either a blockage of an artery or less commonly an artery rupture causing bleeding into the brain.
“People always think that it’s a disease of aging, which it is to some degree, but one out of three strokes occurs in people under the age of 65,” he said. “We see people in their 30s, 40s and 50s suffer a stroke, unfortunately. At Cape Cod Hospital we see a lot of strokes, so we are one of eight extra-high-volume stroke centers in the state of Massachusetts.”
The hospital treats between 50 and 70 stroke patients or patients with transient ischemic attacks (TIAs) every month. Since 2005, both Cape Cod Hospital and Falmouth Hospital have been named primary stroke centers by the Massachusetts Department of Public Health. Both hospitals have also won multiple Get with the Guidelines awards from the American Heart Association and the American Stroke Association.
As the stroke director, Dr. Markowski leads the stroke committee at Cape Cod Hospital that is comprised of neurologists, Emergency Department physicians and nurses, inpatient nurses and rehabilitation therapists. The committee reviews stroke care guidelines and launches new patient care initiatives. Emergency medical technicians and rehabilitation facility clinicians have been brought onto the committee to cover all aspects of care.
Alteplase Enters the Scene
“In terms of acute stroke treatment, there’s only one medication that has been FDA-approved since 1995, and that’s called tPA or the generic is called alteplase,” he said.
The drug is used for ischemic strokes, which are caused by a blockage of a brain blood vessel. Strokes can also be caused by a rupture of a blood vessel in the brain, which are known as hemorrhagic strokes.
One of the difficulties with tPA is a definite window of time in which it must be given, along with other strict criteria. This medication has to be given within three hours after suffering a stroke or, if a patient is under 80 years old, it may be given up to four and a half hours as “off-label use,” or outside of normal administration, according to Dr. Markowski.
“So, for many patients, there is a three-hour window and the benefit of tPA is much better if it’s given sooner rather than later. If it’s given in the first 90 minutes of that three-hour window, the benefit is definitely greater.”
Every minute that goes by without treatment, more brain cells die, he said. For that reason, in the past, when the hospital informed neurologists of a possible stroke patient coming in, they would either leave their clinical practices immediately or get out of bed in the middle of the night to get to the hospital as quickly as possible.
To allow patients to be treated more quickly, Cape Cod Healthcare has invested in a teleneurology system that allows more timely diagnosis, so those who qualify can start tPA as soon as possible.
“Neurologists can examine the patient through a monitor with the aid of an Emergency Department physician or a nurse at the bedside and they can make the decision whether alteplase should be given or not,” Dr. Markowski said. “It’s a quicker process and the sooner stroke patients receive alteplase the better their outcome, so that has been an excellent development in recent years. We use teleneurology twenty-four-seven to improve patient evaluation and improve treatment time to starting tPA.”
Unfortunately, close to a quarter of stroke patients have what is called “wake-up strokes,” meaning they don’t notice the symptoms until first thing in the morning. That means there is no way to tell when the stroke occurred overnight. For this reason along with many other strict criteria, both nationwide and on Cape Cod, only about 8 percent of patients receive tPA.
There is also a procedure called mechanical thrombectomy, or intra-arterial treatment, for acute ischemic stroke patients. It is similar to a cardiac catherization in that blood clots can be accessed through the groin through a catheter to the brain to manually remove the blood clot. The procedure is only done at large university hospitals and it can only remove blood clots in the larger blood vessels on the outer surface of the brain, not the smaller blood vessels deep inside the brain.
The procedure improves the treatment window from three hours to six to 24 hours. The benefit is even greater than tPA alone, and can be performed safely after tPA is given. Only one or two patients a month are transferred, usually to Brigham and Women’s Hospital in Boston, with whom Cape Cod Healthcare has a collaborative working relationship.
When a patient comes into the Emergency Department, the emergency room providers complete an emergent head CT to see if the stroke is a hemorrhagic stroke. This bleeding into the brain occurs in 15 percent of strokes. The other 85 percent of strokes are ischemic strokes that can be treated with tPA, mechanical thrombectomy or both.
“For years, all patients would complete an emergent head CT, as tPA was the only treatment for ischemic strokes,” Dr. Markowski said. “If they have bleeding in the brain, we would avoid clot busting medications and treat them accordingly. Since some landmark studies in 2015, Cape Cod Hospital started routinely completing a CT-angiogram also, which looks to see where the blockage of the blood vessel is (with an ischemic stroke). If the stroke is related to a blockage of a larger brain blood vessel, mechanical thrombectomy may be a treatment option.”
Treated Here on Cape Cod
The vast majority of stroke patients on Cape Cod are treated right at Cape Cod or Falmouth Hospital, said Dr. Markowski.
"All stroke patients we care for have a very standard workup of brain MRI imaging, which shows the area of stroke sooner than a CT scan would,” Dr. Markowski said.” They have vascular imaging to assess the blood flow to the brain, typically with a carotid ultrasound or the CT angiogram, or we can complete an MRI angiogram which is an MRI of the blood vessels. As stroke is a vascular disease, we focus on treating the underlying risk factors including hypertension, high cholesterol, diabetes mellitus and smoking.”
Stroke patients also complete an echocardiogram, an ultrasound of the heart, to look for any structual heart abnormalities that would predispose them to stroke. In addition, they remain on a heart monitor to assess for atrial fibrillation or any other irregular heart rhythm that could cause a stroke.
When looking for the cause of a stroke, doctors are careful to detect whether the patient has a condition known as atrial fibrillation, he said. Atrial fibrillation (AFib) is an irregular heart rhythm that is a significant risk factor for stroke and requires anticoagulation rather than medication like aspirin and Plavix. In AFib, small blood clots can form in the heart and travel to the brain where they block an artery, resulting in a stroke.
When the cause of a stroke cannot be determined despite extensive inpatient workup, Dr. Markowski has many patients evaluated by a cardiologist for prolonged telemetry monitoring. In some patients, a small heart monitor can be implanted under the skin to detect AFib for up to three years.
Atrial fibrillation requires a different management technique like blood thinners. Coumadin used to be the only available treatment, but in recent years there are newer and somewhat safer oral anticoagulant options, he said.
The vast majority of strokes will be discharged to a rehab facility, according to Dr. Markowski.
“Most of the recovery of neurological deficits from a stroke will occur over the first 90 days,” he said. “By six months, further recovery of stroke symptoms is much slower. There is a critical several-week window to get physical therapy, occupational therapy and speech therapy to get these patients better faster, and we have some wonderful rehabilitation services that we start in the hospital before they are transferred to an outpatient rehab facility.”