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Stroke remains a leading cause of death in the United States and in South Carolina. Every year approximately 795,000 individuals in North America experience a stroke of which 610,000 are first time strokes. While stroke recently dropped from the third to fourth leading cause of death in the United States, it still accounted for nearly 136,000 deaths in 2007 and is the leading cause of adult disability. In addition to its tremendous health burden, stroke also takes an enormous financial toll on the US healthcare system costing approximately $41 billion in 2007.1 So despite some successes, stroke remains a priority health care issue.
South Carolina both mirrors and magnifies the burden of cerebrovascular disease and stroke. The Centers for Disease Control and Prevention (CDC) reported an age-adjusted stroke mortality rate of 130 per 100,000 individuals in South Carolina from 2002–2006, compared to 98 per 100,000 individuals nationally. Stroke mortality rates in South Carolina are even higher in counties along the interstate-95 corridor where they can be as high as 168 per 100,000 residents, amongst the highest in the country.2 One major contributor to the disproportionate stroke mortality rates and to the paucity of viable treatment options in South Carolina are the many barriers to health care access. A CDC report found that approximately 22% of US counties did not have a hospital, 31% of counties lacked a hospital with an emergency department, and 77% of counties lacked a hospital that offered neurological services.3 Also, the usage of intravenous tissue plasminogen activator (tPA), the first-line treatment for ischemic stroke, remains remarkably low throughout the U.S., especially in rural hospitals in the South. Similar to the management of myocardial infarction, stroke treatment interventions have profoundly limited time constraints resulting in a treatment paradigm that time is brain - meaning that with every subsequent minute after stroke onset millions of neurons and glial cells infarct.4 In terms of treatment, every lost minute reduces the chance for recovery. When time is brain, barriers to health care turn into absolute roadblocks that prevent access to the multidisciplinary care stroke patients require.
The cornerstone behind ischemic stroke treatment, as well as the first and only FDA approved drug for ischemic stroke, is intravenous (IV) tPA. In clinical studies and routine use, tPA clearly improves the chance for a better, if not full recovery, with an acceptable rate of intracranial hemorrhage if given in centers with the appropriate expertise and resources, and when administered within three hours of stroke onset.5 Recently, in carefully selected patients, IV tPA was also demonstrated to be effective out to four-and-a-half hours from symptom onset.6 Despite the availability of fibrinolytic therapy, it is still underutilized with merely 2–3% of all acute ischemic stroke patients in the United States receiving treatment.7 In fact 64% of US hospitals did not administer t-PA at all during a two year period from 2005–2007. These hospitals tended to be smaller (less than 95 beds), rural, and located in the South and Midwest. Many stroke patients in South Carolina will initially be evaluated in such hospitals and while rural hospitals provide local communities with invaluable services, stroke care requires specialized stroke centers that are experienced in the complexity and coordination required to provide the highest level of care.
For the last 6 years MUSC has been committed to building a Comprehensive Stroke Center (CSC) with the goal of providing South Carolinians with the highest level of care. From 2005–2007 MUSC Department of Neuroscience led the state by hiring three dually trained neurointensivists specifically trained to treat strokes, and developed a designated nursing staff and neurological intensive care unit (NSICU) dedicated to the care of the most acute stroke patients. The ten-bed NSICU represents the first dedicated neurological intensive care unit in the state, and is designed to provide specialized, multidisciplinary care, which has been shown to maximize the chance of favorable outcomes. From 2007–2010 the department, in collaboration with other MUSC departments, expanded its stroke capacity by successfully recruiting 10 additional stroke experts in the fields of emergency medicine, vascular neurology, neurocritical care, neurosurgery, and interventional neuroradiology – creating one of the largest comprehensive stroke teams in the country. To support this team, specialized emergency medicine services and advanced neurologic imaging were incorporated to aid in the management and coordination of early stroke treatment. Construction was completed in 2010 on the first dedicated dual neurointerventional suite in SC to support the development of a multidisciplinary division of neurointerventional surgery, allowing MUSC to bring the most advanced catheter-based therapies into the repertoire of treatment options for patients with all forms of stroke and intracranial vascular disease. As a result of its multi-disciplinary approach the MUSC Stroke Center has fulfilled the requirements to be designated a CSC by the Joint Commission. The criteria for CSC designation include the capacity to treat ischemic and hemorrhagic stroke patients, as well as perform endovascular coiling and thrombectomy procedures. The status as a CSC also entails access to advanced neuroimaging twenty-four hours a day, an established neurological intensive care unit, and participation in clinical stroke research.
In an effort to address the barriers to stroke care across the state, on May 1, 2008 MUSC initiated its telemedicine program in stroke care: Remote Evaluation of Acute Ischemic Stroke (REACH). The telemedicine REACH program is a collaborative venture between fifteen hospitals throughout SC and MUSC (figure 1). The “hub and spoke” system expands the stroke, neurology, neurointerventionalist, and neurosurgical specialist services at MUSC (hub) to community hospitals (spokes) in the state. The REACH program allows stroke neurologists at MUSC to work with community hospital physicians and nurses to remotely evaluate stroke patients who present to one of the partnering hospitals via two-way audio and high fidelity video securely over the internet in real-time, as well as permitting CT and MRI imaging from partnering hospitals to be assessed by any of the specialized stroke doctors at MUSC. Many patients evaluated by REACH often end up being treated and cared for at their local hospitals, however more severe stroke cases can be transferred to MUSC for more specialized care. The collaboration between the MUSC stroke team and community hospital physicians, as well as the combination of clinical and radiological assessment allows the stroke team at MUSC to determine if more severe stroke patients should be transferred to MUSC for further evaluation and treatment.
Consequently when such patients arrive at MUSC they undergo advanced physiological imaging using specialized CT techniques, which may help determine if ischemic, or viable, brain is still present that can be saved through endovascular intervention or aggressive medical management and monitoring. The partnership between community hospitals and MUSC allows for the highest level of care to be administered regardless of the aforementioned barriers to health care.
From May 1, 2008 – February 10, 2011 the REACH program has evaluated 965 patients and administered intravenous (IV) tPA to 35.7% of the patients evaluated, 3.0% of consults received both IV and intra-arterial (IA) thrombolytics, 2.1% underwent IA therapy alone. Fifty-eight percent of patients evaluated by REACH did not receive thrombolysis of which 34% were subsequently transferred to MUSC. The intracranial hemorrhage rate was 1.2%, which is significantly lower than previously published studies. Of the patients who received IV tPA 64% were transferred to MUSC for further care.8 Furthermore studies from the MUSC Stroke Center have demonstrated that tPA utilization results in a cost savings of $3,454 per patient over a six year period based on Markov model analytics. Since its inception the REACH telemedicine program has dramatically increased tPA utilization in South Carolina when considering that previous reports cited that 64% of hospitals, mostly in rural locations in the South and Midwest in the US had not administered tPA at all from 2005–2007. Additionally the percentage of South Carolinians within 30 minutes of expert stroke care has increased from 24% to 43% and within 60 minutes from 38% to 76% since the development of REACH, which greatly enhanced access to stroke care across the state. The program also expands the availability of life-saving neurointerventional and neurocritical care treatment for patients with all forms of stroke throughout the state.
As part of the comprehensive stroke program, MUSC developed the division of neurointerventional surgery with two neurointerventional radiologists and an endovascular neurosurgeon. Neurointerventional therapies, such as endovascular thrombectomy and IA fibrinolytic administration, in conjunction with the REACH telemedicine program, permit the rapid assessment of stroke patient imaging from outside hospitals and selection of appropriate candidates for endovascular treatments. Upon arrival at MUSC such patients are immediately transferred to state-of-the-art neurointerventional suites where these potentially life-saving treatments are administered (figure 2). This allows many patients that historically would not be candidates for intervention to receive the most advanced care from a comprehensive stroke team. Since its development in 2008, approximately 140 ischemic stroke patients have undergone endovascular treatment with an average presenting stroke scale score (NIHSS) of 16. Utilizing physiologic imaging, such as CT-perfusion, rather than time based parameters to select patients for endovascular therapy the average time from symptom onset to treatment was 11 hours (figure 3). This is far beyond conventional time constraints used in most trials that limit therapy to within 8 hours. Using this physiologic imaging selection criteria, up to 53% of patients experienced a good functional outcome at 90-days with a 10% rate of symptomatic intracranial hemorrhage. These outcomes are significantly better than historic controls and on par with all conventional stroke trial outcomes, despite treating patients beyond established standard time criteria. There was a 25% rate of death, again similar to that seen in stroke trials with a similar patient population.9
The sub-acute stroke treatment period is equally important in maximizing functional outcome and quality of life. An entire floor of the main MUSC hospital has been renovated to provide a specialized stroke step-down unit consisting of seventy-three primary stroke beds for the care of patients in the sub-acute period. An average of one hundred and fifty primary stroke nurses trained in neurological and functional monitoring are capable of evaluating the often dynamic clinical status of stroke patients. Stroke patients are cared for by cerebrovascular fellowship-trained neurologists who determine stroke etiologies and provide secondary stroke prevention strategies. The comprehensive team also includes multidisciplinary therapists and specialized case managers who help to provide proper discharge and follow up plans critical in maximizing long-term quality of life in stroke patients. Additionally, despite a 70% increase in the annual number of stroke patients as well as an increase in the complexity of stroke cases treated at MUSC from 2007–2011 (281 in 2006 and 760 in 2011) patients are taking less time in their recovery with a mean length of stay of 8.5 days in 2008 versus 7.8 days in 2011. When patients are discharged their long-term follow-up includes a specialized stroke rehabilitation program that helps patients with the multitude of potential speech, movement, cognitive, and occupational deficits, which is critical to maximizing quality of life.
Recently, the Joint Commission and the American Heart Association positions on CSC recognized the importance of conducting and supporting research with the CSC role. Comprehensive stroke centers are required to participate in clinical stroke studies. Toward this effort MUSC is actively involved in and leading research in all forms of stroke. Clinical trials in acute stroke involve investigating advanced imaging techniques to identify salvageable penumbra beyond traditional temporal reperfusion windows, participating in the pivotal multinational phase III NIH-supported IMS-III study investigating the best way to reperfuse large vessel strokes, and several studies on new catheter based therapies also for large strokes. Other studies involve the acute management and treatment of intracerebral hemorrhage and subarachnoid hemorrhage. Numerous other ongoing studies involve assessing access to stroke care, aggressive primary and secondary ischemic stroke prevention, novel high-resolution intracranial imaging, and novel rehabilitation neurologic imaging and intervention. In all, more than 10 funded research studies in stroke are currently underway.
Lastly, while many of our acute stroke patients have the typical risk factors for stroke, such as advanced age, stroke can also occur in pediatric and young populations. A multidisciplinary team of pediatric neurologists, pediatric intensivists, vascular neurologists, emergency medicine, and neurointerventionalists provide acute stroke care for dozens of young stroke patients every year. Even in the pediatric and young stroke population, the full range of advanced technologies including neurointerventional therapies, are available when needed.
The MUSC stroke center is continually growing in a multi-disciplinary patient-centered approach to stroke care. The positive impact of the stroke center is demonstrated in the improved access to stroke treatment through the REACH program, which is offering more advanced care to more patients than ever before in the state. Additionally the stroke services including, advanced neuroimaging, endovascular-based therapies, a neurointensive care unit, and a dedicated staff of stroke neurologists, emergency medicine physicians, neurointensivists, neurointerventionalists, nurses, and physical therapists will continue to provide South Carolinians with the highest level of stroke care.