In a bold move, Indian River Medical Center has signed an exclusive contract with three highly specialized neurologists who worked previously at Lawnwood Regional Medical Center to turn the Vero Beach hospital into a comprehensive stroke center.
This will be a rare and prestigious designation for a small community hospital, and to the credit of leaders here, the move was put in motion even before the Cleveland Clinic set out to acquire IRMC – a process that should be entering its final phase in a matter of weeks.
The upgrade in stroke care at Indian River is bound to impact the stroke program at Lawnwood, even if it finds replacements for the doctors; there are only 800 physicians in the nation specializing in the interventional neurology, a service that must be offered around the clock, along with stroke critical care and advanced imaging, for a hospital to be designated a comprehensive stroke center.
As the only such center until now along the Treasure Coast, Lawnwood has since 2016 regularly treated Indian River’s most severe cases of stroke. Before that, patients from Vero were transferred to Orlando’s Florida Hospital or Orlando Regional Medical Center or to St. Mary’s Hospital in West Palm Beach. There are no comprehensive stroke centers in Brevard County.
The prospect of having the more acute stroke therapy here is a life-saving one for patients who otherwise would lose precious time being transported to another hospital, potentially losing brain function along the way.
“A transfer time of 60 minutes, that’s 20 million neurons lost. That’s enough to lose the memory of a grandchild. It’s enough time to lose the ability to swallow, and that’s a huge deal,” said Dr. Ayman Gheith, one of the doctors hired by IRMC. He along with Drs. Vikas Gupta and Akram Shhadeh are among only 800 neurologists nationwide who have trained in interventional neurology.
These doctors employ a recently developed technique: brain surgery done from inside an artery that can clear out a clot too big to dissolve with the “clot-busting” drug tPA, in use since 1996 for the treatment of ischemic strokes. Those strokes, almost always caused by blood clots, account for 80 percent of all strokes; the rest are typically caused by bleeding in the brain, known as a hemorrhagic stroke.
Because tPA has to be administered within three hours of the stroke, it is far more limited in its uses. Interventional methods, on the other hand, have been shown to restore blood flow in the blocked artery to the brain’s tissue up to 6 hours after the stroke. And data from a 2017 trial known as DAWN that used a stent retriever – what Gheith calls a “stent on a stick” – opens the window for certain patients up to 24 hours.
Interventional neurology is a field so new, there is not yet a board to certify its specialists. Gheith trained at Medical College of Wisconsin, one of only five in the nation that is accredited for graduate medical education in interventional services, he said. He spent eight years there following medical school, graduating in 2014.
That training was extensive. “To graduate from any fellowship, you need 250 procedures,” he said. “In my fellowship I did over 1,500. Over the last four years, I think I’ve done close to 3,000 more.”
Gheith’s partner Gupta trained in three specialties: neurocritical care, vascular neurology and interventional neurology/endovascular surgical neuroradiology. A graduate of the University of Calcutta who went to med school at the University of Michigan, Gupta’s residencies and fellowships were at the University of New Mexico, the University of Iowa and Rutgers University.
He taught vascular and interventional neurology full time at the University of Missouri, where he was the director of the comprehensive stroke center there.
The third partner, Shhadeh, went to medical school in Damascus, Syria, and did a residency in neurology at Temple University, and fellowships at Rutgers in vascular neurology and endovascular surgical neuroradiology.
The doctors, who came to know each other through training and conferences, are part of an independent group known as Arubah Neuroscience Institute.
The expected takeover of Indian River by the Cleveland Clinic is a major reason the group chose to come to Vero Beach, though both Gheith and hospital officials stress talks began before a deal was even in the works.
“Our mission statement aligned with not only Indian River but also the Cleveland Clinic,” Gheith said. “It was a great opportunity for us to really fill a niche in an underserved area.”
Collectively, the three doctors coming to Vero have specialized in seemingly every aspect of stroke, the nation’s fifth leading cause of death and the leading cause of disability. All three have trained in neuro critical care and interventional neurology, both key to comprehensive stroke care.
They are particularly versed in mechanical thrombectomy – removing large blood clots with advanced surgery.
“If you have a clot length of 8 mm or greater, the chance of it opening up with just the medication (tPA) is zero,” said Gheith. “Although this therapy is not for every stroke patient, a large proportion of those patients would qualify. It could mean a difference between a tracheotomy and a nursing home because of a devastating completed stroke, versus the ability to make a meaningful recovery and go home to your family.”
Guided by various types of radiology, doctors can thread a catheter from a tiny incision in the leg, up through the body and into the brain, performing surgery from inside the affected artery.
Interventional methods were first used in the 1960s to close aneurysms, first with balloons, and later with embolizing coils. It wasn’t until the 2000s that doctors began treating not only hemorrhagic stroke, but ischemic strokes caused by clots. Then in 2015, a cluster of five major randomized trials showed the procedure was effective, something doctors like Gheith had seen with their own eyes: paralyzed patients undergoing a procedure under only light sedation suddenly began to move again.
The surgery-from-within was so dramatically effective, Gheith said, that clinical trials posed ethical questions, since the technique worked so well that there could be a threat of lawsuits if patients in the control group were denied treatment for the sake of science.
’We had been talking for a couple of years and we had said, ‘Gee, maybe you ought to come up from Lawnwood and have two hospitals that you serve,’” said Rick Van Lith, Indian River’s vice president of strategic planning and business development. “Because the science has changed, we wanted to have access to that for the residents of our community. Then the opportunity presented itself for us to get together and develop a program here.”
As talks began in earnest with Arubah in April, Van Lith coordinated with Todd Bibens, Indian River’s vice president of operations, to develop a plan that would not only add an interventional neurology suite, but streamline the entire process of a stroke victim getting optimal care. That meant treating the patient from ER to imaging to procedure or ICU on a single floor of the hospital.
Patients suspected of stroke trigger a phone call from EMS to alert doctors a patient is on the way. (An ambulance is the only recommended way to get to the hospital in the event of stroke symptoms such as a droopy face, weakness or paralysis in the body and confused speech.)
“We’re the docs that meet you in the ER, we’re the ones that make the decision as to whether or not you need a procedure, and if you do, we’re the ones who do it,” said Gheith. “And if you don’t, you go to the ICU and we’re the ones that manage you in the ICU. We basically stay with you from the moment you come in until the moment you’re coming home or going to rehab. That’s what makes it comprehensive care.”
The new higher-acuity stroke center at Indian River will take advantage of the hospital’s recently purchased 256-slice CT scanner that captures quadruple the data in less time than the more common 64-slice scanner, with 90 percent less radiation exposure to the patient. The scanner can be loaded with special software for neurology.
And soon, Gheith says, the hospital will be updating the stroke center with a new biplane angiography machine. With two big C-arms arcing over the table where the patient lies, the doctor can spin the machine around the patient’s head to take pictures, and study those images as they appear just in front of him, on the other side of the patient.
It is similar to the machine used in heart disease treatment, but provides images on multiple planes. Until then, the group will use the existing single-plane machine. “We’ll use the existing facility as we build out something here.”
“Machines are important, but I will tell you something, and I’m going to stress this: It’s really the physicians’ expertise that’s going to make a difference,” said Bibens.
For Gheith, it didn’t take data from published trials to prove that difference his field can make. “We as interventionalists have always known that this was beneficial for patients. When I take a devastated patient who’s completely paralyzed, and I take that clot out and they start to move on the table, that is why we wake up at 2 in the morning and rush into the hospital, because you can take people from the brink of death and send them home.”