The high quality of stroke care at Cleveland Clinic Indian River Hospital was recognized in June when it was certified as a Thrombectomy Capable Stroke Center.
Thrombectomy is not new at Cleveland Clinic – doctors there have been preforming thrombectomy for acute stroke since 2018 and the hospital recently completed a state-of-the-art thrombectomy suite – but the certification by the Joint Commission “recognizes the hospital’s commitment to providing a higher standard of clinical service and provides an additional framework to continually improve outcomes for patients in the communities we serve,” said Cleveland Clinic Indian River President Dr. Greg Rosencrance.”
Thrombectomy – a procedure that uses a wire-like device to remove blood clots in the brain – expands the window of care up to 24 hours after the onset of stroke symptoms.
“We’ve always been a Primary Stroke Center of Excellence, which has allowed us to give a clot busting therapy called Altepase, or tPA,” said Dr. Jim Shafer, a neurologist who serves as medical director for the thrombectomy center.
“Our stroke program has been in place for over a decade and has always met the highest standards of the Joint Commission, but with recent changes in acute stroke care, the paradigm has changed.
“We used to be limited to giving the clot busting medication tPA within 3 to 4.5 hours of a patient’s last known well (LKW),” Shafer said. “With thrombectomy, we can go a step further and, in some cases, remove the blood clot.
“A specialist called an Interventional Neurologist performs a cerebral angiogram very similar to how a cardiac catheterization is performed and can lead a wire into the clogged blood vessel in the brain and actually remove the blood clot causing the stroke.
“The last known well is the last time a patient was known to be at their normal baseline of function,” Shafer continued. “This is a very important factor in acute stroke care because the time from stroke symptom onset gives us an understanding of brain tissue at risk. Every minute of time the brain goes without blood flow – and hence lack of oxygen to delicate brain cells called neurons – 2 million cells are permanently lost. Time is brain.
“With the impetus by the American Stroke Association, the Joint Commission has put in place strict guidelines for stroke centers to receive the distinction of being a Thrombectomy Capable Primary Stroke Center of Excellence,” Shafer said.
“It used to be that we had to know your LKW to be eligible to receive tPA, but now we can treat patients up to 24 hours, utilizing thrombectomy and radiological technology to determine viable and at-risk brain tissue. This is most relevant to cases of patients awakening with stroke symptoms and LKW cannot be determined. Previous to thrombectomy, wake-up strokes, as they are called, were not eligible to receive interventional therapy.
“In the new era of surgical thrombectomy, we can now utilize a retrieval device to remove the blood clot from the brain. To remove the clot, we insert a catheter through an artery in the groin or arm, up into the blocked artery in the brain and pull it out. Patients experiencing stroke symptoms longer than 6 hours, up to 24 hours, may be candidates to undergo thrombectomy. Application of this technology has completely transformed acute stroke care.”
“The new, $10 million thrombectomy suite at Cleveland Clinic Indian River Hospital was funded through the generosity of community residents and the Cleveland Clinic Indian River Foundation,” Shafer said. “This and the dedication and commitment by Cleveland Clinic leadership has greatly assisted us in getting to this level of care.
“By using the clot retrieval technology and advanced radiology techniques, we can effectively and safely treat patients with wake-up strokes and LKW times up to 24 hours.
Some patients are not candidates because the brain damage caused by the stroke is too devastating, [but] … it truly is a miracle of medicine that has expanded the time window to administer treatment to [many] stroke patients.
“We see patients come into the emergency room who were otherwise active and viable be at dinner with friends or family and suddenly they can’t speak and become paralyzed on their right side. Five years ago, this most likely would result in a long rehab course and some form of permanent disability. Now, a vast percentage of patients with the same symptoms can come into our hospital and – in meeting the right criteria – are evaluated and taken right into the suite. They undergo thrombectomy and an hour or two later they sit up and speak as if nothing happened.”
According to the American Stroke Association, about 87 percent of strokes are ischemic strokes. Ischemic strokes occur when a vessel supplying blood to the brain is obstructed.
Within seconds, the lack of oxygen to part of the brain results in stroke symptoms.
Fatty deposits lining the vessel walls, called atherosclerotic plaques, are the main cause for ischemic stroke as they can break off and travel or “embolize” to the brain, blocking a blood vessel.
Hemorrhagic strokes make up the other 13 percent of stroke cases. The most common cause for hemorrhagic or “bleeding strokes” is poorly controlled blood pressure. Other sources can be ruptured vascular malformations or cerebral aneurysms.
In this type of stroke, blood accumulates in the brain and compresses surrounding tissue. However, the same mechanism holds – if no blood is getting to a certain part of the brain, then neither is oxygen. Without oxygen, brain cells die, and stroke symptoms ensue. Dr. Shafer revealed that there is limited intervention to help patients who experience hemorrhagic strokes.
Urgency is imperative when it comes to treatment of stroke victims and the American Stroke Association has coined the term FAST to make it easy for you to recognize stroke symptoms for yourself or a loved one.
You can use the letters in F.A.S.T. to spot stroke signs and know when to call 911:
F – Face Drooping – does one side of the face droop or is it numb? Ask the person to smile. Is the person’s smile uneven or lopsided?
A – Arm Weakness – Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?
S – Speech – Is speech slurred? Is the person unable to speak or hard to understand? Ask the person to repeat a simple sentence.
T – Time – If the person shows any of these symptoms, even if the symptoms go away, call 911 and get them to the hospital.
If you recognize one of the signs, call 911 immediately. Do not drive yourself or a loved one to the hospital because a lot can happen on the way. Local EMS systems are connected to the hospital as part of the stroke alert team. They will do an assessment in the field, contact the hospital and have the stroke team ready when the patient arrives at the hospital.
“Seconds matter with stroke,” Dr. Shafer reiterated. “You lose several hundred thousand brain cells and, in some reports, up to 2 million a minute when oxygen is cut off from the brain due to stroke. Once a neuron dies, this is permanent.”
Since a stroke is a random and unpredictable life event, the most important component of stroke risk reduction is managing factors that increase the risk of stroke.
Risk factors include hypertension, diabetes, high cholesterol, smoking, excessive alcohol and a sedentary lifestyle. In the United States, controlling blood pressure alone in all susceptible persons would reduce stroke incidence by 50 percent. It is very important to see your primary care physician for regular check-ups and maintain an active, healthy lifestyle.
Dr. Shafer has practiced Adult Neurology in Vero Beach and the surrounding area since 1997 and is founder of Vero Beach Neurology and Research Institute in Vero Beach.
He graduated from medical school at the University of Miami at Jackson Memorial Hospital and completed his residency in Adult Neurology at the University of Florida at Shands Hospital.
He works closely with Cleveland Clinic Indian River Hospital as medical director of the hospital’s stroke program. He can be reached at verobeachneurology.com or call 772-492-7051.
