A World-class Team and Innovative Technology Differentiate Stroke Care at Crouse Health

By Tiffany Parnell
Thursday, December 28, 2017

Crouse Health’s nationally recognized team of neurologists and neurovascular neurosurgeons, leading-edge technology, and full spectrum of medical, interventional and surgical treatments for ischemic and hemorrhagic stroke position the hospital’s stroke care among the most advanced in the region.

In 2017, Crouse — one of only two New York State Department of Health-designated Stroke Centers in Onondaga County — celebrated a milestone. For the seventh straight year, the hospital received the American Heart Association’s Get With The Guidelines – Stroke Gold Plus Quality Award. This recognition is given to hospitals that consistently comply with evidence-based standards and quality measures, and speaks to the commitment the Crouse team has made to providing the highest level of stroke care.

The mantra “time is brain” remains top of mind for Crouse’s clinical experts and guides stroke care decision-making. To ensure patients are treated as quickly as possible, Crouse has implemented multiple protocols that reduce the time it takes to move patients through the Emergency Department (ED), complete diagnostic imaging and initiate interventions.

The Care Timeline

En route to the hospital, emergency medical services personnel alert the Crouse ED team that a patient presenting with stroke symptoms is on the way. A team that includes emergency medicine physicians and nurses, who have completed specialized training in caring for stroke patients, then quickly assembles in anticipation of the patient’s arrival.

One of two hybrid OR suites at Crouse used for complex, intricate stroke rescue procedures of the brain.

As soon as the ambulance arrives, physicians quickly evaluate patients and transport them to the CT bay adjacent to the ED. An attending neurologist is on call at Crouse 24 hours a day to respond to stroke emergencies. The attending neurologist examines patients and reads each CT scan to confirm if patients are experiencing a stroke and, if so, determine the course of treatment.

Neurovascular neurosurgeons from Crouse Neuroscience Institute assume the care of patients presenting with a hemorrhagic stroke resulting from an intracerebral or subarachnoid hemorrhage. Depending on the case, patients experiencing a hemorrhagic stroke may go directly to the operating room for surgery or to one of the designated neuro ICU beds within Crouse’s ICU.

The vast majority of stroke patients — more than 80 percent — experience an acute ischemic stroke. These patients may be candidates for intravenous tissue plasminogen activator (IV tPA), which is administered in the CT bay.

Tarakad Ramachandran, MD, FRCP, Stroke Director and Professor Emeritus at Crouse

“If patients arrive at the ED within three hours of symptom onset, we can administer the clot-buster tPA,” says Tarakad Ramachandran, MD, FRCP, Stroke Director and Professor Emeritus at Crouse. “On a case-by-case basis, we may also administer tPA beyond the three-hour window, specifically if patients are younger than 82, do not have diabetes and are not taking Coumadin.”

Crouse’s door-to-needle times for tPA administration are among the fastest in the region. For the past three years, the hospital achieved Target: Stroke Honor Roll – Elite Plus status. According to American Heart Association guidelines, facilities that receive this recognition initiate IV tPA within 60 minutes in 75 percent or more cases of acute ischemic stroke and within 45 minutes in at least 50 percent of cases. The team at Crouse frequently exceeds those expectations. Recently, Dr. Ramachandran initiated tPA within 27 minutes of a patient’s ED arrival.

From January–October 2017, 94.5 percent of Crouse Health stroke patients received tPA within 60 minutes. The Central New York average is 74.1 percent.

Following tPA administration, patients undergo additional imaging, including a CT perfusion study. This study allows physicians to assess cerebral blood flow, identify the core of the infarcted tissue and assess the amount of at-risk, potentially salvageable tissue located in the penumbra, the peripheral area surrounding the core of infarcted tissue. To perform this study, Crouse utilizes the 320-slice Toshiba Aquilion ONE. One of the most advanced CT systems and the first to show real-time organ function, the Aquilion ONE allows physicians to scan the entire brain in one pass and visualize cerebral blood flow. Results of the CT perfusion study and CT angiogram, as well as the patient’s NIH Stroke Scale score, are used to determine if further intervention, such as mechanical thrombectomy, is necessary.

Eric Deshaies, MD, FAANS, FACS, Medical Director of the Crouse Neuroscience Institute and Director of the Neurovascular and Stroke Program at Crouse

“Crouse is the only area facility that has three fellowship-trained endovascular neurosurgeons available 24 hours a day, seven days a week, to perform minimally invasive clot retrieval,” says Eric Deshaies, MD, FAANS, FACS, Medical Director of the Crouse Neuroscience Institute and Director of the Neurovascular and Stroke Program at Crouse. “At other hospitals, they may have a neurologist or radiologist on call, but you need a neurosurgeon to back up these procedures because neurologists and radiologists cannot care for complications, such as bleeding of the brain, that may occur during thrombectomy.”

The neurovascular neurosurgery team performs thrombectomies in one of Crouse’s two hybrid ORs — suites that allow physicians to perform minimally invasive clot retrieval and open surgery in the same room. Crouse is the only facility in the region that has two hybrid ORs, which help prevent the need to move patients from the operating room to the radiology suite for imaging during emergent stroke care.

During each thrombectomy in the hybrid OR, a team of dedicated nurses and neurointerventional radiology technicians assist physicians, and the team has access to highly specialized equipment designed to examine the blood vessels of the brain and spinal cord.

“Some facilities perform these procedures using cardiac equipment or regular radiology equipment, but the sensitivity is not nearly as good,” Dr. Deshaies says. “The procedures are safer when completed using the equipment and technology we have here at Crouse.”

Following intervention with tPA, a minimally invasive procedure or open surgery, patients are transported to one of the neuro-designated beds in the ICU, where they receive care from a collaborative, specialized team of physicians, physician assistants, nurse practitioners and nurses.

A Three-year Journey

As part of Crouse Health’s commitment to delivering the highest quality stroke care, Crouse recently applied for Comprehensive Stroke Center certification. A designation developed by the American Heart Association/American Stroke Association and The Joint Commission in 2012, Comprehensive Stroke Center certification is the highest level of certification available to hospitals that care for stroke patients.

Cindy Wood, MSN, BSN, RN, Director of Nursing-Neuroscience at Crouse

“For the past three years, we’ve been on a journey to become a Comprehensive Stroke Center,” says Cindy Wood, MSN, BSN, RN, Director of Nursing – Neuroscience at Crouse. “We’ve put processes in place to bring us into that arena, and we applied for the accreditation in December. We’re looking to receive accreditation during the first quarter of 2018.”

Comprehensive Stroke Centers differ from Primary Stroke Centers in several ways. For example, Comprehensive Stroke Centers have dedicated neuro ICU beds available to patients 24 hours a day, seven days a week, perform stroke research, and offer neurosurgical and endovascular procedures, according to The Joint Commission.

“In many Primary Stroke Centers, physicians may have to transfer patients to other facilities if, for example, they don’t get to the hospital in time to receive IV tPA,” says Tarakad Ramachandran, MD, FRCP, Stroke Director and Professor Emeritus at Crouse. “A Comprehensive Stroke Center is self-sufficient and can care for any type of stroke. Uniquely, we have that capability at Crouse.”

From Rehabilitation to Ongoing Survivor Support

Crouse has developed relationships with some of the most advanced rehabilitation centers in the country, including Good Shepherd Rehab in Allentown, Pennsylvania, and Sunnyview Rehabilitation Hospital in Schenectady. These facilities support the care of patients of all ages and acuity levels — from those who need therapy to regain strength in their legs to those who have severe cognitive deficits or are using a ventilator.

Following discharge, patients also have an opportunity to take part in a variety of local stroke and aneurysm support groups, including Triumph Over Stroke CNY, a survivor-led support group sponsored by Crouse that meets on the first Wednesday of each month. During support group meetings, survivors receive education from a variety of Crouse providers, including physician assistants, nurse practitioners, psychologists and physical therapists.

“We employ a multi-modality approach to not only the initial therapy and recovery, but also long-term care,” Dr. Deshaies says. “Once we get patients through stroke treatment, our focus shifts to prevention and managing residual symptoms.”

As part of Crouse’s focus on prevention, stroke education begins in the hospital for patients, their caregivers and family members and continues on an outpatient basis at the stroke clinic where patients receive follow-up care.

“Getting patients to the ED in time to receive tPA is still a struggle nationally and in Syracuse,” Dr. Ramachandran says. “Only 4 to 9 percent of patients who could benefit from tPA receive it, mainly because they run short on time. We educate our patients and their loved ones, and they have a basic idea of how to recognize stroke and what to do if symptoms occur. Increased awareness in conjunction with rapid intervention are the keys to improving the outcomes of patients who suffer from strokes.”

Advancing Progress Through Research, Education

Crouse Health is on the leading edge of stroke treatment — as well as the forefront of research and continuing education. Clinical research trials are underway in the areas of stroke and brain aneurysm. The hospital also has a relationship with Toshiba and beta tests the company’s new software and equipment as they are developed.

To utilize the most up-to-date technologies, the provider teams must remain apprised of advancements in the field. The nurses who care for stroke patients are Stroke Certified Registered Nurses and complete eight continuing medical education credits each year. Crouse physicians regularly attend conferences to expand their knowledge of stroke care, and members of the physician and nursing teams have also completed the Neurocritical Care Society’s Emergency Neurological Life Support (ENLS) course. In 2017, Crouse offered the ENLS course to the emergency medical services agencies with which it partners.

To learn more about Crouse’s stroke services, visit crouse.org/services/stroke-care.