Ep. 8: Caring for patients who suffer a stroke

What providers should look for in patients and when to refer to neurology specialist

Episode Transcript

Courtney Collen (Host): Hi there. Welcome to our medical series Called to Care by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance that they can use in their primary care practice and more information about when it’s time to refer patients and families to more specialized care. Joining me for these conversations is Joseph Segeleon, MD, who is vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. He’s here to help us dive even deeper into these topics to provide the best insight and care for our patients and communities. Welcome, Dr. Segeleon, good to see you.

Dr. Joseph Segeleon: Good to see you, Courtney. It’s great to see you again.

Host: In this episode specifically, we are talking all about stroke and really the more awareness around this topic, the better… is that right?

Dr. Joseph Segeleon: Yes. As I was preparing for this podcast, I came upon a statistic that there’s 700,000 ischemic strokes in the United States per year. And I had no idea that it was so prevalent. So, I just think this is a fantastic topic and a great opportunity for our referral providers to learn more.

Host: So joining us to talk more about this topic is Divyajot ‘DJ’ Sandhu, MBBS, MD, an expert in neuro critical care who specializes in neurointerventional procedures at the Sanford Neurology Clinic at the Sanford Brain and Spine Center in Sioux Falls, South Dakota. Dr. Sandhu, thank you so much for joining us.

Dr. Divyajot Sandhu: Thanks, Courtney. Thanks, Dr. Segeleon.

Dr. Joseph Segeleon: So, let’s start off, Dr. Sandhu, tell us a little bit about an interventional neurologist and what kind of training does one have to become one of those?

Dr. Divyajot Sandhu: So, there’s three basic ways that one can do what I do. The first one of those is the path that I chose, which is that you do neurology, then you do critical care plus vascular neurology, then you do interventional neurology. You could do the same thing as an added-on fellowship after neurosurgery residency. And you can do the same thing as one of two added-on fellowships after a radiology residency. The way that we differ from the other two is that we, as in the neurologists, that’s who this ‘we’ is. We have stroke training, which the other two specialties don’t. And that was why I actually got attracted to this specialty as to what is the specialty? Think it’s not apples to apples, but think of this as what interventional cardiology is to cardiovascular thoracic surgery. So interventional neurology or endovascular surgical neuroradiology, whichever big moniker you want to give this is to open neurosurgical procedures. So that is the gist of what we do.

Dr. Joseph Segeleon: Okay, great. Well, thank you for that. Well, why don’t we just get at it and let’s get to the information on stroke. Let’s say we have a patient in a rural community or outside of the metropolitan Sioux Falls area. What kind of signs and symptoms should I be concerned about when the patient comes through the emergency department that brings to mind? Is there a possibility of ischemic stroke going on?

Dr. Divyajot Sandhu: You’ll see over the course of the coming months and years one acronym used commonly it’s that B.F.A.S.T acronym. And the B is for balance E is for eyes F is for face, A is for arm, and S is speech. Tv is for time. So we’ll take a second each for those. The most commonly and widely-known initial symptoms of a stroke might be a person who came in with sudden – and this is somewhat important – onset of slurred speech, a face that is drooping on one side and arm and or a leg on the same side, in very few instances on the opposite side also that is weak or clumsy or has loss of sensation. So those would be the common ones that we think of when it comes to an acute either ischemic or hemorrhagic stroke, both the ones that are slightly less common, but no less disabling would be the ones in which people have sudden onset of trouble with balance, a severe dizziness, again, sudden onset of severe dizziness. Along with sudden changes in vision it could either be loss of a part of vision or it could be Frank double vision. So those would be the main five or six things in a person, of any age actually, that would concern me for an ischemic stroke or a tragic one. Okay.

Dr. Joseph Segeleon: So, let’s pretend I’m the referral provider and I’m in the emergency department and someone comes in with those symptoms, walk me through what my evaluation should be, walk me through, how do I contact you and how do I get you involved? I understand there’s also a time sensitivity to this this procedure in this clinical condition as well.

Dr. Divyajot Sandhu: Absolutely. We’ll talk a little bit about the time, because time is key at the beginning, and then we’ll go into what happens once a person is in an emergency room or in a triage center. Time is important because what happens is that the brain itself has no stores of energy. There’s no glucose store, there’s no glycogen store. There’s nothing. So it depends on continuous and complete blood supply for all of its energy needs. And the human brain is a massive sump of energy. There’s the most per volume blood supply, even more so than kidneys, which are the second one. And that leads on to you stop blood flow for even a minute or two, the classic teaching was that, you know, every minute that lose, you lose 2 million neurons. I don’t know how true that is or who came up with that 2 million number. Why’s it not 2.5, you know, but you do lose quite a few of those. That was one of my facts by the way that I had for you so thanks for stealing my thunder on that. So, then the issue is that once you hit 25 or 26 years of age, you’re not making any more than four to 500 new neurons a day, that’s it. If you lose the inmate millions, you’re never going to make those up. So, that leads on to that  critical importance of time. We have treatments and we’ll talk about them later, which can be extended out to 24, 36, 48 hours. That doesn’t mean that you take 48 hours. Every minute saved is actually brain saved still. Then let’s say yes, that person a comes to the emergency room and there is a concern for this being a stroke, be it the hemorrhage kind or the ischemic kind. In the interests of that establishing a timeline, the first thing that can be asked and determined from family friends and EMT is when was this person last known well at their baseline?

Second, if this was a witnessed event, what time did the event start that establishes your time zero. Then you go on to things along the lines of establishing the severity of clinical deficits. There’s numerous scales which are used, which are validated for use both by emergency medical personnel in the field, and then also physicians and, and other providers in emergency rooms. We won’t go into the names of all of those scales. There’s several… there’s the LA scale, there’s the Spanish scale then there’s the NIH, which is the more, most commonly known one. All of these are designed to establish how severe a stroke might be, if it is indeed a stroke, then once you’ve done that initial clinical examination determine the time of onset or the last time that the patient was well.

You now have this validated clinical scoring system to indicate that this is the person’s severity of deficits. Now you come on to basic testing and we can split that testing into labs cardiac testing which forms a critical part of all stroke evaluations. And then imaging as far as the labs are concerned, things that can be done for instance, by an EMS provider make sure that blood glucose is checked. That’s very important. And if the blood glucose is less than 50 or more than 400, then the chances of false positives for strokes go up and also the chances of complications from lytic therapy, they go up also in both of those instances. So you do that lab in the field once a person’s in the emergency and lab draws available you check very few basic things. One is an INR just to make sure that they’re not already adequately anticoagulated in which case TPA, which is the IB lytic that I mentioned is an absolute contra-indication you do a blood count, complete blood clown does count as done because platelets less than a hundred thousand are also considered a contra-indication for intravenous lytics. And then we’ve already talked about the glucose. Those really are the only labs that the American Heart Association stroke association mandates that need be done before. The consideration for intravenous TPA is made that’s it, this then leads us to imaging. The only image that needs to be done completed is a non-contrast head CT. And that head CT is because you need to make sure that this isn’t a hemorrhagic stroke. This isn’t a bleed before you consider intravenous lytics. Once you’ve done that clinical evaluation timeline has been established, you have your labs which have ruled out severe hypoglycemia, hyperglycemia, thrombocytopenia now and, and INR of 1.7 is the magic number … anything less than that. Even if a person is anti-coagulated with warfarin, it’s still safe to give them TPA. You don’t have any alternative explanations for why this person might have had this sudden change. Now, the person should be considered as a candidate for intravenous TPA, as long as they are within four-and-a-half-hours of last known normal. If however, this is someone who woke up with their deficits and they went to sleep six hours ago, they’re not a candidate for TPA based on these specific indications and contraindications that we talked about. If they went to bed normal, if the onset of these symptoms was unwitnessed now the goalposts shift because you cannot use a basic head CT in order to make a determination as to whether it’s safe to give them TPA or not.

So, unbelieve that aside for now, because we’re still in a non-metropolitan emergency room. So, those determinations have been made in that say that this person is considered a candidate for TPA. You, as the physician who is seeing these patients, don’t have to involve me in this discussion because this is all standard of care. It has been validated numerous times over with multiple clinical trials, randomized controlled trials. However, what we find is most of our referring physicians, they involve us right at that first step that we started this whole discussion with, which is this person considered a possible ischemic or hemorrhagic stroke at that time, that’s when my partner and I, or anyone who does what I do is involved. We like that also, because then, you know, this whole thing is we are aware of this. We know how the patient initially presented if there’s any nuances that we need to determine and we need to find out more information on before making decisions though, can be, those can be taken care of at the outset rather than doing all of this 20 minutes into the evaluation. This person has been discussed with me and both the referring physician or provider and I think that, yes, it’s a good idea to give them intravenous TPA. And this person’s given a set loading dose and a set weight-based dosing of TPA.

Presuming that this is all in ischemic stroke not the hemorrhage kind, the next step is to find out whether there’s a large enough blood vessel that was occluded and caused the stroke. And if so then is this blood vessel approachable via endovascular intravascular routes and is there for amenable to a thrombectomy retrieving the clot? How do we do that? And this is where the role of advanced imaging comes in. What is that advanced imaging?

Dr. Joseph Segeleon: Excuse me. So, this is occurring now at the metropolitan center or at Sanford, is that correct?

Dr. Divyajot Sandhu: It’s some of our referring physicians sites, for instance, Worthington hospital has the capability of doing all of these advanced imaging studies that I talked about seven out of the other 10, 70% of the other 10 will not have that ability. Okay. And in that case we will need these patients emergency transfer to us using the quickest way possible.

Dr. Joseph Segeleon: Gotcha. Okay, go ahead.

Dr. Divyajot Sandhu: So, then the advanced imaging comes in whether it is at the offsite or in Sioux falls the, the modes of imaging will be CT profusion and CT angiography. The profusion imaging is determined, is designed due to determine exactly that how much of brain tissue is under perfused, but viable, and how much of brain tissue has suffered permanent damage already. There’s several numbers and ratios, et cetera, that we won’t go into. But if that mismatch between under perfused and viable versus under perfused and non-viable tissue is large enough, then these patients would benefit from a revascularization via the intravascular route. And that revascularization target is what the CTA is used to determine. Which vessel, how to get there and what equipment to use to get there and retrieved that thrombus as effectively and quickly as possible.

Dr. Joseph Segeleon: So perhaps you’ll go into this later, but so there’s four and a half hour is the time window for TPA. Is there also a time window for some of these intra vascular interventions as well?

Dr. Divyajot Sandhu: Yes, so that time window is one of the things that has seen the most drastic change over the past two-and-a-half-years starting from about the mid 2018 time. Let me  go back to the TPA also because in certain very carefully selected patients and the, the selection is based on MRI imaging for these patients. The TPA window also has been extended past four-and-a-half hours, but again, that’s a very small subset of patients. Then the time window for the intravascular interventions, that as things stand today, is set at 24 hours post onset of symptoms. So you do have that long of a period of time that you can intervene on these patients again, based on what the profusion imaging looks like. Because if this is a patient that has good collaterals that are taken care of, that under perfused, but yet viable brain tissue, then these patients, these stroke volumes will slowly advance. It won’t be that all of the stroke is established right at the outset. That’s why that window and can be extended out to 24 hours based on what the profusion imaging looks like.

Dr. Joseph Segeleon: The TPA alone, is there a percentage the resolve on that alone?

Dr. Divyajot Sandhu: So, the general thinking is that about one-third of the patients that will be given intravenous TPA. They will have improvement, not resolution, improvement in their clinical deficits to the point that it will make a difference as to their final discharge destination. By which, I mean that those patients, they will actually be able to make it such that they can live independently with maybe some amount of assistance or none whatsoever versus had they not been given TPA, they would have required continuous assistance or would not have made it out of the hospital.

Dr. Joseph Segeleon: Great. Thank you. So I come into the medical center here, and I do have a large vessel occlusion in my reading, and I understand there’s a fair number of – and I’m going to call them gadgets. I’m sure there’s really fancy names for these. But what kind of options do you have to physically do thrombectomies or to remove the occlusion?

Dr. Divyajot Sandhu: So, at its core, it really is nothing but extremely glorified plumbing. Honestly, that’s, that’s all that there is to it. So what you do is that you start off with a large enough peripheral vessel. You can use the common femoral, you can use the radial artery, either one of those two. Then, that is your point of entry into the circulation you use then the largest of most commonly, two to three telescoping catheters. Catheters being just plain pipes. Then, the first of these is designed to get you from your point of access, be it the radial or the, or the femoral up into the neck. Now, it could be a carotid artery in the neck, or it could be a vertebral artery in the back of the neck, depending on what the eventual location site of the thrombosis. Then you use a mixture of techniques and broadly those techniques are one: you have proximal florist, and that proximate florist is you have a balloon mounted on a catheter, inflate the balloon. If you’re, let’s say, in the, in the left common carotid artery or left internal carotid artery, you, include all forward flow from that point on. Next step, you use a large diameter tube, large diameter catheter, and with the help of micro wires, and microcatheters navigate that all the way to the proximal face of the clot. Once the catheter and the clot are in contact with each other, you turn a constant negative pressure pump on. And what that pump does, is supposed to do, is that it slowly ingests a little bit of the clot, such that the clock is court now at the distal tip of this aspiration catheter.

Some of us, what we do is that’s all that we do, especially if we think that the clot is in a large enough vessel and is new enough and is mobile enough that it will be aspirated just by this method. We under constant vacuum, not vacuum, but negative pressure draw the whole system back out with the hope that the clock doesn’t fragment comes out in one single piece. I have, and again, all of us have changed our practice numerous times, depending on how the data has influenced that change in practice. I also use in most instances, a third piece of this whole system, which is a stent retriever and the stent retriever basically is a snare it’s, it’s a mesh type snare that you expand that you open you unfold in the thrombus itself. So, in addition to the negative pressure that you have applied to that large bore aspiration catheter, you know, also have a snare, a mesh, and which basically engulfs and incorporates the thrombus in it. So now you have one more mechanism that’ll hopefully avoid any fragmentation of the thrombus of the clot and thereby avoid the one big complication that we have – one of the two big complications that we have – which is fragmentation and therefore embolization of this one thrombus into smaller, more distal vessels. In which case, it becomes difficult and then eventually impossible to retrieve it because the vessels just don’t allow a catheter to go in because the size is so small. So it’s some mixture of one or all three of those gadgets.

Dr. Joseph Segeleon: Well, thank you that, you know, it’s fascinating when I, when I think of my career over 20, some years, 25, 26 years, neuro intervention is really one of those specialties that has just exponentially evolved and has just become more technically advanced. And I have had the opportunity to hear you speak … the advances that you make, and the difference that you make in people’s outcomes is really fascinating. Really amazing stuff. I understand Sanford Health in North Dakota and South Dakota are the only comprehensive stroke centers. Can you expand on what does that mean exactly for our referral providers?

Dr. Divyajot Sandhu: So it’s a designation that was devised by the joint commission for hospital accreditation. And, at its jist,  at least in the U.S. it is the highest level of accreditation of certification of expertise that a hospital can be given when it comes to treatment of both ischemic and hemorrhagic stroke. And I thought honestly until we went through this whole process over the past 12-to-18 months and that we at Sanford Sioux Falls had all of these pieces already. And we were basically just dragging our feet and not willing to go through the effort of getting the certification. What I found was we have the 24 hours, seven days, 365 days a year neurosurgical. And this is, and this is open neurosurgical expertise. There were critical care expertise and neurointerventional expertise. We’ve had that since at least 2013 or 2014 before I was even here. What we didn’t have was these protocols, these processes, these educational programs and parameters assessments for everyone except the physicians. And this is not just a physician based exercise. I mean, the physicians are a very small part of this whole process. So what we did, what we found out with comprehensive stroke, and I think what distinguishes a comprehensive stroke center for all other hospitals that are able to do thrombectomies is how much more education of how much more staff it entails to get to a comprehensive level. That’s the big difference. And I think that is what distinguishes us now, because now for instance all of our nurses, who would potentially take care of a stroke patient, all the way from the emergency room to discharge in rehab, even they have had to undergo training in assessment of a stroke patient.

They have had to undergo the same training on the National Institutes of Health Stroke scale that I did when I trained as a resident, as a fellow, and also even our critical care providers, the medical critical care providers have had to do emergency neurological assessment and life support training, which they didn’t back in training. That, I think, is the big distinguishing feature now that we have over everyone else that’s in the area. And otherwise more of our people are more comprehensively trained to pick up on any changes that might be concerning for recurrent stroke, new stroke, and also to act upon them at all hours. It doesn’t have to be that, you know, Dr. Sandhu has to be in house or Dr. Kim has to be in house to pick these changes up. Our nurses can pick these changes up on their own and alert us that’s the big deal.

Dr. Joseph Segeleon: Well, it really, you know, sends home the message of why it’s called comprehensive. And I think it also speaks to the essence and the incredible importance of teamwork and understanding that everybody adds value to that team. And I am proud of our Sanford centers for achieving this hallmark, and I’m also, you know, working in this medical center, just proud and admire the teamwork that all of you have in the stroke centers. Finally to wrap up, if I’m an outside provider and I want to refer and let’s call it a non-acute patient, if I want to refer a non-acute patient to you, how do I go about that?

Dr. Divyajot Sandhu: So, the most common way that we get referrals are basically primary care physician a non-neurologist, for instance, they see a patient in clinic for suspected neurological disease. Imaging is done or on the basis of the clinical exam. They just refer those patients either via Epic the electronic medical record, or via old school phone line to the clinic here. Then, what ends up happening is our triage nurses get the basic information for that patient. What was the clinical concern? What is the clinical question and what kind of testing has been done to diagnose that clinical disorder or to answer what the question was. All of that is presented to either Dr. Kim or I – one of us. We review those we look at the images, see if there’s anything else that needs done. And then after that really is just scheduling the patient with us, that’s it. And I don’t think we’ve gotten better. I personally have gotten better at getting more patients in more quickly, because we were realizing that there was far too much of a lag between, for instance, you have a patient that you think needs an urgent referral, but does not warrant going to the emergency room or an acute care setting because they won’t be diagnosed appropriately in that setting. But yet you need them to be seen within the week. We have now accomplished that, at least when it comes to a cerebrovascular neurology or an interventional neurology question. If you have someone that needs seen within the week, we will see them. It might not be at the time that they want to be seen, the patient, it might be at a different time, but they will be seen.

Dr. Joseph Segeleon: Well. Excellent. Thank you. And Dr. Sandhu, I can’t thank you enough. This has been an enlightening discussion. I feel like we could probably go on for a couple hours. But I’ve learned a tremendous amount. We are so fortunate to have you at this hospital, and I know your partner, Dr. Kim as well, and the comprehensive stroke center resources that we have in Sanford really help our population, help our providers and really on the cutting edge of medicine. I thank you for your time. It was really enjoyable talking to you.

Host: Dr. Segeleon and thanks for being here again, to help guide the conversation. Dr. Sandhu, it was wonderful to meet you and to learn more about your practice and the care that you provided patients. We covered a lot of valuable information for our referring physicians, and we’re so grateful for all that you do here at Sanford.

Dr. Divyajot Sandhu: Thanks for having me here. Thank you.

Host: Our Called to Care podcast series by providers for providers continues right here with our Sanford Health experts. I’m Courtney Collen. Thank you so much for being here. We’ll see you soon.

Learn more about stroke care at Sanford Health.

Posted In Brain & Spine, Neurology, Specialty Care