New Stroke Protocol Helps Minimize Brain Damage

Claudia Spitzer was terrified when her grandfather, Danny Spitzer, started driving erratically one Saturday afternoon in January. But she didn’t panic. Instead, this levelheaded sixth grader used her cell phone to text her mom for help, thereby giving her grandpa a chance to survive the stroke he didn’t even realize he was having.

Danny had taken Claudia (“CB”) and her younger brother, Zach, to CB’s basketball game. Afterward, Danny and the kids headed toward his home. But within a few minutes, Danny was veering his pickup truck off the road, barely avoiding other vehicles. CB knew something was wrong so she sent a text message to her mother: “Grandpa is driving in yards and going off the road. I’m scared!”

Deb was in Columbus, watching her older daughter play in a basketball tournament. Alarmed by the text message, she called CB immediately and asked to speak with her father-in-law. He sounded fine to her, but CB said she was absolutely sure something was wrong.

Deb quickly called her husband, Darrin, and they came up with a plan. CB would ask her grandpa to pull over, explaining that Darrin was looking for them.

When her grandpa complied, CB was able to tell her mother their exact location. She spent the next 10 minutes chatting with Danny about sports, hoping to keep him distracted. Darrin, who had called 911 from his car, arrived at the scene just as an ambulance did.

Fast, Appropriate Treatment

Paramedics tended to Danny immediately and transported him to a nearby hospital. There, a neurological exam and computed tomography (CT) scan suggested that he was experiencing an ischemic stroke, meaning that a clot was blocking the blood flow in his brain. The doctors administered intravenous tPA, a clot-busting drug, then made arrangements for Danny to be transferred to Miami Valley Hospital.

They knew that MVH was the only hospital in the region where Danny could get the advanced treatment he needed.

Time was of the essence, says Bryan Ludwig, MD, a neurointerventional specialist at MVH. "tPA is an excellent therapy because it immediately begins to break up a clot. However, if the clot is substantial, sometimes this medication is unable to destroy the clot completely," says Dr. Ludwig, who is also a clinical assistant professor of internal medicine at Wright State University Boonshoft School of Medicine.

“Danny needed to be where we could perform more tests and, if possible, remove that clot. Every second counts with stroke, because when part of the brain is starved for blood, it starts to die,” says Dr. Ludwig.

Danny was transported to MVH’s emergency department (ED) by a mobile intensive care unit (MICU). There, within the span of about 20 minutes, he underwent tests that began to reveal the extent of the stroke damage. His family— Including his wife, Nancy—waited anxiously for news.

“Magnetic resonance imaging (MRI) showed us that the clot was affecting the blood flow throughout the left hemisphere of Danny’s brain,” Dr. Ludwig explains. “The whole area was starved for blood, and it looked as if one artery in particular was getting only a little bit of flow. We had to get Danny into the angiography suite right away to open up that artery.”

Dr. Ludwig performed a cerebral catheter angiogram, a procedure that uses a special dye, imaging technology and a catheter to measure blood flow through the brain. He began by creating a small incision in the leg to gain access into the artery, and then threaded the catheter past the heart to the affected area in the brain. After confirming the presence of an artery-clogging clot, he used a suctioning device to remove the clot through the catheter. Immediately, blood began to flow more freely.

Because this cerebral catheter angiogram procedure is so new, it is only available at select institutions. “Without this kind of intervention, there’s no telling what kind of damage Danny would have experienced as a result of the stroke,” says Dr. Ludwig. “The clot was blocking blood flow to a large portion of his brain. Fast, appropriate treatment gave him the best possible opportunity for a successful recovery and meaningful quality of life.”

Streamlining Care

The opportunity to help patients like Danny is the very reason Dr. Ludwig came to MVH in April 2010. He joined fellow neurointerventionalists William R. Protzer, MD, and John Terry, MD, to form NeuroInterventional Specialists, Inc., located on the hospital campus.

Previously, patients needing vascular intervention for stroke, a cerebral aneurysm or similar disorders were sent to hospitals in Cincinnati, Columbus or Cleveland. But now, with three neurointerventional specialists at MVH, patients can receive the care they need day or night, quickly and close to home.

For the last year, Dr. Ludwig and his colleagues have been developing and refining a stroke protocol to streamline care for stroke patients. One of the main objectives is to get these patients to MVH as quickly as possible. “Other local hospitals can perform a CT scan to diagnose a stroke, and they can administer tPA if needed,” Dr. Ludwig explains. “But only Miami Valley has the sophisticated MRI software to pinpoint the extent of brain damage caused by the clot in the artery, and the interventionalists to open up the artery.”

ED personnel throughout the region know that if a patient is exhibiting signs of stroke, they can call a provider-only number at MVH. This connects them to a physician in the ED, who can discuss the case, and a neurologist, who can provide guidance about tPA therapy. Meanwhile, the phone call “auto launches” an emergency response vehicle—a CareFlight helicopter if weather permits, or an MICU ambulance—to the patient’s location.

As soon as the patient arrives at MVH, the team moves quickly to perform additional tests and create a treatment plan. Within an hour, the patient can be in the angiography suite getting prepped for surgery. “This kind of rapid response requires everyone on the medical team to work as one unit,” Dr. Ludwig says. “We don’t waste any time; we don’t make moves we shouldn’t. Every minute is important when it comes to stroke.”

What happens after surgery is just as important as what happens in the angiography suite, Dr. Ludwig explains. “Procedural repair is important, but a patient’s neurological condition can go downhill quickly if he or she doesn’t get good care afterward in the hospital,” he says. “At MVH, we have a team that is specially trained to care for stroke patients and others with a neurological condition. This is a better alternative than simply applying general ICU (intensive) care to neurological patients.”

Working Toward a Full Recovery

Stroke patients and their families may not be aware of all that goes on to ensure a successful outcome, but they certainly benefit from it. Just ask Nancy Spitzer, whose husband, Danny, continues to make progress.

“When Dr. Ludwig met with us before Danny’s procedure, he was very serious and caring,” recalls Nancy. “He explained the procedure, but I didn’t really understand what he was talking about—I was just so glad that something could be done. Danny received excellent care at MVH during his entire hospitalization, and we are really thankful for all the people who helped him.”

For his part, Danny, age 65, is continuing to undergo rehabilitation at a facility closer to his home in South Charleston, Ohio. Nancy says he is in “pretty good shape,” able to do things for himself and converse. He is not yet able to drive or return to work, but his family is optimistic that he’ll experience a full recovery.

“I hope everything will be the same as before so we can go fishing and work jigsaw puzzles,” CB says.