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Tuesday, January 5, 2010
Stroke/ICU Fellows Drs. Julius LaTorre and Sayonna John, and staff member Dr. Lee Schwamm review brain images of a critically ill patient in the Neuroscience ICU who received advanced tertiary care treatments for stroke.
Specialists are available around the clock to evaluate patients with symptoms of acute stroke and perform emergency surgical and catheter-based interventions. Patients who suffer a stroke or who undergo an emergency or scheduled interventional procedure, receive inpatient care in the Vascular Center’s dedicated 17-bed neurointensive care unit.
While patients typically see one physician in nonemergency situations, experienced stroke specialists representing every area of vascular disease— interventional radiology, neurology, neuroradiology, neurointerventional radiology, neurosurgery, vascular and endovascular surgery, vascular medicine, and interventional cardiology—work together behind the scenes to collaborate on patient care. They assess patients’ conditions, recommend appropriate diagnostic testing, and design individualized treatment plans. Treatment may include innovative medical, surgical, and endovascular interventions. The availability of endovascular therapy gives patients an option not available at most hospitals.
Massachusetts General Hospital’s long history of advancing stroke care is recognized regionally, nationally, and internationally. The Massachusetts Department of Public Health has designated the hospital a Primary Stroke Center. This year, the hospital received the American Stroke Association’s (ASA) 2009 Get with the Guidelines—Stroke Gold Performance Achievement Award for maintaining an 85 percent or higher adherence to the ASA’s guidelines for two or more consecutive years.
Prevention Is the Best Medicine
Addressing carotid artery disease before a patient has a stroke is key to reducing his or her risk for ischemic stroke. Clinicians at Massachusetts General Hospital also evaluate and treat patients for high blood pressure and other common causes of stroke.
During comprehensive physical examinations, physicians listen for carotid bruits—abnormal sounds in the carotid artery that may be signs of partial carotid blockages. Bruits significantly increase a patient’s risk of dying prematurely of vascular causes. Physicians also develop risk profiles that identify patients at greater risk for carotid artery disease due to high blood pressure, high cholesterol, diabetes, tobacco use, and coronary or peripheral artery disease. In addition, stroke specialists test patients’ reflexes, muscle strength, and the function of the eyes and tongue for signs of subtle previous strokes.
Since physicians in the Stroke and Carotid Artery Disease program approach care in the context of the comprehensive Vascular Center, they evaluate patients’ stroke risk and their risk for other vascular diseases. Superior Imaging Technology Plays a Pivotal Role
Ultrasound is a safe, simple, painless, and reliable test that helps confirm the presence and severity of carotid disease. Massachusetts General Hospital researchers confirmed that duplex ultrasound is a reliable, noninvasive method of determining carotid artery disease.
Neuroimaging technologies, including magnetic resonance imaging (MRI), computed tomography, and functional MRI, produce images that can help physicians determine whether a patient has suffered a stroke, where the stroke occurred in the brain, and the likely mechanisms that caused the stroke. Functional MRI perfusion studies can often identify at-risk tissues before damage occurs. Some of these techniques were developed or validated at Massachusetts General Hospital and are now standard tools available on commercial machines worldwide. These advances have led to significant improvements in stroke prevention and the classification and treatment of stroke patients. However, the effectiveness of these tests varies considerably depending on the skill of those who perform and interpret them.
Massachusetts General Hospital is home to the only vascular laboratory in Massachusetts accredited in all testing categories, including carotid artery imaging, by the Intersocietal Commission for the Accreditation of Vascular Laboratories. All imaging studies and scans are interpreted by experienced board certified subspecialists.
Severity of Carotid Narrowing Determines Treatment Options
Medical management and lifestyle modification are appropriate for most patients who have a narrowing in the carotid artery of less than 80 percent if they have no symptoms of carotid disease and no carotid bruits. Therapy may include taking medications to thin the blood and control high blood pressure, high cholesterol, and diabetes. Physicians also counsel patients about the importance of quitting smoking, losing excess weight, eating a healthy diet, and exercising regularly.
Carotid endarterectomy surgery is the standard of care for patients with significant carotid narrowing of approximately 80 percent or more. Studies show that stent-based procedures are as safe as carotid endarterectomy in patients who cannot tolerate open surgery because of chest pain related to coronary artery disease, severe lung disease, advanced kidney failure, previous radiation of the neck, or past carotid artery surgery. Patients who are not ideal candidates for surgery may be eligible for endovascular procedures as part of clinical trials under way at Massachusetts General Hospital.
All patients are being assessed using the National Institutes of Health Stroke Scale (NIHss) before they undergo carotid artery surgery or stent-based procedures. Patients are reevaluated 24 hours and 30 days after their procedures to document any neurological complications, such as transient ischemic attacks.
Massachusetts General Hospital Launches Unprecedented Quality Improvement Program
Massachusetts General Hospital leadership and Vascular Center physicians demonstrated their commitment to quality stroke care by developing the most ambitious quality measurement and improvement program ever undertaken in the United States.
Dr. Julius LaTorre responds to 24-hour pages to consult on acute stroke cases.
As of January 1, 2009, under the direction of Massachusetts General Hospital neurologists, all patients are being assessed using the National Institutes of Health Stroke Scale (NIHss) before they undergo carotid artery surgery or stent-based procedures. Patients are reevaluated 24 hours and 30 days after their procedures to document any neurological complications, such as transient ischemic attacks. The neurologists who perform the NIHss assessments are not part of the delivery of care, so they provide independent and unbiased data on quality. This level of rigorous evaluation is not routinely performed outside the context of a clinical trial.
The data will help the hospital track and compare outcomes in patients based on the type of procedure they have or the physician who performs the procedure. In the near future, physicians will be able to tailor their care based on this prospective outcomes data.
During the first quarter of 2010, the hospital plans to release the data to the public to encourage informed health care decision making among referring physicians, patients, and payors.
Replicating Success Across the Nation, Around the World
Massachusetts General Hospital specialists lend their expertise to programs and services that help improve stroke care beyond the hospital’s walls.
Get with the Guidelines—Stroke
In addition to his position as vice chair of the Massachusetts General Hospital Department of Neurology, Lee H. Schwamm, MD, is the national chairman of the American Stroke Association’s Get with the Guidelines (GWTG)-Stroke Steering Committee. Dr. Schwamm also helped design the GWTG-Stroke program. Today, more than 1,300 hospitals throughout the United States use the program’s seven evidence-based guidelines to treat stroke patients and capture data to benchmark their results. The GWTG-Stroke registry recently surpassed 1 million patients. Massachusetts General Hospital has participated in the program continuously since 2001.
Dr. Schwamm also developed pioneering telemedicine technology, called TeleStroke, that brings expert stroke care to patients at community hospitals that do not have neurologists on staff. Through TeleStroke, neurologists can virtually examine and interview patients with symptoms of an acute stroke, review their brain scans, and make treatment decisions collaboratively with emergency physicians.
Neuroimaging technologies, including magnetic resonance imaging (MRI), computed tomography and functional MRI, produce images that can help physicians determine whether patients suffered a stroke, where the stroke occurred in the brain, and the likely mechanisms that caused the stroke.
Neurologists from Massachusetts General Hospital and Brigham and Women’s Hospital are available around the clock for TeleStroke consultations at 27 participating hospitals in Massachusetts and southern New England. Nationally, several large hospitals, including Yale-New Haven Hospital and the University of Virginia, use the TeleStroke software and technology to support acute TeleStroke networks in their areas.
Studies show that telemedicine is safe and effective when used as part of a comprehensive stroke system of care in which tertiary hospitals provide ongoing support and services to partner hospitals.
Electronic Support via the Internet
For the past decade, Massachusetts General Hospital has maintained a comprehensive website that serves as a resource for physicians and hospitals across the world that look to the hospital to set the standard for best stroke practices. The website—acutestroke.com—provides information about Massachusetts General Hospital’s stroke protocols and approaches to acute stroke care.
Today’s Research Means a More Hopeful Future
Massachusetts General Hospital has numerous stroke research efforts under way. Under Karen Furie, MD, director of the Massachusetts General Hospital Stroke Service, Massachusetts General Hospital is one of only eight facilities across the country selected to participate in the National Institutes of Health–funded Specialized Programs of Translational Research in Acute Stroke (SPOTRIAS) network. Members of the SPOTRIAS network perform early-phase clinical projects, share data, and promote new therapies for acute stroke.
Kenneth Rosenfield, MD, director of vascular medicine at Massachusetts General Hospital, is the national principal investigator of the only ongoing randomized trial in the United States, ACT 1. ACT 1 compares the effectiveness of carotid endarterectomy and carotid angioplasty and stenting procedures.
Hospital researchers are also investigating platelet effects, genes that predispose people to stroke or identify patients who are more likely to respond to specific therapies, and the causes of intracerebral and subarachnoid hemorrhagic strokes.
For more information about the Vascular Center services or to refer a patient, please call 877-644-8346 or visit the Vascular Center website
Massachusetts General Hospital established the Vascular Center to provide comprehensive care for patients with vascular disease. As a dedicated vascular center with specialists in every area of vascular disease, the Vascular Center offers a uniquely focused, multidisciplinary approach to vascular medicine. Specialists in seven critical disciplines work together. These include cardiac surgery, cardiology/vascular medicine, nephrology, neurology, neurosurgery, vascular and endovascular surgery, and vascular radiology.
Treatments and Services: Aortic Disease Program; Brain Aneurysm and Arteriovenous Malformations Program; Peripheral Artery Disease Program; Stroke and Carotid Artery Disease Program; Venous Disease Program; Visceral Vascular Disease Program
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