This article is a part of University of Maryland Rounds, which features clinical and research updates from the University of Maryland School of Medicine and University of Maryland Medical Center. See more Rounds articles.
Top-notch ischemic stroke care hinges on the ability to discern not only which patients can benefit from the clot-busting drug tPA, but who shouldn’t receive the medication. And based on new studies, physicians now also need to decide which patients can benefit from emergent stent-assisted recanalization to re-establish blood flow to the brain. University of Maryland Medical Center (UMMC) now extends this expertise to patients 35 miles away in Westminster as part of a new partnership with Carroll Hospital Center incorporating telemedicine video technology that’s the first of its kind in the Baltimore-D.C. area.
The Telestroke Program was established in December 2014 after Carroll Hospital Center approached UMMC leaders hoping to increase their support for stroke diagnosis and management in Carroll’s emergency department. UMMC neurologists had consulted via phone with Carroll ER physicians for years about incoming stroke cases there, but the Telestroke Program takes UMMC’s involvement to a new level, says Marcella Wozniak, M.D., Ph.D., an associate professor of neurology at University of Maryland School of Medicine.
Similar to University of Maryland’s eCare program, which launched in 2013 and offers remote critical care services to 11 hospitals throughout the state of Maryland, the Telestroke program relies on a high-resolution video camera along with cutting-edge technology that transmits patients’ clinical data from Carroll Hospital Center to UMMC. Neurologists at UMMC can manipulate the equipment remotely to examine the patient’s eyes, for example, or zoom back to see larger body areas. UMMC stroke neurologists can also view the patient’s CT scan, which greatly assists in decision making. “Putting technology like this in place means that patients and families have instant access to specialized care, increasing safety and quality,” explains eCare Director, Marc Zubrow, M.D., associate professor of medicine and vice president of telemedicine.
‘Almost Like Being There’
“We physically can’t touch the patient, but we can speak to them, watch them being examined, ask the physician to examine them in particular ways, directly obtain history from the family and patient and render a recommendation to the family and physician in the remote hospital,” Dr. Wozniak explains. “It’s almost like being there.”
The vast majority of all stroke patients suffer from ischemic strokes, in which blood clots cut off blood flow to a part of the brain. But quickly distinguishing this type of stroke from hemorrhagic stroke, which results from a weakened vessel rupturing and bleeding into the brain, is critical. Many ischemic stroke patients can benefit from intravenous tPA, Dr. Wozniak says, but the drug must be administered intravenously within 4.5 hours after a stroke occurs. In contrast, hemorrhagic stroke patients must not receive tPA, since it can make their brain bleed even more profusely.
ER physicians sometimes need assistance discerning ischemic stroke in patients, since “there’s no one lab or imaging test in the ER that tells whether one is having an acute ischemic stroke,” says Dr. Wozniak, who is also acting director of the Maryland Brain Attack Team at UMMC. In 2014, this team achieved The Joint Commission’s Advanced Certification as a Comprehensive Stroke Center, a new distinction earned by only about 70 stroke centers in the United States.
‘A Great Resource’ for Diagnosis
“Consulting with stroke neurologists increases the ability to treat certain patients who may not have been identified as having a stroke, and not treat other patients, who may be having other symptoms, like migraine or seizures,” she adds. “The ER physicians at Carroll are very skilled, but our additional expertise increases the specificity of a diagnosis, and does this rapidly. It’s clear from research studies that the more quickly these patients can be treated, the better their outcomes."
The Telestroke consultation also helps guide decisions about which patients should be transferred to UMMC for treatments not available at Carroll Hospital Center, which includes emergent recanalization techniques that can pull large clots from brain arteries using lattice-like mesh stents. Brand-new research has “unequivocally” helped identify which patients would most benefit from this type of procedure, Dr. Wozniak says.
“ER physicians are doing a great job evaluating and screening people for stroke therapies, but because stroke patients are only a small fraction of the many ER patients they see, that’s where they like to have the expertise of a stroke neurologist to help with the evaluation,” she says. “The Telestroke Program is a great resource for them.”
To learn about the telemedicine efforts at the University of Maryland, please contact Dr. Marc T. Zubrow at 410-328-4833.