SIR: Stroke treatment training program improves outcomes

2019 03 22 17 43 2330 Texas Austin 400

Interventional radiologists at Johns Hopkins University (JHU) have developed an innovative program to train their colleagues to perform endovascular thrombectomies and achieve better outcomes for stroke patients. So far, the results are impressive, according to a presentation on Monday at the Society of Interventional Radiology (SIR) 2019 meeting in Austin, TX.

Over the course of six months, JHU researchers brought in a neurointerventional radiologist to teach four interventional radiologists how to unblock clogged arteries in the brain quickly and effectively using thrombectomy, the gold standard. When the newly trained interventional radiologists proceeded on their own, their patient outcomes as measured by 90-day mortality were better than the current benchmark.

"More importantly, having this team of trained interventional radiologists allows us to avoid transporting medically fragile patients to other hospitals and allows us to provide critical and timely stroke care as soon as possible," said Dr. Kelvin Hong, division chief of interventional radiology at Johns Hopkins.

The cost of strokes

Stroke is the fifth-leading cause of death and the leading cause of disability in the U.S. Unfortunately, few people have access to endovascular thrombectomy. With this treatment, physicians can clear clogged arteries in the brain, increase the survival rate for patients with an acute ischemic stroke, reduce the likelihood of long-term disabilities, and hasten functional recovery.

Dr. Kelvin Hong from JHU.Dr. Kelvin Hong from JHU.

"In order to gain these benefits, thrombectomies must be initiated and performed quickly," Hong said. "Favorable outcomes from endovascular thrombectomy are very time-dependent. In essence, time is brain. Yet there are many eligible stroke patients who could be treated and are not."

One reason why many stroke patients do not receive optimal care is the limited number of qualified clinicians. Thrombectomy is only available to 2% to 3% of eligible patients in the U.S., in part because many hospitals do not have physicians onsite to perform the treatment. Patients must be sent to another facility, which also adds to the time to treatment.

To find an efficient and sustainable way to expand access to thrombectomy, Hong and colleagues developed an interventional radiology stroke practice team at Suburban Hospital in Bethesda, MD. The initiative consisted of four interventional radiologists who made themselves available 24/7 for special training by a neurointerventional radiologist for six months. The neurointerventional radiologist was transported to the hospital by helicopter for every stroke case during the training period.

"Instead of bringing the trainee to the trainer, we brought the trainer to the trainee," Hong said. "In this way, we allow for the process to get the patient scanned and on the table and a preliminary preparation of the patient for the procedure, all while the trainer was being transported. We saved a significant amount of time."

Critical time to treatment

After the interventional radiologists began performing the thrombectomies on their own, the researchers set out to measure their technical prowess and the success of the program.

Hong and colleagues reviewed 35 stroke cases and compared the outcomes with results from the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) meta-analysis published in 2016 in the Journal of the American Medical Association. The findings in that report have become the benchmark for the standard of care for stroke.

When they compared the performance of the Suburban Hospital stroke team against the findings in the HERMES analysis, the Johns Hopkins researchers found no statistically significant difference in patient outcomes at 90 days after stroke.

JHU program vs. HERMES for stroke thrombectomy
  JHU stroke team HERMES
Mortality in first 90 days after stroke 14.0% 15.3%*
Median time from symptom onset to restoration of blood flow 325 minutes 285 minutes
*Difference was not statistically significant.

In the comparison, there was a median 40-minute difference in the time between onset of stroke symptoms and restoration of blood flow in the brain. To address this disparity, the researchers plan to improve patient transfer time and workflow prior to the procedures, along with other time metrics, Hong said.

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