The Stroke CenterAbout The UH Stroke CenterThe UH Stroke Center Printer Friendly Page

With such sobering statistics, it’s no overstatement that treatment for acute stroke and stroke prevention demand the latest technology skillfully used by a highly experienced medical team. The brain — our center of thought, emotion, and all vital functions — is the last frontier in medical exploration. Academic medical centers with specialized neurology programs are at the forefront of the advancements in stroke and other brain and spinal cord diseases and injuries.

Academic Stroke Center

The Stroke Center at University Hospital’s Neurological Institute of New Jersey (NINJ) in Newark is one of New Jersey's outstanding academically based comprehensive stroke programs. One of the leaders in New Jersey and in the New York metropolitan area in all phases of acute stroke treatment and prevention, the Center is fully integrated with the New Jersey Medical School, where all the Center’s physicians teach and conduct research. The center operates in a university-level "centers of excellence" environment that brings together topflight clinicians and basic science researchers from a variety of subspecialties.

The Stroke Center provides:

• Acute stroke treatment 24/7 with a multidisciplinary stroke response team and comprehensive diagnostics
  
• A specialized Neuro-Intensive Care Unit and step-down Stroke Unit, with dedicated intensive care medical and nursing staff
  
• Physical Medicine and Rehabilitation services for stroke and cerebrovascular trauma — in-patient and outpatient
  
• Stroke prevention and early intervention services, coordinated with Neurocardiology specialists
  
• A New Jersey Level I Trauma Center incorporating the NorthSTAR helicopter emergency and critical care transport system

University Hospital is considered a high-volume stroke center, which speaks to its breadth of experience and expertise. The stroke team treats close to 1,000 patients annually with all forms of acute stroke — approximately 235 cases each quarter. About 20 percent of those cases involve hemorrhagic stroke, which is well above the average 15 percent seen at other hospitals.

Acute Treatment & Intensive Care 24/7

The Stroke Center’s multidisciplinary team of stroke specialists is on site around the clock every day to respond with the speed required for the best possible outcome in the case of acute stroke (stroke in progress). Trained in all areas of acute stroke, they constitute our Brain Attack Team (BATeam).

The BATeam takes its name from the new expression for stroke in the medical community: "Brain Attack." This expression conveys not only the severity of the problem, but also the urgency in getting treatment. Like a heart attack, stroke now can be effectively treated before causing the fatality and severe disability commonly associated with it.

The Stroke Center’s BATeam can spring into action on a moment’s notice to treat acute stroke. Team members are on duty 24 hours, seven days a week, and accessible on call to provide the complete range of diagnostic, emergency and intensive care services essential in this type of emergency.

Members of the Stroke Center’s BATeam include:

• Emergency Department Staff
• Neurologists
• Neurosurgeons
• Neuroradiologists
• Endovascular Specialists
• Neuro-Intensive Care Specialists
• Neuro-cardiologists*

*The Stroke Center is at the forefront of merging neurovascular and cardiovascular expertise in the treatment of stroke. The direct link between heart disease and cerebrovascular disease is increasingly clear. University Hospital’s cardiology team is providing invaluable support in pre-empting situations that could lead to stroke, as well as improving stroke patients’ chances of survival and recovery without disability.

The value of stroke teams has been verified in recent studies. For example, the proportion of stroke patients receiving tissue Plasmogen Activator (tPA), a drug that can minimize or eliminate the damage caused by ischemic stroke, increased from approximately three percent to more than 10 percent in centers that implemented stroke teams.

Advanced Diagnostic Capabilities

The foundation of good stroke treatment is a precise, rapid diagnosis. The Stroke Center has round-the-clock access to a broad array of diagnostic modalities, including sophisticated new technologies that provide the fastest, most precise results. This means less time from the onset of symptoms to treatment — a significant advantage in avoiding irreparable damage, since “time is brain.”

With these advanced diagnostic capabilities, the Stroke Center can also detect vascular conditions leading to TIA, stroke or a recurrence of stroke — such as carotid stenosis and cerebral aneurysms — so they can be treated before causing actual damage.

The Stroke Center’s diagnostic capabilities include:

• Brain imaging tests
• Computed axial tomography (CAT or CT) scan
• Magnetic resonance imaging (MRI)
• Blood flow tests
• Carotid ultrasound
• Cerebral angiography
• Computed tomographic angiography (CT-angiography or CT-A)
• Magnetic resonance angiography (MRA)
• Transcranial doppler (TCD)

Leading the Way in Stroke Treatment & Prevention

The Stroke Center’s close relationship with New Jersey Medical School, a leading research institution, puts it at the forefront of new developments in stroke treatment and prevention. Stroke Center patients have access to the latest drug therapies and medical technologies — some of which are still in clinical trials and not yet widely available.

The Center is staffed and equipped to evaluate, treat and prevent all forms of stroke and vascular conditions leading to stroke, including:

• Transient ischemic stroke (TIA)
• Acute ischemic stroke
• Intracerebral hemorrhage (ICH)
• Subarachnoid hemorrhage (SAH)
• Complications of vascular disease, including raised intracranial pressure, sepsis, respiratory failure and venous thrombosis
• Aneurysms, vascular malformations and fistulas
• Large vessel cerebral atherosclerosis
• Cardiogenic and aortic arch embolism to the brain and spinal cord
• Small cerebral artery occlusive disease
• Hemodynamic/ hypoperfusion related brain ischemia
• Cerebral venous thrombosis
• Vasculopathies including inflammatory, infectious, toxic vasculopathies and moyamoya disease
• Hereditary and acquired hypercoagulable states
• Hematological disorders such as disseminated intravascular coagulation, thrombotic thrombocytopenic purpurea
• Antiphospholipid antibody syndromes
• Substance abuse-related cerebrovascular disorders
• Hypertensive encephalopathy
• Genetic and metabolic cerebrovascular disorders

In addition to standard surgical and drug treatments, the Center specializes in innovative endovascular (intra-arterial) procedures originally developed for use in the heart. These minimally invasive procedures have transformed the prognosis for heart attack victims and significantly reduced the incidence of heart attacks. Now they are doing the same for stroke victims.

The BATeam is among the first in the country to apply these proven cardiac techniques in the brain. The innovation is based on the understanding that arterial damage, such as plaque buildup and rupture, occurs in the brain much in the same way as it does in the heart.

Advanced Treatment for Acute Ischemic Stroke

The goal in treating acute ischemic stroke is to break up the clot blocking blood flow to the brain. The Stroke Center is breaking new ground by improving on current treatment options and helping to develop even more effective alternatives.

tPA Therapy: A standard treatment for ischemic stroke is tissue Plasminogen Activator (tPA) administered intravenously to break up the clot that is blocking blood flow. However, the method is effective only if the patient receives it within three hours of the onset of stroke symptoms. The vast majority of patients do not arrive in time to benefit from intravenous (IV) tPA.

Angiogram showing a blockage of one of the arteries of the brain. Arrow points to area of blockage.

Angiogram showing the same artery after patient was given tPA. Note the filling of the vessels. Arrow points to the area that was blocked.

Using minimally invasive endovascular techniques, The Stroke Center has been able to double the window of opportunity for some patients requiring tPA “clot-busting” treatment— extending the timeframe of effectiveness from three hours to six. In this procedure, the physician inserts a thin, flexible catheter into an artery (usually in the groin area) and steers it up to the area of the blockage and then administers the tPA directly to the clot through the catheter.

This method of delivering tPA demands special imaging equipment that allows the physician, who must be specially trained in endovascular techniques, to watch the catheter as it is threaded up through the arteries. University Hospital is one of fewer than 150 hospitals in the nation offering this procedure.

Mechanical Clot-Busting: The Stroke Center is working with an exciting potential companion or alternative to tPA therapy. It could further speed up the process of removing clots involved in ischemic stroke, thereby opening the window of opportunity for treatment even wider. It might also work more efficiently on larger clots that pose more of a challenge from tPA.

The MERCI retriever (Mechanical Embolus Removal in Cerebral Ischemia), a cork-screw shaped device, is the first FDA approved mechanical device for the treatment of ischemic stroke. Using an endovascular approach, much like the delivery of tPA to the site of a clot, the device is delivered at the end of a catheter and is used to physically pull out all or part of a clot.

Ischemic Stroke Prevention

Another goal in treating acute stroke is preventing its recurrence. The UH Stroke Center is skilled in the latest procedures for preventing ischemic stroke — including some still in the investigative stages — as well as traditional preventive treatments:

Angioplasty with Stenting: Cardiologists have been using angioplasty and stents for years to open clogged arteries in the heart. It is a very new concept in stroke treatment.

In this procedure, a metal mesh tube called a stent is mounted at the tip of a catheter over a deflated balloon. The catheter is inserted in an artery and used to navigate the stent to the area of blockage in the brain (a process known as angioplasty). Once there, the balloon is inflated, which expands the stent within the artery. This presses the material causing the blockage against the wall of the artery and restores normal blood flow.

The Stroke Center’s endovascular team has gone even further in improving outcomes by exploring the use of new drug-eluting stents in this procedure. These stents are coated with a medication that impedes the growth of scar tissue, which can reclog arteries following angioplasty. This can delay or prevent the need for additional angioplasty or invasive surgery.

Embolic Protection: A problem encountered during angioplasty and stenting is that emboli (clot- producing debris) can be dislodged and cause another blockage. Cardiologists experience this problem during cardiac angioplasty, where floating debris can be drawn into the heart, causing a heart attack. They use an embolic protection device during the procedure to prevent this from happening.

Slides showing the embolic protection device(L) and debris collected (R)

The Stroke Center is believed to be among the first to effectively use an embolic protection device in treating patients at risk for developing a cerebrovascular blockage during angioplasty and stenting. A microfilter is mounted on the tip of the catheter and deployed at the site of blockage like a tiny fishing net to trap even microscopic debris.

Advanced Techniques for Treating & Preventing Hemorrhagic Stroke

The Stroke Center provides the latest procedures for treating and preventing hemorrhagic stroke, which, although rarer than ischemic stroke, is also more deadly. The Center sees more than 100 cases of the most lethal form of stroke, subarachnoid hemorrhage (SAH), each year, and a recent comprehensive study found that SAH patients have a 40 percent greater likelihood of survival at a high-volume hospital (defined in the study as more than 35 cases annually).

Hemorraghic patients currently have fewer treatment options than do ischemic stroke patients. The UH Stroke Center offers:

Surgical Clipping: Surgical clipping can be used when the stroke is caused by a ruptured aneurysm or to prevent an aneurysm from rupturing.

Endovascular Coiling: This is a newer, much less invasive technique for treating certain types of ruptured and unruptured aneurysms.

In addition, because of the Stroke Center’s affiliation with New Jersey Medical School, patients suffering from or at risk for hemorrhagic stroke may be eligible for groundbreaking treatments not yet medically available.

The hours and days following treatment of acute stroke are critical to a patient’s survival and prognosis for recovery without disability. In fact, a patient’s condition may remain life threatening for weeks, depending on the type and severity of the stroke. Emergency intervention – fixing the immediate problem causing the acute stroke (such as removing the blockage or repairing the burst aneurysm) — accounts for just 30 percent of a patient’s chances for survival.

University Hospital’s comprehensive Neuro-Intensive Care Unit (Neuro ICU) provides the specialized critical care and monitoring and the dedicated staffing that most patients require to ensure that the stroke damage is contained and to prevent the serious complications — including death — that can result following acute stroke treatment.

The unit is staffed around the clock by physicians, nurses and other medical professionals with specialized training in intensive care specifically for neurological patients. Patients are closely monitored and receive appropriate preventive or interventional therapies — including drug treatment and endovascular/surgical procedures. The time factor remains critical here. All action is taken promptly and accurately.

Part of the critical care and recovery process includes a comprehensive stroke evaluation to determine the factors that contributed to the patient’s stroke. This will allow for a treatment plan to eliminate or modify those factors.

Rehabilitation may start within 24 hours as well. The extent of the therapy depends on the severity of the patient’s condition. At its simplest and earliest, rehab is useful in preventing some of the complications that may develop while the patient is in critical care. For example, patients with limited or no movement may develop muscle contracture, arthritis, frozen joints and other problems of immobility.

For patients who are farther along, physical, occupational and/or speech therapy may be initiated as well.

The Stroke Center provides a dedicated four-bed “step-down” Stroke Unit for patients who have been stabilized and no longer require the intensive level of care provided in the Neuro-ICU. The level of care provided in the Stroke Unit still exceeds that provided in a traditional inpatient setting, and the staff has the specialized training and experience in neuro-intensive care.

The focus in step-down is on round-the-clock monitoring to ensure that the patient remains stable and can eventually be moved to the most appropriate destination for recovery and rehabilitation. Stroke Unit staff can detect even the smallest changes in a patient’s condition and quickly return the patient to the neuro-ICU if necessary.

Improving Recovery Through Rehabilitation

Rehabilitation services, if needed, are available throughout a patient’s hospitalization as well as on an outpatient basis. Because stroke can affect so many functions — from high-level thought to basic motor skills, University Hospital’s Physical Medicine and Rehabilitation Department provides stroke-specialized treatment through its Acquired Brain Injury Clinic.

Risk Management & Stroke Prevention

The Stroke Center’s outpatient program, located in the Doctors Office Center at University Hospital, provides comprehensive stroke risk management and prevention services. A wide range of outpatient neuroradiology services for stroke risk evaluation and treatment — such as CT, MRI and Doppler ultrasound — are conveniently located within the Doctors Office Center as well.

Research & Education

Stroke Center physicians are on the faculty of the New Jersey Medical School, keeping the Center at the forefront of developments in stroke treatment and prevention. The Center maintains active involvement in research supported by the National Institutes of Health, medical foundations and other sources. This offers eligible patients the opportunity to participate in clinical trials of new and potentially more effective drugs and technologies aimed at reducing stroke damage and preventing recurrence — usually at no expense to themselves or their health insurer.

Stroke Center physician-researchers are published in the world’s leading medical journals and routinely contribute to advances in the medical community’s understanding of all aspects of stroke.

The Center conducts ongoing stroke education for emergency medical services personnel to familiarize them with the signs of acute stroke and the steps that must be taken in responding in order to achieve the best result possible for the patient. In addition, it has launched a large-scale public awareness campaign to get the word out the stroke is a treatable medical emergency and “Minutes Matter" when it comes to ensuring the best outcome.

Currently, the Center is a principal investigator for a nationwide, multicenter study sponsored by the National Institute of Neurological Disorders and Stroke comparing two drugs commonly used in stroke prevention: Warfarin vs. Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) Trial. The study will determine which of two commonly used treatments for ischemic stroke patients — Warfarin, an anticoagulant, or aspirin, a drug that affects platelet function — is better for preventing death and stroke in patients with certain cardiac conditions leading to stroke.

University Hospital is also the principal investigator for a nationwide, multicenter study currently under way comparing outcomes achieved through stent-assisted angioplasty with outcomes achieved through endarterectomy. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) is looking at the use of these procedures in treating carotid artery stenosis to prevent recurrent strokes in patients who have had a transient ischemic attack (TIA) or mild ischemic stroke.

Other current and prior groundbreaking research includes:

• A study examining whether a combination therapy of two types of blood thinning medications — intravenous abciximab and intra-arterial reteplase can be safely used to clear blockages in patients with ischemic stroke.
  
• Research involving the use of localized hypothermia in expanding the time frame for acute stroke treatment.
  
• A study by the Department of Physical Medicine and Rehabilitation at New Jersey Medical School of reports of individuals experiencing a stroke during or immediately after a salon shampoo. Researchers found that neck extension required for a salon sink shampoo results in altered blood flow to the brain, which may be a risk factor for stroke.
  
• Preclinical and clinical studies evaluating blood clot “retrieval” devices, catheters for endovascular procedures, stents for ischemic stroke prevention and other treatment and prevention devices.

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