Neurological Institute
Stroke Alert! Alert! Winter 2021
What it truly means to be
comprehensive
THIS ISSUE WINTER 2021
• What it truly means to be comprehensive
• Behind the IR/OR doors
• It takes a village to care for a stroke patient
• NEURO ICU
• Community awareness
• Rehabilitation
• Brain awareness risk screening
• We don’t just follow the standards,
• EMS role • Emergency department
we create them
What it truly means to be comprehensive Baptist Neurological Institute brought together internationally recognized neurosurgeons, neurointensivists, vascular neurologists, multidisciplinary clinical teams and the latest technologies and research for one reason — to fight the devastating impact of ischemic and hemorrhagic stroke on patients and families in our region. Baptist Health and Lyerly Neurosurgery are at the forefront of the latest advances in stroke and cerebrovascular care including: n
Providing open-access, 24/7 call schedule coverage by three neurointerventionalists
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Operating rooms staffed 24/7 with designated neuro-trained teams
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24-bed closed neurocritical care unit with 4 board certified neurointensivists
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24/7 dedicated vascular neurosurgeon
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24/7 vascular neurology and telestroke services staffed by our own team of physicians
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To assist with expedited care, connect directly with our neurointensivists by calling 202-BRAIN through the PCLC (Patient Care Logistics Center).
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3 dedicated neurointeventional platforms with bi-plane to ensure availability at all times
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Elevating the level of care available to the surrounding community via telestroke capabilities, with easy access to:
• 11 teleneurologists • 12 telestroke partner sites • Response times of five minutes or less • 24/7 support n
Continuous focus on quality and patient care goals
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Participation in more than 35 clinical trials, bringing the latest treatments to the region
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Expanding the time window for stroke treatment up to 24 hours and beyond
BAPTIST HEALTH STANDARDS: Door to CT completed: 20 minutes
Door to needle:
JOINT COMMISSION STANDARDS: Door to CT completed: 20 minutes
Door to needle:
It takes a village to care for a stroke patient Types of Stroke TYPE
CAUSE
TREATMENT
Ischemic
Blocked blood vessel
‘Clot-busting’ drugs, stent placement, or thrombectomy
Hemorrhagic
Burst or leaking blood vessel
Surgical procedures to repair blood vessel and stop bleeding, such as pipeline, stenting or coiling of aneurysms
Transient ischemic attacks (TIAs), or mini-strokes
Blocked blood vessel
Medical therapy or intervention to reduce the risk of future blood clots
No matter the type, all strokes can have the same symptoms.
Photo taken pre-COVID-19
: 30 minutes
Door to puncture: 45 minutes
: 60 minutes
Door to puncture: 90 minutes
Community awareness When it comes to stroke, seconds count. That’s why the ability to identify stroke symptoms for yourself or others and quickly seek medical care is critical to decreasing disability and maintaining long-term brain function. Baptist Health’s community outreach efforts focus on educating the general public to identify stroke signs and symptoms and empowering them to call 911 in the event of an emergency. In addition, Baptist Neurological Institute actively engages and participates in community-based events and educational opportunities to increase awareness of strokes and aneurysms regionally.
Saving brains with all our hearts. Symptoms of stroke? Dial 911 immediately!
B
E
F
A
S
T
Balance
Eyes
Face
Arm (or Leg)
Speech
Time is Brain!
Is there a sudden
Is there sudden
Is one side of the
Ask the person to
Does the person
Call 911
loss of balance
trouble seeing out of
face drooping?
raise both arms.
have sudden
immediately.
or coordination?
one or both eyes?
Ask the person
Does one side
trouble speaking or
If known, take note
to smile.
drift downward? Is
understanding?
there weakness or numbness on one side?
of when the symptoms began.
Brain aneurysm risk screening If any of the criteria below are noted, please consider if the patient is an appropriate candidate for aneurysm screening and submit a referral to a Lyerly Endovascular Neurosurgeon.
n n n n n
Personal history of brain aneurysm or subarachnoid hemorrhage(1) One first degree relative with brain aneurysm (first degree includes parents, offspring and siblings)(1) Two or more relatives of any degree with brain aneurysm(1) Female smoker age 30-60(2) History of fibromuscular dysplasia, polycystic kidney disease, coarctation of the aorta or primordial dwarfism(1)
Lyerly Neurosurgery Referral Phone: 904.861.0316 Referral Fax: 904.393.7892
(1)
Thompson, B. G., BrownJr, R. D., Amin-Hanjani, S., Broderick, J. P., Cockroft, K. M., ConnollyJr, E. S., … Torner, J. (2015, June 18). Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms. https://www.ahajournals.org/doi/full/10.1161/STR.0000000000000070.
(2)
Ogilvy, C., Gomez-Paz, S., Kicielinski, K., Salem, M., Maragkos, G., Lee, M., . . . Thomas, A. (2020, June 10). Women With First-Hand Tobacco Smoke Exposure Have a Higher Likelihood of Having an Unruptured Intracranial Aneurysm Than Nonsmokers: A Nested Case-Control Study. Retrieved October 28, 2020, from https://academic.oup.com/neurosurgery/advance-article-abstract/ doi/10.1093/neuros/nyaa227/5855656?redirectedFrom=fulltext
EMS role Our EMS partners in the field play a key role in improving patient outcomes through rapid response, triage, assessment, stabilization, and expedited transport to the appropriate facility. Through an EMS prenotification process encompassing the “last known well” and LAMS score, the Baptist Health stroke team and ED staff are activated to prepare for the patient’s arrival, thereby decreasing delays. Continued partnership with local EMS agencies through education and open discussion allow us to elevate the level of stroke care in our community and improve patient outcomes.
Emergency department Annual training and education allow all front line responders to assess and triage potential stroke patients who may walk in seeking medical assistance. Upon identification of a potential stroke, a stroke alert is called and the patient is brought directly to the stroke triage sign for physician evaluation. Patients arriving by EMS make a quick stop though the ED for rapid evaluation and are taken directly to CT scan. Once a stroke alert is called by the physician, the patient is taken directly to CT scan followed by the stroke team (EMS, RN, paramedic, neuro nursepractioners, stroke neurologist, and pharmacist). Rapid decision is then made for TPA administration, followed by perfusion studies to identify large vessel occlusion (LVO) and potential thrombectomy candidates.
Stroke alerts at all Baptist Health emergency rooms are covered by Vascular Neurologist and/or our telestroke Program, made up of Baptist Health vascular/stroke trained neurologists and neurointensivists.
Behind the IR/OR doors Specialists in stroke & cerebrovascular care Our internationally recognized neurosurgeons offer more advanced treatment options for strokes, brain aneurysms and other cerebrovascular conditions than any other providers in the area. Our groundbreaking, minimally-invasive procedures include flow diverter technology, stenting and coiling, and more traditional methods, such as clipping and bypasses. n
Arteriovenous malformation
n
Brain aneurysm
n
Carotid artery disease
n
Carotid endarterectomy
n
Carotid stenosis
n
Cavernous malformation
n
Dural arteriovenous fistulas
n
Embolization treatment
n
Stroke
n
Vertebral artery stenosis
n
Trigeminal Neuralgia
State-of-the-art technology and facilities Baptist Health is the only health system in the region with pediatric and adult cerebrovascular care under the same roof, including: n
Advanced neurosurgical operating suite with intraoperative MRI and CT capabilities
n
Dedicated neuro intensivitist
(c) alila www.fotosearch.com
Neuro ICU Not only do we strive to exceed the goals for reperfusion, we aim to provide top-of-the-line post-operative care. Our dedicated Neuro ICU allows for better outcomes during the patient’s hospital stay and sets them up for success upon returning home. The Neuro ICU is a 24-bed Intensive care unit, staffed 24/7 with physicians, nurse practitioners and nurses with specialized neuroscience training to provide continuous monitoring and care for all neurological emergencies. Neurological changes can be subtle. If not caught early and treated with rapid intervention, consequences could be devastating. Our experienced team, dedicated solely to advanced stroke care, knows what to look for to ensure positive outcomes and mitigate potential risks.
Mohamad Chmayssani, MD Neurocritical Care
Yogesh Moradiya, MD Neurocritical Care
Neerai Naval, MD Neurocritical Care
Jharna Shah, MD Neurocritical Care
The Baptist Stroke and Cerebrovascular Center is located at the downtown Jacksonville campus in our beautiful Weaver Tower. Nestled in the bend of the St. Johns River, each room provides elegant and peaceful views to enhance a calming environment for health and recovery. Lyerly Neurosurgery and Baptist Neurology providers work with state-of-the-art technologies, and they strive to beat the national standards for optimizing patient outcomes. Our Neuro Critical Care Team provides intense, highly specialized care by a team of dedicated Neuro-Intensivists, Advanced Practice Providers, and specialty trained neuroscience nurses. The nursing team delivers quality and compassionate care and holds specialty certifications on a national level.
Highlights n
42% of nursing staff have one or more National Neuroscience Nursing Certifications
Ongoing performance improvement projects • Restraints – patient safety • Buddy system – self care for nurses • Reducing HAP (hospital-acquired pneumonia) – Targeted population is the non-vent high-risk for aspiration stroke patients n
n Emergency neurologic life support • Taught by our NP’s and nurse manager • 4 NP instructors and 1 nurse manager instructor
Rehabilitation Rehabilitation services play a critical role in the safety and continued recovery of all strokes and neurologically impaired patients. In the hospital setting, our team of physical therapists, occupational therapists and speech and language pathologists initiate the return of function and cognition through exercise, mobility training and the use of adaptive equipment. n
Physical therapists help stroke patients who demonstrate deficits in mobilizing out of bed and walking.
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Occupational therapists aid stroke patients with functional transfers and ADLs.
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Speech and language pathologists help patients who have difficulty communicating and/or swallowing.
Our hospital rehab team will collaborate not only with each other, but with the neurologist, nurses, and case management team in order to make the appropriate recommendations for post-acute care. For a list of post-acute outpatient rehabilitation services for patients recovering from a stroke offered at Baptist Health, please visit the Neurological Rehabilitation section at our rehabilitation services site here:
baptistjax.com/services/rehabilitation-services/ neurological-rehabilitation
We don’t just follow the standards, we create them We are pleased to highlight the following clinical trials for this quarter. Success n
urpose – Assess safety and performance of the Comaneci Embolization Assist Device as a temporary endovascular P device used to assist in the coil embolization of wide-necked intracranial aneurysms with a neck width < 10 mm. A wide-necked intracranial aneurysm (IA) defines the neck width as > 4 mm or a dome-to-neck ratio < 2.
Inclusion • Documented intracranial ruptured or unruptured aneurysm, suitable for embolization by coils • Treatment with coil embolization assisted by the Comaneci Device for wide-necked intracranial aneurysms with neck width < 10 mm. A wide-necked intracranial aneurysm defined by the neck width as > 4 mm or a dome-to-neck ratio < 2 n
n Exclusion • K nown hypersensitivity to nickel-titanium
Escape-next n
urpose – Determine the efficacy of the neuroprotectant, nerinetide in reducing global disability in participants with P acute ischemic stroke undergoing endovascular thrombectomy excluding thrombolysis. Study arm will be placebo by vehicle only or Nerinetide single intravenous infusion of 2.6 mg/kg (up to a maximum dose of 270 mg) over 10 ± 1 minutes.
Inclusion • Acute ischemic stroke (AIS) selected for emergency endovascular treatment • Age 18 years or greater • O nset (last-known-well) time to randomization time within 12 hours • Disabling stroke defined as a baseline National Institutes of Health Stroke Score (NIHSS): – NIHSS > 5 for internal carotid artery (ICA) and M1-middle cerebral artery (MCA) occlusion; or – NIHSS > 10 for M2-MCA occlusion • Confirmed symptomatic intracranial occlusion at one or more of the following locations: Intracranial carotid I/T/L, M1 or M2 segment MCA n
Stem n
urpose – to assess the safety and effectiveness of Middle Meningeal Artery (MMA) embolization with SQUID for the P management of Chronic Subdural Hematoma (cSDH).
n
I nclusion • Male or female subject whose age is > 30 at the time of consent • Pre-morbid mRS 0-1 • cSDH measures > 10 mm in greatest thickness • cSDH exerts mass effect upon the subjacent brain, as indicated by local cortical flattening or midline shift • Imaging characteristics indicative of chronicity (> 50% of the volume of the collection should be isodense or hypodense to normal cortical gray matter on Computed Tomography (CT)) • Subject presents with one or more of the following neurological symptoms: headache; cognitive decline; speech difficulty or Aphasia; gait impairment or imbalance; focal neurological deficit (weakness, paresthesia or sensory deficit involving of one or more extremities or facial droop); and/or seizure
NeVa stent retriever for treatment of LVO strokes n
urpose – to assess the safety, performance and efficacy of thrombus removal in subjects presenting with acute P ischemic stroke with the NeVa stent retrievers.
The NeVa device has a large offset opening that allows clot to rapidly incorporate inside the device. It has a balanced design that optimizes radial force balanced with large opening and minimal metal coverage. The device also has a clot capture basket that retains the clot to prevent downstream migration. Inclusion • Clinical signs and symptoms consistent with the diagnosis of an acute ischemic stroke, and subject belongs to one of the following subgroups: – Subject has failed IV t-PA therapy – Subject is contraindicated for IV t-PA administration – IV-tPA given within 3 hours of symptom onset – Age >18 and less than equal to 85 – NIHSS score > 8 and > 25 – Prestroke mRS score of > 1 – Intracranial arterial occlusion of the distal intracranial carotid artery or middle cerebral artery (M1/M2), anterior cerebral artery (ACA), posterior cerebral artery (PCA), basilar artery, or vertebral artery demonstrated with DSA n
Ongoing research summary TIMELESS
PROST
EMBOLIZE
PhaseBio
PERFORMANCE-II
ADVANCE
Study type
Interventional
Interventional
Interventional
Interventional
Interventional
Interventional
Estimate enrollment
456
316
600
200
305
140
Allocation
Randomized
Randomized
Non-Randomized
N/A
N/A
N/A
Intervention Model
Parallel assignment
Parallel assignment
Parallel assignment
Single group assignment
Single group assignment
Single group assignment
Masking
Quadruple
Single (outcome assessor)
None (open label)
None (open label)
None (open label)
None (open label)
Primary purpose
Treatment
Treatment
Treatment
Treatment
Treatment
Treatment
Start date
March 2019
October 2019
September 2019
March 2020
June 2020
April 2020
Estimated primary completion date
November 2021
December 2020 August 2021
December 2023
September 2022
April 2024
For a complete list of all current Baptist Health Research Institute trials please visit baptistjax.com/patient-info/baptist-research-institute/clinical-trials
Neurological Institute
Emergency Transfers: 904.202.BRAIN (2724) Fast-Access Office Appointments: 904.861.0316 Referral Fax: 904.384.1005