Telemedicine Help

Emergency medical services brought her to a local hospital, where they contacted our stroke specialists using telemedicine, a video chat application like aceTime or Skype. Using a laptop, tablet, or telephone to connect to an apparatus at the local emergency room, we can see, examine, and talk with the patient in real-time, and discuss the case with family and the rest of the medical team. The first choice of treatment—clot-busting intravenous tissue plasminogen activator (IV tPA), the only FDA-approved medication for acute stroke—was out of the question. It must be used within four and a half hours of the start of symptoms. This patient had last been seen to be acting normally seven hours before she arrived in the emergency room.

Catheter Clot Removal

Luckily, thanks to new data published in the New England Journal of Medicine in January and February, patients can now be treated with a special catheter-based procedure called an endovascular thrombectomy, or blood clot retrieval, to remove blood clots up to 24 hours post-stroke. The catheter is threaded up through the groin, similar to a cardiac catheterization procedure, and special devices are deployed to remove the blood clot. We were able to transfer the patient to our own institution and remove a large clot blocking blood flow to the right side of her brain.

She made what seemed like a miraculous recovery almost immediately, and left the hospital several days later, walking and talking normally, with just a slight facial droop. Until recently, this procedure was available only for patients who arrived within six hours of their first symptoms.

New Data Extend Window

The new results represent a significant breakthrough in stroke treatment. Even 25 years ago, patients who arrived in the emergency room outside of the IV tPA time window received mostly supportive care and little active treatment. Now, with advanced therapies and new devices, neurologists are widening the time window for stroke care.

Some Exceptions

As exciting as the new findings are, some caveats still exist. Catheter-based therapies can only be used to treat patients who have what doctors call large-vessel occlusive strokes, which are typically caused by clots blocking the larger vessels of the brain, including the internal carotid artery and the middle cerebral artery. Since these strokes involve bigger swaths of brain tissue, symptoms are usually more severe—patients may be unable to understand or produce language or look fully to the left and the right—and patients may be more likely to end up in a nursing facility long term, become dependent upon others for activities of daily living, or die than patients whose strokes affect smaller vessels. Other factors may prevent eligible patients from having this life-saving procedure, including that too much damage has already occurred, which could put them at risk for bleeding. 

Small Percentage but Serious

These types of stroke are much less common, but they are considered the most disabling and least likely to respond to medication. In fact, a 2017 study in Frontiers of Neurology found that large-vessel occlusive strokes account for one-third of all blood clot strokes, but are responsible for three-fifths of dependency and nine-tenths of all stroke-related deaths. 

Post-Stroke Success

Just one year ago, our 49-year-old patient might have been transferred from the hospital to a rehabilitation facility. She might never have regained the use of her left arm or leg or been able to live independently, speak normally, or to return to work. I’m happy to report that when she returned for her three-month post-hospital follow-up visit in our outpatient stroke clinic, she no longer had a facial droop, and exhibited no other symptoms. As far as she and her family were concerned, her recovery was a true miracle. I agree completely.

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