Stroke Diagnosis & Treatment

On a national level, only about 5% of stroke patients receive intravenous t-PA, a clot-busting drug, for acute ischemic stroke (caused by a blood clot). This is primarily related to missing the critical 3-hour window of opportunity for treatment.

The CNI Stroke Program works closely with Swedish Medical Center, where 22% of stroke patients are treated with IV t-PA. Our efficient Stroke Alert system provides coordinated, aggressive treatment for stroke patients. Our physicians are experienced in identifying the safe administration of t-PA, a complex treatment. Administered through an IV or vein/systemically, t-PA is currently the only FDA-approved treatment for stroke.

Diagnostic Tools

Blood Tests – Typically included as part of the general exam, the blood tests will help your physician identify any disorders of the blood and will provide levels of cholesterol and blood sugar to test for diabetes as well as other risk factors. Based on findings, your physician may determine that more specialized blood tests are required.

Computed Tomography (CT) Scan – One of the most common tests given to patients for stroke or stroke risk, the CT scan gives your physician a picture of the anatomy of your brain, helping to identify areas lacking adequate blood flow. For patients who are having a stroke, a CT scan is used to determine if it is caused by a blood clot, a ruptured blood vessel or aneurysm. Specifically, a CTA is used to scan the blood vessels, while a CT perfusion is used to scan how blood supplies the brain tissues. Patients who may be pregnant should discuss all potential risks with their doctors before proceeding with a CT scan. The CT scan administered at Swedish may include a CT, CTA and perfusion study because of the speed, 5 –10 minutes, required to complete the entire test. An MRI, while more specific than the CT, takes much longer to do and requires the patient to hold very still for an extended period of time—up to 30 minutes—so it is not used as the initial screening test.

Magnetic Resonance Imaging (MRI) – An MRI is a more sensitive scan that can help your physician identify areas in your brain lacking adequate blood flow—at earlier stages. Because of the strong magnetic field and radio frequencies, people who have a heart pacemaker or any kind of metallic implant in their body shouldn’t have an MRI unless their physician approves the procedure. Patients will not be able to wear anything metallic during this procedure. The MRI test, while more specific than the CT, takes much longer to do and requires the patient to hold very still for an extended period of time—up to 30 minutes—so it is not used as the initial screening test. 

Angiography – A test where a catheter is threaded through an artery in the groin and up into the brain. X-rays and dye are used to see abnormalities in the vessels. 

CT Angiogram – The CT Angiogram, “angiography,” is a minimally invasive medical test that helps physicians diagnose and treat medical conditions. Angiography uses one of three imaging technologies and, in some cases, a contrast material to produce pictures of major blood vessels throughout the body. Angiography is performed using x-rays with catheters, computed tomography (CT), and magnetic resonance imaging (MRI). CT imaging uses special x-ray equipment to produce multiple images and a computer to join them together in multidimensional views. In CT angiography (CTA), computed tomography using a contrast material produces detailed images of both blood vessels and tissues.

Non-invasive Vascular Assessment (NIVA)
Your physician may request a NIVA exam, if you have had symptoms suggestive of a TIA. The NIVA exam uses advanced imaging techniques to painlessly evaluate the circulatory system without the use of needles, dye or radiation. A carotid NIVA exam evaluates the carotid arteries in your neck for narrowing or obstruction. A venous NIVA exam is used to look for blood clots in your veins. This is performed with ultrasound, a non-invasive imaging technique that uses sound waves to look inside your veins and blood vessels. The reflected sound waves produce both auditory and visual signals. The patterns tell the doctor how much atherosclerotic obstruction exists in the arteries and, therefore, how compromised is the blood flow to the brain. 

Echocardiogram – This test is done to check for any abnormalities of the heart, such as abnormal heart rhythms, coronary artery disease or previous heart attacks. An echocardiogram uses ultrasound waves, delivered at the chest wall, to examine the heart. It is a safe and painless procedure that helps doctors diagnose a variety of heart problems.

Transesophageal Echocardiogram (TEE) – A type echocardiogram is done from inside the esophagus (the tube leading from the mouth to the stomach). Because the esophagus lies just behind the heart, the TEE provides clearer images of the heart than a standard echocardiogram. The TEE provides better images and is generally performed when doctors want to examine hard-to-see structures of the heart.

Treatment Options

An acute stroke (brain attack) is very similar to a heart attack in that a blood clot suddenly blocks a blood vessel feeding the brain. If that blood clot can be quickly dissolved, the effects of the stroke often can be partially or totally relieved, and blood flow is restored to that part of the brain. Just as treating heart attacks rapidly leads to positive outcomes, an effective therapy for treating acute stroke with clot-busting medicines is now available.

The faster a blood clot is dissolved in the brain, the better. If a stroke patient arrives at the emergency room when symptoms occur, the emergency room doctor and neurologist can administer t-PA intravenously within the first three hours of symptoms. However, if three hours of symptoms has elapsed, an x-ray guided angiogram and catheter-directed administration of t-PA often can be performed. This catheter-directed treatment has been shown to work well up to six hours after stroke symptoms occur. After six hours the brain often has suffered irreversible damage and these clot-buster drugs are not recommended.

Intravenous Clot-Busting Therapy – By dissolving blood clots to the brain quickly, the quality of life in stroke patients is improved medicine, Intravenous administration of tissue plasminogen activator (t-PA), has its best effect when given intravenously within the first three hours of stroke symptoms

Catheter-Directed Therapy – After three hours of symptoms has elapsed from onset of stroke, an x-ray guided angiogram and may be advanced from the groin directly into the brain and the offending blood clot. Using x-ray guidance, a physician guides a thin, hollow plastic tube from the groin directly into the blood clot to dissolve it by infusing only a small amount of the clot-busting drug. t-PA has been shown effective when administered up to six hours after stroke symptoms have begun and often reverses the effects of the stroke. After six hours the brain often has suffered irreversible damage and these clot-dissolving drugs are not recommended.

Rehabilitation

The effects of a stroke are greatest immediately after the stroke occurs. From that point on, you may start to improve. However, the speed with which you improve, as well as how well you improve, depends on the extent of your brain injury and your response to rehabilitation.

Key points to keep in mind about improvement and recovery after a stroke:

  • Recovering your abilities begins after the stroke is over and you’re medically stable.
  • Some improvement occurs spontaneously and relates to how the brain works again after it’s been injured.
  • Stroke rehabilitation programs help you improve your abilities and learn new skills or coping techniques.
  • Depression after stroke can interfere with rehabilitation and is important to treat just as the stroke itself.
  • Improvement often occurs quickly in the first months after a stroke. It continues with your ongoing efforts.

CNI NeuroHealth Center

Colorado Neurological Institute provides many services that extend beyond the acute stay and into “life after a stroke.” Chief among these is the CNI NeuroHealth Center, an outpatient neuro-rehabilitation clinic where stroke patients benefit from expert speech, occupational and physical therapy services. All services are delivered in one location, optimizing convenience, and include not only rehabilitation, but also patient education and support, complementary therapies and research. Comprehensive services and resources at the CNI NeuroHealth Center include:

  • Physical, occupational and speech therapy by qualified therapists.
  • Services for patients with Medicare, most major insurance plans, and private pay.
  • Services to medically uninsured and underinsured patients through the generous support of our donors.
  • Social work services to evaluate current benefits, identify additional services available in the community and connect the client with these services.
  • Special programs and equipment, including LSVT Loud training for individuals with Parkinson’s Disease, Vital Stim training for swallowing disorders, LiteGait partial body weight support for individuals learning to walk and working on balance.
  • Scholarship assistance for neuro-optometry, neuropsychological and driving evaluations and the purchase of small durable medical equipment.
  • Education on disease processes as part of therapy treatment.
  • Multidisciplinary clinics with CNI physicians including Vision, Spasticity/Movement Disorders and Huntington’s disease.
  • Specialized seating and equipment evaluations.
  • Team communication and case management.

For an appointment or information, call the CNI NeuroHealth Center at 303.788.4010 or ask your physician for a referral.

What is Involved in Rehabilitation?

Rehabilitation actually starts in the hospital as soon as possible. Once patients are stable, rehabilitation may begin within 24 to 48 hours after a stroke occurs. During this acute phase, clinical rehabilitation priorities of the Stroke Unit Rehabilitation Team (SURT) include:

  • Prevention of complications
  • Initiation of early interventions, applying standard evaluation
  • Clinical analysis of functional abilities

Some of the first steps of rehabilitation involve promoting independent movement, because many patients are paralyzed or seriously weakened. For example, you’ll be asked to change positions frequently while lying in bed and engage in passive or active range-of-motion exercises to strengthen stroke-impaired limbs. (Passive range-of-motion exercises involve a therapist helping a patient move limbs repeatedly. Active exercises can be performed by a patient with no physical assistance from the therapist.) Generally, you will progress from sitting up and transferring between the bed and a chair to standing, bearing your own weight and walking—with or without assistance.

Rehabilitation continues to evolve as new techniques become available. Depending on the severity of a stroke, rehabilitation options may include:

  • A rehabilitation unit in the hospital or at a rehabilitation hospital
  • Home therapy
  • Home with outpatient therapy
  • A long-term care facility that provides sub-acute therapy and skilled nursing care

The Goal of Rehabilitation
The goal in rehabilitation is to improve function so you can become as independent as possible. This should be accomplished while preserving dignity and motivating you to relearn old skills that the stroke may have taken away which may include eating, dressing and walking. Rehabilitation also teaches new ways of performing tasks to compensate for any residual disabilities. Some patients need to learn to bathe and dress using only one hand, or how to communicate effectively when their language ability has been compromised. There is a strong consensus among rehabilitation experts that the most important element in any rehabilitation program is carefully directed, well-focused, repetitive practice.

Even though rehabilitation cannot reverse the damage caused to the brain by stroke, it can substantially help you achieve the best possible long-term outcome.

CO-DOC Telemedicine Program

Launched in 2006, the CO-DOC Telemedicine Program (Collaborative Digital Online Consultant) is a collaborative effort between the Colorado Neurological Institute (CNI), Blue Sky Neurology and Swedish Medical Center. This innovative program serves communities in Colorado that require 24/7 acute stroke neurology coverage but lack an on-staff stoke specialist. The CO-DOC Telemedicine Program meets this need, deploying proven technology to deliver highly specialized stroke expertise every second of every day.

Today, the CO-DOC Telemedicine Program has expanded to several medical centers in rural, frontier and urban communities throughout Colorado. The central hub for the CO-DOC system is at Swedish Medical Center in Englewood.

Current statistics (as of May 30, 2011)

  • 18 partner sites and 20 cameras
  • Over 500 remote consultations
  • Of the number of patients evaluated for stroke through CO-DOC, approximately 22% are determined to be appropriate for acute treatment with t-PA, a “clot-busting” medication. This rate is estimated to be four times higher than the national average for t-PA administration, which is 5.5% according to the American Heart Association.
  • 57% of CO-DOC Telemedicine patients remain in their community, and don’t need to be transferred from their home facility to another hospital for specialized care. The important aspect of this statistic for our partner site administrators is that effectively 100% of the patients would have been recommended for transfer without the telemedicine consultation, thus saving the families and patients the cost and inconvenience of long-distance travel to busy metropolitan areas.

How the Technology Works

Through the CO-DOC Telemedicine Program, stroke specialists at Blue Sky Neurology can be joined remotely by a site-independent, Internet-based, HIPAA-compliant telemedicine system to any hospital in our service area. This secure connection allows the neurologist to provide real-time acute stroke consultations–a critical service when literally every second counts.

The CO-DOC Telemedicine program is a proprietary system that requires the installation of a portable monitoring machine in emergency departments and a wireless laptop and headset combination that resides with an on-call neurologist. CO-DOC delivers smooth video through any Internet connection, automatic adaptability and error correction, dramatic zoom capabilities, excellent audio and video synchronization and no echo. Both the patient and physicians have two-way audio and video capabilities.

Community Education

Community education about the signs and symptoms characterizing an acute stroke is an essential part of the CO-DOC Telemedicine program. Just as important is the knowledge of the system within each community. The CO-DOC project manager and other CNI staff, as well as the program’s medical director, Christopher V. Fanale, MD, a recognized stroke-treatment expert, are committed to educating both the host sites’ health care providers as well as their communities at large.

About the CO-DOC Telemedicine Partners

Colorado Neurological Institute
Since its founding as a non-profit organization in 1988, the Colorado Neurological Institute (CNI) has earned a reputation as a world-class facility, offering patients access to innovative clinical trials and new surgical techniques. CNI’s specialized teams touch lives and change the future through a blend of physicians’ knowledge, skills and talents that provide the highest level of care to patients with nearly every neurological condition and adults and children with hearing loss and ear disease.

Blue Sky Neurology
Blue Sky Neurology in Englewood, Colorado was established in January 2005 is a CO-DOC Telemedicine program partner. The physicians of Blue Sky Neurology are all university-trained and board certified in neurology. Additionally, all members are fellowship-trained in subspecialties of neurology, many having additional board certifications, including two of only three fellowship-trained stroke neurologist in the state. Blue Sky Neurology strives to provide the most advanced, full-service, neurological care using the latest evidence-based guidelines.

Swedish Medical Center
Swedish Medical Center in Englewood, Colorado, serves as the Rocky Mountain Region’s referral center for neurosciences and comprehensive stroke care. Swedish is the only facility in the region to be four-times certified by the Joint Commission as a Primary Stroke Center. As a Level 1 Trauma Center, Swedish provides the most advanced care for adult and pediatric trauma. Each year Swedish continues to care for more than 142,000 patients with a team of 2,000 dedicated employees, 300 volunteers and more than 1200 physicians.