The work of survival never stops. Stroke victims arrive 24 hours a day, 7 days a week at New Hanover Regional Medical Center (NHRMC) in Wilmington, North Carolina, which saw 1,200 stroke patients last year.
Some arrive by helicopter. Others by ambulance. A few are able to walk through the main doors. But, despite the paths that brought them there, they are all united by one goal.
To be saved.
Enter two osteopathic physicians: neurologist Vinodh Doss, DO, and neurosurgeon Jeffrey Beecher, DO. Together this pair of highly trained DOs are ushering in a better era of treating Wilmington stroke patients through a new, often life-saving procedure called mechanical thrombectomy, an endovascular solution that uses a stent retriever to pull out a blood clot blocking blood flow to the brain.
They are doing so in the center of America’s Stroke Belt, where people suffer from strokes at significantly higher rates than the rest of the country. This DO team is a major reason that cerebral aneurysms, arteriovenous malformations (AVMs) and all cerebrovascular disease can now be treated for the first time in Wilmington, which means many patients no longer have to be sent to another city for care. That’s significant when there’s a current shortage of physicians who’ve undertaken the rigorous training required to perform neuroendovascular surgery.
“We’re completely changing patient outcomes,” says Dr. Beecher. “Instead of having severe disability and mortality, patients are having minimal disability. I anticipate having 100 stroke interventions this year.”
Board-certified in neurology and vascular neurology and fellowship-trained in endovascular surgical neuroradiology, Dr. Doss brought his expertise in interventional stroke care to NHRMC a year ago. With the recent addition of Dr. Beecher, board-certified in neurosurgery and fellowship-trained in cerebrovascular and endovascular surgery, the NHRMC can now offer 24/7 stroke treatment to the residents of Wilmington.
Why mechanical thrombectomy
“In medicine, we are traditionally wary about using the term breakthrough … however, the dramatic benefits of endovascular thrombectomy actually justify the use of this term,” physicians wrote in an opinion piece for the journal Stroke last year, in response to landmark clinical trials in 2015 showing the procedure’s effectiveness. In 2015, the American Heart Association also updated its stroke treatment guidelines to recommend mechanical thrombectomy as an endovascular treatment for patients with acute ischemic strokes (AIS) who met certain criteria.
Previously, the standard stroke treatment was to give an IV medication of tissue plasminogen activator (tPA) to dissolve the clot and restore blood flow. For certain patients with large blood clots, mechanical thrombectomy in conjunction with tPA can extend the treatment window up to 24 hours, based on 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke, published in Stroke.
“We’re able to provide this critical treatment to our stroke patients regardless of time of day,” says James McKinney, MD, medical director of NHRMC’s stroke program. “Historically, we had to transfer some patients at least two hours away for this treatment.”
How it works
Whether by chopper or by ambulance, the NHRMC is notified of an incoming stroke patient. “Our stroke team meets the patient at the emergency department door,” says Dr. Doss. “A stroke severity score is provided that alerts Dr. Beecher and I that this may be a potential interventional candidate. We will then review the relevant imaging and swiftly take the patient to the angiography suite.
The phrase, “time is brain,” used in a study by the National Center for Biotechnology Information, refers to the loss of nervous tissue that is “rapidly lost as stroke progresses.” According to the study, “the typical patient loses 1.9 million neurons each minute in which stroke is untreated.”
“We have extraordinary treatment times. Our median door to needle time for IV thrombolytics is 28 minutes,” says Dr. Doss. “Our median door to revascularization time for thrombectomy is 80 minutes.”
Making the change
According to the American Heart Association (AHA), stroke recently dropped from the nation’s No. 4 killer to No. 5, but still kills more than 130,000 people annually.
The challenge of making a change within these dynamics is twofold: 1) educating health care professionals and 2) educating patients about the signs of stroke. “A stroke can happen to anyone at any age. You have to be aware of the signs so that you can get prompt medical attention and the best imaging at the highest level, as quickly as possible,” says Dr. Beecher. “We also have to educate our emergency room doctors to better identify if a patient is having a stroke, to get them over to us.”
Identifying stroke factors and responding to them immediately is a key component of successful stroke intervention.
“Time is of the essence,” adds Dr. Doss. “If symptoms are ignored, oftentimes the patient will get worse, and we cannot help. There are not a lot of stroke interventional specialists, and systems of care are struggling to identify patients and get them to the right place for treatment.”
When identifying possible signs of stroke, Dr. Doss recommends following the FAST acronym:
F – Face drooping
A -Arm weakness or leg weakness
S – Speech difficulties
T -Time to call Emergency Medical Services (EMS)
“Dr. Beecher and I have the same mentality,” says Dr. Doss. “We welcome all calls or consultations so that patients that could be potential interventional candidates are not denied treatment.”
For Dr. Beecher, the journey has been one of impact and change. “I have found that stroke intervention is personally rewarding, and has one of the most dramatic effects on patients and their families. I hope to provide the best in both open and endovascular treatment of all cerebrovascular disease.”