When someone suffers a stroke, the medical intervention response time can mean life or death.That is why Cedars-Sinai physicians Shlee Song, MD, director of the Comprehensive Stroke Center and Telestroke Program, and Michael Alexander, MD, director of the Neurovascular Center and Endovascular Neurosurgery, are so passionate about stroke care expansion and advancement.
Dissatisfied with the static treatment provided by outside telestroke services, Cedars-Sinai began its own Telestroke Program in 2015 to ensure personalized intervention can occur quickly at any of the healthcare system’s hospital locations throughout the Los Angeles region.
Any time a patient experiencing a stroke comes into a participating hospital, staff alerts the telestroke team to provide their expertise. Within just a few minutes of that alert, Cedars-Sinai physicians can join the patient and their local care team virtually to facilitate care tailored to the patient’s condition. For example, the patient may quickly receive a clot-busting drug such as tenecteplase (TNK), or they may receive endovascular treatments if they are experiencing a large vessel occlusion.
Previously, many of these locations did not have an in-house neurologist to make these treatment decisions.
“We saw a major shift in the stroke world after endovascular trials were published in 2015,” said Song, who is also a professor of Neurology and vice chair of Neurology System Integration at Cedars-Sinai. “A lot of treatment was offered at tertiary and quaternary centers, but not at all hospitals in the area. We worked closely with our colleagues at Torrance Memorial Medical Center, an affiliate of Cedars-Sinai, to pilot the program because, at the time, they received a low volume of stroke patients despite serving a large population.”
At first, a small group of physicians covered overnight and weekend shifts via video visits to fill coverage gaps. Their timely, expert input had a strong, positive impact on stroke alert response times, and a higher number of eligible patients were treated for stroke, so the program soon expanded to operate 24/7.
“A lot of patients’ families appreciate the program because it’s within their hospital region and they don’t have to travel to Cedars-Sinai,” Song said. “Now, a lot of care is provided at regional hospitals, and the most complex cases are transferred to Cedars-Sinai to receive neurocritical care, if needed.”
Since implementing the Telestroke Program, Cedars-Sinai has seen improvements in patient outcomes and is currently the second-ranked hospital in the country in terms of 30-day mortality for stroke, despite seeing a very complex patient population.
The program has also resulted in a substantial increase in the number of patients treated at Cedars-Sinai hospitals and affiliates, and neurologists have seen significantly better patient outcomes with the support of virtual visits.
To keep the momentum going, Cedars-Sinai researchers continue to participate in several clinical trials to advance treatment of—and even hopefully prevent—stroke.
Stenting Trials Prove Successfulfor Treating Stroke
Song and Alexander have participated in several clinical trials that have helped to inform the personalized care the Telestroke Program provides.
A previous trial conducted by researchers outside of Cedars-Sinai showed negative results for stenting patients who had cholesterol blockages in the brain. Because of these results, the American Hospital Association (AHA) and American Stroke Association (ASA) changed their recommendation for stenting from Level 2B to Level 3—meaning they did not recommend stenting arteriesin the brain, even in patients who had failed medical therapy.
However, these researchers did not adhere to FDA guidelines when conducting their study. Alexander knew that adherence would result in better outcomes.
Following this trial, Alexander led an FDA-mandated trial to study the periprocedural complication rate of stenting. He used the same stent as in the previous study and adhered to FDA standards of patient selection and periprocedural management—and saw a significant improvement in results.
“After our trial, the AHA and ASA changed back to a 2B recommendation, which means that if a patient had failed medical therapy, had 70% blockage and presented with a stroke, they should be considered for stenting,” said Alexander, who is also professor and vice chair of Neurosurgery at Cedars-Sinai.
“They actually changed their national recommendation based on the trial we ran, and the number of stents being used for both secondary prevention and for patients getting a thrombectomy has increased dramatically in the past two years,” Alexander said.
The trial also showed how delaying this type of intervention might actually improve outcomes.
“The results showed how to lower the complication rate for the procedure,” said Song. “Not only has patient selection improved, but we’ve also improved the timing of the treatment. We work with neuro-intensivists to make sure the patient is stabilized and following their full treatment plan, and then we perform that interventional procedure around day seven in consultation with the neuro-interventionalist to reduce risk of post-procedure complications.
As a next step, Alexander is currently involved in a study comparing stenting to medical therapy for carotid artery disease and blockages and will conduct another stent study next year to determine how they can improve outcomes long term.
Using Vessel Wall Imaging to Tailor Care
Trials exploring vessel wall imaging have also proven effective in tailoring care. In a patient population as complex as Cedars-Sinai’s, stroke patients may have intracranial stenosis or another type of blockage in the brain. Despite maximal medical management, these patients may still experience stroke symptoms or a subsequent stroke. Vessel wall imaging can be used in these cases to highlight the most active plaques that may be causing the patients’ symptoms.
“Vessel wall imaging requires a high-resolution MRI and can help distinguish a cholesterol plaque from a dissection or tear in the artery,” said Alexander. “It can show inflammatory changes in the artery or a plaque rupture, and we can see very minute details in the blood vessel wall that can help us tailor treatment for the patient.”
Currently, Song and Alexander are involved in a trial examining whole brain vessel wall imaging and are working to tighten the inclusion criteria to select patients with the most active disease—ideally those with symptoms of a stroke or high-risk transient ischemic attack within the past two weeks. Vessel wall imaging will help guide treatment and individualize care depending on the patient’s risk factors. Additionally, researchers hope it will prevent patients from having a second stroke, as they are at high risk following the first.
“I hope we can use these diagnostic tools to tailor therapies and figure out which treatment is best,” Song said. “Sometimes we decide to use two blood thinners or extend their use, all in an effort to personalize a patient’s treatment while considering the patient’s bleed risk.”
The researchers are also working to understand how to prevent strokes, hoping fewer patients will be affected in the future.
“We’re heavily invested in clinical trials looking at stroke prevention,” said Alexander. “Most of our trials now look at stroke prevention, and I’m proud to say we’ve been the leader in this area for several years.”