For Stroke Patients, Timing is Crucial in Getting Effective Treatment

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Dr. Ramesh Grandhi, assistant professor of neurosurgery at UT Health San Antonio, explains the visual results of the mechanical thrombectomy procedure.

Bonnie Arbittier / Rivard Report

Dr. Ramesh Grandhi, assistant professor of neurosurgery at UT Health San Antonio, explains the visual results of a thrombectomy procedure.

Of the 1,645 Medicare patients in San Antonio who suffered the most common type of stroke over a recent one-year period, only about 2 percent underwent a procedure that doctors say can drastically improve outcomes for stroke patients.

A data analysis shared with the Rivard Report by Definitive Healthcare, an organization that creates hospital databases, showed that of those Medicare patients in the San Antonio and New Braunfels area admitted with ischemic stroke – in which a blood clot wedges itself into an artery and blocks blood flow to the brain – only 34 received the procedure known as a mechanical thrombectomy. The period covered by the analysis was June 2016 through June 2017.

“This is one of the most effective procedures that we do in medicine,” said Dr. Ramesh Grandhi, assistant professor of neurosurgery at UT Health San Antonio, and one of six neurosurgeons in San Antonio qualified to perform the procedure. “The thing that prevents a patient from receiving a thrombectomy is that they reach a hospital too late and their brain has already shown signs of stroke,” meaning parts of the brain have already suffered harm.

Dr. Ramesh Grandhi, assistant professor of neurosurgery at UT Health San Antonio, shows the type of catheter he uses in the mechanical thrombectomy procedure.

Bonnie Arbittier / Rivard Report

Dr. Ramesh Grandhi, assistant professor of neurosurgery at UT Health San Antonio, shows the type of catheter he uses to perform a thrombectomy.

In a mechanical thrombectomy procedure, a catheter is pushed up the arteries from the groin to the blood clot. A device at the end of a metal wire, called a stent retriever, is pushed into the clot, then pulled out of the body along with the clot, restoring blood flow to the brain – often within a matter of minutes.

When someone suffers a stroke, the best outcomes depend on getting treatment quickly, which means a patient or someone nearby must recognize the warning signs and take action. Stroke symptoms include drooping facial muscles, arm weakness, and difficulty speaking, according to the American Stroke Association. In some instances, catching a stroke early means the difference between a patient sustaining permanent brain damage or being able to recover with minimal adverse effects.

A February 2016 analysis in the medical journal The Lancet concluded that during stroke studies that took place in 2015, 38 out of 100 patients treated with thrombectomy “will have a less disabled outcome” than with standard care, and that “20 more will achieve functional independence.”

Thrombectomies, which have been used in hospitals for around a decade, won't work in all cases, doctors said. The brain should not be showing signs of damage from loss of blood flow; guidelines recently were updated to reflect that the procedure can be performed on eligible patients up to 24 hours from the onset of symptoms.

Since the beginning of 2018, there have been close to 200 people transported to area health care facilities by San Antonio EMS for a reported stroke, according to Joseph Arrington, public information officer for the San Antonio Fire Department (SAFD). The actual number of people having strokes is likely higher, because EMS data reports calls immediately coded as a stroke but does not account for cases in which patients' symptoms were determined to be stroke-related en route to a hospital.

Arrington said stroke patients are taken to one of 10 certified stroke centers in San Antonio. Only three are designated as comprehensive stroke facilities and locations where thrombectomies can be performed: Methodist Hospital, University Hospital, and St. Luke’s Baptist Hospital. While not a state-recognized stroke facility, the Brooke Army Medical Center employs a neurosurgeon trained to perform the procedure, which can take anywhere from eight minutes to 90.

Two physicians from UT Health San Antonio are responsible for all thrombectomy procedures at University Hospital and St. Luke’s Baptist Hospital, while Methodist employs three neurosurgeons who perform the procedure.

University Hospital

Bonnie Arbittier / Rivard Report

University Hospital.

Despite a coordinated system of evaluation and treatment for stroke, SAFD Medical Director Dr. David Miramontes said “not enough” thrombectomies are taking place.

“People out in the community don’t recognize stroke symptoms, and often when they do they don’t call 9-1-1, they call family,” said Miramontes, who also is an assistant professor of emergency health sciences at UT Health San Antonio. “Then they may go to a freestanding [emergency clinic] or a hospital that doesn’t perform these procedures.”

SAFD is working to implement a new protocol to determine whether a patient has a large artery clot that would be eligible for a thrombectomy by evaluating  a patient's vision and his or her ability to comprehend. If a paramedic is able to determine whether the patient is a candidate for this procedure, the patient will be immediately transported to a facility where the procedure can take place.

“We have a very robust stroke system of care in the city, and we work very closely with EMS agencies," said Kassandra Hunt, the stroke program coordinator with Methodist Hospital. “[Thrombectomies are] not done enough as a whole because people don’t show up to us in time.”

Stroke is the most common cause of permanent disability, the second most common cause of dementia, and the fourth most common cause of death in the U.S. Those who survive it are often burdened with heavy rehabilitation costs, limitations in their daily life, and lost wages and productivity.

“Regardless of the cost of the procedure, if you end up with a disability you are going to end up paying a lot of money over time,” Hunt said.

Risk of stroke increases for people who have high cholesterol, diabetes, obesity, are inactive, have poor diets, and smoke. Stroke affects all ages, with the risk of stroke increasing with age.

In 2015, stroke was the third-leading cause of death among Texans of all ages, 44.6 deaths per 100,000 people, according to the Department of State Health Services (DSHS) 2017 Texas Stroke System of Care Report.

About 44 people per 100,000 died due to stroke in 2014, according to a 2016 DSHS report on heart disease and stroke for the region that includes 28 South Central Texas counties, including Bexar County. In that year, deaths due to stroke were more common along black residents than white or Hispanic, with nearly 73 deaths per 100,000 people.

Michelle Patterson, stroke director at St. Luke’s Baptist Hospital, said that the rates of thrombectomies are likely in line with the rates of other cities throughout Texas. She said that about 2.5 percent of people who experience an ischemic stroke are treated with a thrombectomy, which “may not seem like many people.”

“If the rate is low, it’s not because we don’t have enough physicians and it’s not because we are missing opportunities" to perform the procedure, Patterson said. “We need to get people to recognize the signs of a stroke and get to a hospital quickly.”

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