Technology is already available to greatly improve outcomes for people suffering from strokes, but the present healthcare system is standing in the way of people getting it, according to Stacey Pugh, VP and general manager of the neurovascular unit at Medtronic.
The most important thing that could boost stroke treatment is passing proper legislation about taking patients in emergency situations to comprehensive stroke centers for proper treatment, Pugh explained during her keynote discussion at DeviceTalks West last month.
Technology has changed, but systems of care have not.
“The most important thing we can do today in stroke unfortunately isn’t innovation. It’s legislation,” Pugh said.
A stroke occurs when blood flow to an area of the brain is cut off, resulting in a deprivation of oxygen to brain cells, which then start to die. When brain cells die during a stroke, the abilities of that area of the brain are lost. Nearly 800,000 people a year experience a new or recurrent stroke in the U.S., according to the National Stroke Association.
Medtronic presently has a small device on the market – the Solitaire revascularization device – that reduces stroke mortality. It goes through the groin and into the brain – integrating into a clot and pulling the clot out of a large vessel occlusion. But only about 10–15% of people in the U.S. who are eligible to receive the therapy get it.
“There’s a couple of reasons for that,” Pugh said. “Part of it is stroke systems of care. The underlying medical system hasn’t evolved with the technology.”
The American Heart Association and the American Stroke Association help designate primary and comprehensive stroke care centers. The Solitaire is generally only available at comprehensive stroke care centers; primary centers are limited to doing a CT scan to locate a bleed or blockage and administering the clot-busting drug tPA, according to Pugh. Without legislation, an ambulance can drive past several comprehensive stroke centers that are capable of performing the intervention with the Solitaire before arriving at a primary care center – even if the stroker sufferer is outside the time window in which tPA is effective.
“There’s nothing in 30 states that says you have to be transferred to a comprehensive center,” Pugh said.
Go to a primary center before a comprehensive center, and data shows that it’s a 90-minute delay on average, according to Pugh.
“Ninety times 1.9 million [dead brain cells a minute] – it’s not a pretty sight,” Pugh said. “So, for every 30 minutes you’re delayed from getting intervention, you decrease the likelihood of a good outcome – not zero disability but what we would consider reasonable functional independence – by 10%.”
The present system of transport for stroke patients reflects a time when TPA was the only way to treat stroke – and the idea was to get stroke sufferers access to the drug as quickly as possible, Pugh said. Before there was device intervention, comprehensive and primary centers were not much different from each other. They could both administer tPA and determine if a patient needed a higher level of care – for bleeding in the brain, for example – and transfer the patient as needed.
“We’ve been able to show in that study that you could drive a patient an additional 20 miles and take them to a comprehensive stroke center, and they still get tPA faster. So the only reason to stop in the primary center was to get a patient tPA faster, but you can get it faster going to the comprehensive center, even with an additional 20 miles, because speed is everything in these centers,” Pugh said.
The odds of getting treatment are better if a stroke patient is a trauma patient as well, according to Pugh. There is a system in the U.S. that states if a patient is having a massive injury, they are guaranteed a direct route of care. There are designated trauma centers that are well-known. That’s not the case with stroke. There is no designated pathway for getting stroke treatment.