Treating Stroke’s Triple Threat

By Thomas Crocker
Wednesday, June 14, 2017
Specialty: 

The Comprehensive Stroke Center (CSC) at University Health System is South Texas’ premier destination for the treatment and prevention of the three major manifestations of stroke: ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage.


(left to right) Shaheryar Hafeez, MD, Assistant Professor of Neurosurgery; Rachel Garvin, MD, Associate Professor of Neurosurgery; Ali Seifi, MD, Medical Director of the Neuro ICU at University Hospital and Assistant Professor of Neurosurgery at UT Health San Antonio

In 2016, University Hospital became the first in the region to receive CSC certification from The Joint Commission and the American Heart Association/American Stroke Association (AHA/ASA). This designation reflects the high-level clinical services available, including:

  • Access to leading-edge therapies through clinical trials
  • A Level 1 trauma center located in San Antonio’s largest emergency department (ED)
  • An on-site inpatient and outpatient rehabilitation center and follow-up clinic
  • Round-the-clock, in-house availability of neurology, neurosurgery and neurocritical care services
  • South Texas’ only neurocritical ICU that is staffed by neurocritical care specialists at all times
  • The region’s only Magnet hospital
  • A multidisciplinary approach to stroke care that includes partnering with neurology and neurosurgery specialists from UT Health San Antonio defines the CSC more than any other factor. This clinical collaboration is never more evident than when a stroke patient arrives in the ED.

Restoring Blood Flow

As soon as University Hospital receives word a stroke patient is en route, a large team of clinicians with a diverse skill set begins to assemble in the ambulance bay. This group may include a UT Health San Antonio neurology faculty member, a vascular neurology fellow, a stroke physician assistant, a neurology resident, an emergency medicine physician and emergency medicine residents. When the patient arrives, he receives a CT scan to determine whether the stroke is ischemic or hemorrhagic.


Ramesh Grandhi, MD, Assistant Professor of Neurosurgery at UT Health San Antonio

“After the CT, we get the patient into a monitored setting, complete a full neurologic workup and decide whether the patient qualifies for intravenous [IV] tissue plasminogen activator [tPA], a thrombolytic agent,” says Lee Birnbaum, MD, MS, Medical Director of the CSC at University Health System, Associate Professor of Neurology and Neurosurgery, and Ross J. Sibert Research Fund Distinguished Chair of the Vascular Neurology Program at UT Health San Antonio. “For small-vessel occlusions, tPA may be the only therapy needed. If we suspect a large-vessel occlusion, we may order a CT angiography and CT perfusion to better understand the brain tissue at risk. Patients with a large-vessel occlusion may need a catheterization study and thrombectomy by a neuro-interventionalist to remove the clot from the brain.”

The CSC recently received Gold Plus Target: Stroke Honor Roll–Elite Plus recognition from the AHA/ASA for administering IV tPA to at least 75 percent of acute ischemic stroke patients within 60 minutes of presentation and to 50 percent of such patients within 45 minutes. In 2016, the CSC’s average door-to-tPA time was 54 minutes.

Exploring Novel Therapies

Research is a hallmark of the Comprehensive Stroke Center (CSC) at University Health System, where patients have access to some of the newest therapies to treat and avert stroke as part of clinical trials. On the prevention side, the CSC is participating in POINT, an international, multicenter clinical trial sponsored by the National Institute of Neurological Disorders and Stroke (NINDS). The trial examines the safety and efficacy of using low-dose aspirin and the drug clopidogrel to prevent ischemic stroke and heart attack. The CSC is also involved in a study exploring whether aspirin or a group of new anticoagulants is more effective at preventing cryptogenic stroke.

The CSC is the world’s leading enroller in MISTIE, a NINDS-sponsored, phase 3 trial focused on the management of spontaneous intracerebral hemorrhage.

“We are using a minimally invasive procedure to partially evacuate clots with image guidance and dissolve what remains with thrombolytics, such as tissue plasminogen activator,” says Jean-Louis Caron, MD, FRCSC, FAANS, FACS, Professor of Neurosurgery at UT Health San Antonio. “We are randomizing participants to the trial and should finish by early summer. Data should be available after all the follow-up is complete, in the next 18 months. Hopefully, this procedure will change how we manage these patients in the long run.”

Halting Brain Bleeds

If a patient’s initial CT scan indicates a hemorrhagic stroke, additional imaging, such as a CT angiogram, may be necessary to rule out an aneurysm or arteriovenous malformation (AVM). Patients with brain bleeds due to hypertension receive aggressive medication management to keep systolic blood pressure less than 140 mm Hg, according to Dr. Birnbaum. For non-hypertensive hemorrhages, neurosurgical intervention may be the most appropriate form of care. Certain intracerebral hemorrhage patients may be candidates for an experimental procedure in which a drain is placed and tPA is infused to remove the clot; see “Exploring Novel Therapies” for more information.

“Primary care physicians play an essential role in secondary stroke prevention, which is why we communicate with them about their patients in a variety of ways, including by phone and via our EHR.”
— Jean-Louis Caron, MD, FRCSC, FAANS, FACS, Professor of Neurosurgery at UT Health San Antonio

Lee Birnbaum, MD, Medical Director of the Stroke Center at University Hospital; Associate Professor of Neurology and Neurosurgery at UT Health San Antonio

For a subarachnoid hemorrhage, which occurs when a brain aneurysm ruptures, endovascular repair may be an option for patients instead of open-skull surgery.

“Subarachnoid hemorrhage is a complex pathology that involves delicate brain surgery to put a clip on the aneurysm through an incision in the skull or seal it from the inside with platinum coils using catheter embolization,” says Ramesh Grandhi, MD, Assistant Professor in the Department of Neurosurgery at UT Health San Antonio. “The ideal scenario is to detect a patient’s aneurysm before it ruptures, which opens the door to the use of more of the advanced therapeutic devices and techniques in our armamentarium.”

Prioritizing Support, Education and Prevention

University Health System offers services to help patients navigate the complexities of stroke care and recovery.

Social workers and care coordinators are available to connect families with health system and community resources that can assist with issues such as insurance and transportation. Recovering stroke patients have the opportunity to socialize with and learn from each other — as well as a variety of educational guest speakers — at a free outpatient support group that meets the second Thursday of each month at the Robert B. Green Campus in downtown San Antonio. A twice-weekly support group for patients’ family members and spiritual services through the Peveto Center for Pastoral Care are also available.

A key part of supporting stroke patients is ensuring they are informed enough to take steps to prevent subsequent brain attacks. The process of education and secondary prevention begins during patients’ inpatient stay in University Hospital’s stroke unit. An inpatient support group allows patients to learn about stroke and preventive lifestyle modifications.

“The first 24 hours of stroke care are critical,” says Lee Birnbaum, MD, MS, Medical Director of the Comprehensive Stroke Center (CSC) at University Health System, Associate Professor of Neurology and Neurosurgery, and Ross J. Sibert Research Fund Distinguished Chair of the Vascular Neurology Program at UT Health San Antonio. “Once a patient’s level of acuity decreases, we start to do a workup as to why the stroke occurred and how to prevent another.”

The CSC provides community education and resources focused on primary prevention, as well. An example is the Stroke Risk Profiler, an online evaluation tool that estimates users’ likelihood of having a stroke and provides suggestions to mitigate the risk. Access it at CheckMyHealthSA.com.

The Road to Recovery

For patients, life after stroke begins in the neurocritical ICU in University Hospital’s Sky Tower.

“This unit is unique in our area in that it’s strictly for neurologically injured patients and it’s staffed around the clock by three fellowship-trained neurocritical care physicians,” says Jean-Louis Caron, MD, FRCSC, FAANS, FACS, Professor of Neurosurgery at UT Health San Antonio. “Each physician has a different clinical background, either emergency medicine, internal medicine or neurology. The neurocritical care specialists manage every aspect of patients’ post-stroke acute care, including ventilation, blood pressure management and intracranial pressure monitoring, if necessary.”


(left to right) Rachel Garvin, MD, Associate Professor of Neurosurgery; and Jean-Louis R. Caron, MD, Professor of Neurosurgery at UT Health San Antonioat UT Health San Antonio

Shaheryar Hafeez, MD, Assistant Professor of Neurosurgery at UT Health San Antonio

Patients transition from the neurocritical ICU to the neuroscience unit on the same floor, where a neurology or neurosurgery team continues their care. There, clinicians from the Reeves Rehabilitation Center in the hospital’s Horizon Tower evaluate patients for transfer to their unit for inpatient rehabilitation. The center offers physical therapy, occupational therapy and speech therapy and complements its providers’ expertise with high-tech clinical tools, such as a driving simulator and a wearable exoskeleton for gait therapy.

“The neurologists and neurosurgeons get patients through their emergent periods, but the rehabilitation specialists make them whole again,” Dr. Grandhi says. “Twice a week, our team meets with the physician director of inpatient rehabilitation to discuss which neurosurgery patients might be good candidates for inpatient therapy. The earlier we identify them, the sooner we can get them better and back home. The rehabilitation physicians know this patient population and their potential complications, such as hydrocephalus, well, and can consult the neurosurgical service quickly if a problem arises.”

Reeves’ discharge-to-home rate exceeds the national average for inpatient rehabilitation facilities by 87 percent. After discharge, CSC providers follow up with patients by phone at the 90-day mark to check on their level of function and independence. Patients who need outpatient rehabilitation can visit the Medical Center Pavilion across Medical Drive from University Hospital to work with Reeves providers. Individuals with ongoing neurologic needs, or those who have had a stroke and want a re-evaluation after receiving care at another hospital, may see a neurologist, neurology fellow or physician assistant at the stroke follow-up clinic in University Hospital’s Rio Tower.

The Specialization Advantage: University Hospital is home to the largest neurocritical ICU in the region.

By Tiffany Parnell

Neurocritical ICUs differ from traditional ICUs because they provide dedicated critical care and monitoring for patients who have sustained a neurological illness or injury, such as severe traumatic brain injury, ischemic stroke, intracranial and subarachnoid hemorrhage, meningitis, encephalitis, and Guillain-Barré syndrome.

An Evolving Field

Neurocritical care is a subspecialty of critical care that has emerged and grown over the past 30 years, according to a Frontiers in Neurology review. University Hospital hired its first neurointensivist — specialists who complete two years of fellowship training in neurocritical care following their residencies — roughly 10 years ago. At that time, several beds within the ICU were designated for patients in need of neurocritical care.

Today, these patients receive care in the dedicated 26-bed neurocritical ICU that is staffed by three neurointensivists with diverse areas of expertise:

  • Ali Seifi, MD, Medical Director of the neurocritical ICU, is triple board-certified in anesthesiology, internal medicine and neurocritical care.
  • Rachel Garvin, MD, is dual board-certified in emergency medicine and neurocritical care.
  • Shaheryar Hafeez, MD, the newest member of the neurocritical ICU team, is dual board-certified in neurology and neurocritical care.

These varied skill sets ensure neurointensivists are also equipped to care for medical conditions that may occur concurrently with neurological injuries and illnesses, including pneumonia, liver injuries, sepsis and heart failure.

Enhancing Stroke Care

The neurocritical ICU is a key component of University Hospital’s Comprehensive Stroke Center certification.

“Comprehensive Stroke Centers that have been accredited by The Joint Commission have 24/7 coverage by stroke, vascular and neurocritical care attendings,” Dr. Seifi says. “They also have a dedicated neurocritical ICU with 24/7 availability that can care for complex stroke patients.”

While University Hospital isn’t the only hospital in the region to receive Comprehensive Stroke Center certification, other local facilities are accredited by organizations that may have slightly different standards. For example, credentialing bodies other than The Joint Commission may not require 24/7 coverage or require physicians to perform as many endovascular procedures or treat as many patients using tPA every year.

Having physicians available at all times maximizes the benefits patients in the neurocritical ICU receive from advanced monitoring, which may include monitoring of intracranial pressure, continuous electroencephalography, brain oximetry and cerebral perfusion pressure. For patients’ families, the round-the-clock coverage also ensures a personal touch — a neurointensivist speaks with family members every day to review CT and MRI scans, manage expectations, and help coordinate post-hospitalization care.

In addition to the advanced monitoring and enhanced communication, the neurocritical ICU has a portable CT scanner. Physicians can obtain images of the brain at the patients’ bedside instead of moving them outside of the ICU.

“The ability to perform daily CT scans at the patients’ bedside has a significant impact on patient safety,” Dr. Seifi says. “Less transport means less room for error.”

Finally, members of the neurointensive team, as well as residents, nurse practitioners, physician assistants and other attendings, gather for medical scientific rounds every morning to review each patient’s case.

“Our approach is very different from private institutions in which only one physician sees each patient,” Dr. Seifi says. “When you combine all of these elements, it results in very good care for the patient.”

Poised to Grow

Dr. Birnbaum envisions a future in which the CSC serves a larger area of South Texas via air ambulance.

“We would also like to explore the possibility of bringing a mobile stroke unit to Bexar County,” he says. “That would allow us to take stroke care into the field.”

“My colleagues and I treat the triple threat of stroke, but our CSC is a triple threat itself,” Dr. Grandhi says. “We are at the forefront of clinical care, basic science research and translational research.”


For more information about the Comprehensive Stroke Center at University Health System, call 210-358-8555 or visit universityhealthsystem.com/services/neuroscience/stroke.