Dr. Henry H. Woo is a cerebrovascular and endovascular neurosurgeon and director of the Cerebrovascular Center at Stony Brook University Medical Center. He holds dual appointments in the Departments of Neurosurgery and Radiology at SBUMC.

 

 

Every 40 seconds, someone in the United States has a stroke, and every four minutes someone dies of one.

Despite these staggering statistics, which distinguish stroke as the leading cause of disability and third leading cause of death, and despite the fact that stroke affects the U.S. economy to the tune of roughly $70 billion annually, stroke remains the most underserved field in medicine.

Fewer than 5 percent of stroke patients receive any form of acute treatment that could improve their outcomes. Yet, up to 40 percent of stroke patients arrive at emergency rooms in time to take advantage of therapy that would reduce neurological disability - if only it were offered.

But the lack of access to specialized physicians (in particular, neuroendovascular specialists and neurosurgeons); concerns about bleeding complications in the brain; the false assumption that many stroke patients cannot be treated or that a future stroke can't be prevented; and the potential for legal consequences to practicing physicians, mean that too many stroke victims suffer poor outcomes - from partial or full paralysis and reduced brain function, to death.

None of this is surprising. Compared with the crushing, radiating chest pain that is universally recognized as a symptom of heart attack, the wide array of stroke symptoms makes diagnosing such a cerebrovascular event much more difficult. Proper evaluation by tertiary care centers with highly trained specialists and advanced diagnostic technology is critical.

Moreover, while clinical trials and studies have demonstrated the effectiveness of intravenous and endovascular treatments for more than a decade, they are still vastly underused.

Therein lies the problem. And it's one that is greatly illuminated in Suffolk County. Despite our large and expanding population, before I joined Stony Brook in 2007, there wasn't a single physician here who specialized in endovascular or surgical procedures to treat stroke.

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The people of Long Island deserve better. In fact, the New York State Department of Health is striving for improvement by proposing a new designation for Comprehensive Stroke Centers that are capable of delivering the full spectrum of care - from diagnosis to intervention and rehabilitation - to patients with stroke and other cerebrovascular disease.

 

Currently, 10 Suffolk County and 11 Nassau County hospitals are designated by the state as "Primary Stroke Centers." Three of the 21 are also certified as such at the national level by The Joint Commission. Both designations are based mainly on the ability to diagnose a stroke early with standard CT imaging, and the ability to administer an intravenous clot-dissolving drug.

While admirable, this bar is too low. What must come next - what we must do better - is to get our patients the advanced treatment they need. This will save lives, save brain function, and reduce the debilitating physical and rehabilitative aftereffects a stroke can cause.

We must provide advanced imaging and treatment, including sophisticated magnetic resonance and computed tomography, intra-arterial treatments for stroke, neurosurgical coverage for bleeding complications, and complex treatments to prevent stroke recurrence.

The concept of designating such an elevated level of comprehensive care to our most critical patients is not unique. It has long been established in the form of Level I Trauma Centers, and it was formalized for the diagnosis and treatment of heart disease when the Centers for Medicare and Medicaid Services set a guideline of 90 minutes or less between arrival in the emergency department and intracoronary balloon inflation - helping hospitals work together to triage and transfer patients in need of more advanced cardiac care.

We know this model works for brain attacks as well. Elsewhere in New York, there are already "hubs" and "spoke" models of regionalized stroke care, where patients are assessed by emergency medical personnel or in their community hospital and then, if necessary, transferred to a center with state-of-the-art capabilities. The University of Rochester and University at Buffalo are two examples of how regionalization has occurred, which has enhanced the relationships between community hospitals and a comprehensive stroke center "hub." Indeed, across the country, the most effective regions for stroke care have similar systems.

To make it work, specialists must be accessible at all times, imaging results must be able to be shared quickly between hospitals, there must be advances in electronic communications of medical information, and there must be an efficient transfer system. With all factors in place, stroke patients can be assessed more effectively and transferred more quickly. Speed is essential, as lost time means lost brain tissue. Those patients who do not require additional evaluation or more specialized care can be appropriately treated at their community hospital.

The proposed new Comprehensive Stroke Center designation would require this full-scale, multidisciplinary strategy, including around-the-clock access to less invasive treatments and the neurosurgical treatments for strokes that occur as a result of large brain-vessel blockages or any form of brain bleeding. Designated centers would also provide treatment to address the origin of the stroke, which often reveals itself with the most subtle of symptoms and warning signs of a more devastating stroke yet to come.

 

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But the budget constraints in New York have stalled this progress in revolutionizing how we treat strokes. Brain disease doesn't care about a balanced budget, however, and it will continue to strike more often as the population ages. Recent health care legislation in Washington placed an emphasis on providing more value for care, by establishing organizations like the National Quality Forum and the Emergency Care Coordination Center, and dedicating $1.1 billion to fund comparative effectiveness research. Unfortunately, it will be years before we start feeling the impact of these initiatives, and decades before they are fully implemented.

May is National Stroke Awareness month. We need a heightened awareness of the most advanced levels of stroke care, to curtail the debilitating effects of "brain attack." The medical community has already addressed this need with heart attack and trauma. Through Comprehensive Stroke Center designation, we can achieve the most desirable outcome: the potential for stroke patients to enjoy the quality of life in their prime, or in their latter years, that they have worked so hard to attain.