Perspectives on Stroke and Neuro Critical Care

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The University of New Mexico Hospital recently became the first certified Comprehensive Stroke Center in New Mexico and maintains a reputation of excellence in neurocritical care and advanced neuromonitoring. Here, some of the leading figures in this effort reflect on the ways in which such achievements reinforce the cross disciplinary concept of stronger together.

Andrew P. Carlson, MD, MS-CR, FAANS

Vascular Neurosurgeon

It was a cold January evening in 2015 that I was invited to an Emergency Medicine Journal Club to discuss the newly published results of MR Clean. The audience of emergency medicine physicians was interested, but skeptical. Our institutional approach to large vessel occlusion management was fragmented at best, with the perception of IMS III and the other similar trials being futility for interventional treatment. Having spent time in my residency and fellowships focused on the concept of oligemia and quantitative blood flow imaging, it seemed obvious to me that there was a population that with appropriate selection would benefit from revascularization. This moment was a transition point in our institution, where there was an earnest move from fragmented stroke and neurocritical care toward a collaborative approach, evidenced six years later by becoming the first comprehensive stroke center in New Mexico and a thriving multidisciplinary neuro intensive care unit. It was not purely the changes in evidence and guidelines that allowed us to make this transition, but rather the institution of monthly collaborative meetings between neurosurgery, neurology, emergency medicine and radiology was the deciding factor. Issues that disrupted our nascent workflows were resolved by understanding the perspective and challenges facing the other services, rather than festering into larger, disruptive approaches.

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Coupled with this, we have built on a strong foundation in the ICU related to invasive monitoring to care for these critical stroke patients. As a neurosurgeon who could place monitors and interpret physiology data, I had a “head start” in supporting such a monitoring program. What I have discovered over years is that having interest, “buy-in” and involvement from the entire care team allows these efforts to transition from a side project into a centrally relevant institutional effort. When I round in the ICU now, frequently the intensivist or even the bedside nurse is alerting me that they think their patient may be having spreading depolarizations on review of the bedside monitoring data. Despite challenges of building a comprehensive stroke and acute neurological injury care system, we are definitely stronger working together across disciplines.

Michel Torbey, MD, MPH

Vascular Neurologist-neurointensivist

I had been a part of development of a previous comprehensive stroke center at The Ohio State University, which was an instructive process that allowed me to bring many new perspectives to UNM when I joined as the chair of neurology. One of my central passions, however, is in advancing a state of the art multimodal monitoring program. I was attracted to UNM in part because of the monitoring program that was developed at UNM by Drs. Howard Yonas and Andrew Carlson in the ICU. The future of neurocritical care is in tailoring the treatment provided to individual patients. The collaborative approach at UNM across multiple disciplines in the ICU (neurologists, neurosurgeons and emergency medicine physicians), as well as a culture valuing the importance of physiology directed therapy, is a true differentiator.

Robert L. Alunday, MD

Emergency Medicine Physician/Neuro-intensivist

Helping to build up our cerebrovascular program has definitely been a joy of mine. When I started at UNM in the summer of 2014, we were far from a comprehensive stroke center. Although we were the only referral center in the state of New Mexico for aneurysmal SAH, on the ischemic stroke side, we were severely understaffed. We had a single over-stretched cerebrovascular neurologist and a stroke educator who was also our data abstractor and stroke coordinator. Real-time evaluations and treatments were also slow with consultations for ischemic stroke were handled the same as all neurology consultations in the emergency department (ED), with initial evaluation by the emergency physician, followed by a non-contrast CT, followed by a consult page to the neurology resident who for the most part staffed these consults with a general neurologist, neurophysiologists or movement disorder neurologists.

The ED and radiology had never heard of direct door-to-CT. MRI techs had never done an emergent MRI before. We had no institutional protocols on how to implement emergent and expedited evaluation for LVOs.

With my fellowship training in neurocritical care, as well as residency training in emergency medicine, and being a part of both departments (neurological surgery and emergency medicine), my contribution was in helping create the stroke-alert process. This process included direct door-to-CT by each ambulance crew with suspected stroke patients, pre-hospital activation of emergent neurology consultation, simultaneous (rather than serial) evaluation by emergency medicine and neurology starting at the ambulance entrance, as well as systematic evaluation for large-vessel occlusion strokes.

To make this happen, we had many multidisciplinary meetings. We did extensive education to all stakeholders (faculty and staff and residents in emergency medicine, neurology, neurosurgery, radiology, EMS, nursing) and convinced them to activate stroke alerts beyond three hours after onset, trust EMSs vital signs, forget old wives tales of contrast induced nephropathy, changed culture of a series approach to stroke care to a more parallel one, where nurses, techs, pharmacists, emergency medicine physicians and neurologists literally work shoulder to shoulder to diagnose and treat acute strokes as quickly as possible. And sure enough, our time-to-treatment numbers drastically improved. In addition, we created standardized thrombectomy criteria, streamlining the process of activating the neuro-interventional team.

I used to think that I was instrumental in keeping this process afloat, but as we have built up the program, added more expertise and experience, I see that I helped build something that no longer requires my daily diligence. I used to show up to every stroke alert that came into the ED, regardless of where I was in the hospital, what clinical shift I was on or if I was in my office doing non-clinical work. I have steadily decreased this over time, all the while our times to alteplase and times to thrombectomy have continued to improve. As I reflect on all the work that that our team has put into this, I know none of us could have done this alone, and that we are truly stronger together.

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