Medical personnel at Sacred Heart Medical Centers Primary Stroke Center, in Spokane, are pioneering team protocols used to diagnose and treat a stroke while a patient is still in the emergency room.


The protocols streamline collaboration among radiology, emergency room, neuroscience, and support staff, including case managers, physical therapists and educators.


The latest scanning technology is one of the keys to allowing medical teams here to assess stroke patients more quickly and treat them while theyre still in the midst of a stroke, says Dr. William Keyes, a neuroradiologist with Sacred Heart Medical Centers Primary Stroke Center and Spokane-based Inland Imaging LLC.


Stroke ranks as the third-leading cause of death in the U.S., according to the American Heart Association. Most strokes and heart attacks are caused by blood clots.


Speedy diagnosis of a stroke is important, because a drug treatment with the strongest potential to reduce or reverse stroke injury must be applied immediately to be most effective, Keyes says.


Computed tomography (CT) brain scans help medical professionals recognize a stroke and minimize its spread, potentially reducing the damage a stroke causes, and promoting quicker recovery, Keyes says.


In many cases, quick treatment can reverse the injury caused by blockages in vessels that provide blood to the brain.


On a computer screen, Keyes displayed digital, 3-D snapshots, generated from three series of X-ray images, of a brain of a patient who was treated for stroke. The first scan, which he called a plain CT, was unremarkable, even though the patient was having a stroke.


In years past, nothing would have been done, Keyes says.


But more sensitive imaging, called CT perfusion, depicted on a computer screen a blue area of dying tissue, called an infarct, which is caused by inadequate flow of blood through vessels that supply that part of the brain. Another type of CT, called an angiograph, identified the affected blood vessels.


In this case, the infarct was found in time to administer intravenously the clot-busting drug tPA, or tissue plasminogen activator. Because of the effectiveness of tPA when administered at the early stages of a stroke, CT scanning is becoming the standard of care to identify early signs of stroke injury.


Without timely treatment, the patient would have suffered more extensive brain damage, which could have required extensive therapy and resulted in a lower degree of recovery.


Wilton Hille, a retired Spokane minister, says he probably would be in a nursing home today if not for immediate stroke treatment he received at Sacred Heart.


His stroke symptoms started with slurred speech and paralysis in the right side of his face while he was dining at a restaurant with friend Lawrence Hudson.


Being a man, I was trying to hide it, he says.


But it became obvious to Hudson that Hille had a serious health problem when the paralysis spread down Hilles right side and he couldnt hold a menu.


Hudson called Hilles wife, Sue, who asked him to get Hille to Sacred Heart if at all possible.


By then Hille knew he needed help. It took two people to help him out of the restaurant and into Hudsons car. I knew something was going on, Hille says. I was conscious but I couldnt respond.


Then, he blacked out.


At the hospital, emergency room physicians immediately suspected Hille was having a stroke and ordered CT perfusion and angiograph imaging studies, because time is of the essence in treating stroke cases, Keyes says.


The brain imaging confirmed Hille was in the midst of an acute stroke. The images, which identified the size and location of the stroke, also enabled doctors to determine Hille was eligible for immediate drug treatment, specifically tPA.


Hilles improvement was almost immediate. His first memory of regaining consciousness is one of people clapping.


They tell me there was a round of applause, because I raised my right hand and scratched my head, he says.


Barely 36 hours had passed from the time his slurred speech, facial drooping, and partial paralysis were first observed, until he was back home, fully recovered. Hille, now a year older at 72, credits the team approach at Sacred Heart for reversing the degree of his stroke injury. He has had no recurrence of stroke symptoms.


Were it not for the timely stroke assessment and treatment, he says, Im sure there would have been some lasting paralysis.


Keyes says active neurologists, with Dr. Madeleine Geraghty, director of the stroke center, among their leaders, are keeping the Spokane medical community on the forefront of stroke treatment.


The Primary Stroke Center isnt a physical place; rather, its more like a team whose members draw on resources from several departments.


Its a center without walls, Keyes says.


The center is the first in the country to be certified by the Joint Commission on Accreditation of Healthcare Organizations, he says.


Because we were keeping track of so many time elements, JCAHO adopted as part of its certification things we were already doing, Keyes says.


A patient doesnt have to be in Sacred Heart or even in Spokane to benefit from the work of the Primary Stroke Center, Keyes says. Through an online network called the picture archiving and communication system (PACS), radiologists at Sacred Heart or anywhere in the system can view CT scans taken in outlying areas, including Pullman, Moses Lake, and Colville, in near-real time.


If problems are caught in time, outlying hospitals can begin an intravenous tPA treatment and transport a patient to Sacred Heart for further treatment.


Intravenous administration of tPA is approved for use only within three hours of the first appearance of stroke symptoms. Outside of that timeframe, but within a six-hour window, tPA can be administered through a catheter directly into the affected vessel in the brain.


Research is under way to find methods to extend the effectiveness of clot-dissolving drugs beyond the current limits. Sacred Heart is one of 60 medical centers in the midst of trials on a new drug derived from the blood-thinning agent in the saliva of vampire bats, which keeps blood flowing from the bats prey. If the drug gains U.S. Food and Drug Administration approval, it could be administered intravenously up to nine hours after the appearance of stroke symptoms.


When drugs fail to dissolve a clot, another tool available to neurologists at Sacred Heart is a tiny cork-screw like instrument called the Merci Retriever, which can remove a clot mechanically. The Merci device can be used eight to 12 hours after stroke symptoms appear.


Contact Mike McLean at (509) 344-1266 or via e-mail at [email protected].