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Stroke Care at Suburban Hospital (5/8/2014)

Dr. Zurab Nadareishvili

Every four minutes in the U.S., a life is lost to stroke. As the fourth leading cause of death, stroke claims the lives of nearly 140,000 Americans each year. The stroke survival rate has been increasing, however, thanks to advances in prevention, diagnosis and treatment. The Suburban Hospital Stroke Program ensures access to these advances.

Established in 1999, the NIH Stroke Center at Suburban Hospital is the cornerstone of the Suburban Hospital Stroke Program. A partnership between Suburban Hospital and the National Institutes of Neurological Disorders and Stroke (NINDS) of the National Institutes of Health, this unique collaboration allows Suburban Hospital to offer one of the most advanced stroke treatment programs anywhere. The Stroke Program recently earned recertification as a Primary Stroke Center by The Joint Commission. Dr. Zurab Nadareishvili, medical director of the Suburban Hospital Stroke Program, explains what you need to know about stroke.

What is a stroke?

There are two major types of stroke: ischemic and hemorrhagic. Ischemic strokes are the most common, accounting for more than 85 percent of all strokes. They result from a blockage of blood flow to the brain, usually caused by blood clots or the narrowing of blood vessels. A hemorrhagic stroke occurs when a weakened blood vessel bursts, creating bleeding within or around the brain. Both kinds of stroke quickly rob brain cells of oxygen-carrying blood, and body functions controlled by those cells are damaged or permanently lost.

What is a TIA?

A TIA is a transient ischemic attack. TIA patients experience the same symptoms of a stroke but the symptoms are temporary and there is no stroke evident on MRI. A TIA is a warning sign of an impending stroke and should be taken very seriously. An individual who suffers a TIA has a very high risk of stroke immediately following the TIA. That’s why these patients should be admitted to the hospital and observed. At Suburban Hospital, our Clinical Decision Unit utilizes the same diagnosis and treatment modalities with TIA patients as we do with stroke patients, including imaging studies such as MRI and MRA (a type of MRI) to determine the cause of the TIA and to see if an actual stroke has occurred. If no lesion (area damaged by stroke) is seen on MRI and the clinical presentation is consistent with TIA, we still treat these patients very aggressively, as the goal is to prevent a major stroke.

What happens when someone arrives at the Suburban Hospital Emergency Department with symptoms of a stroke?

The Suburban Hospital Stroke Team is available 24/7 to help diagnose and treat stroke. As soon as a stroke patient arrives at Suburban Hospital, the team is called. If the patient arrives within the time window for treatment with clot-buster medication, the Stroke Team will begin that treatment. Patients who arrive outside of the time window still get an MRI and evaluation by the Stroke Team, which will initiate secondary stroke prevention measures.

What is the treatment for stroke?

Early treatment is crucial to survival and recovery. Depending on the type of stroke, the treatment varies greatly. Treatment for hemorrhagic stroke includes medication and possibly surgery. For acute ischemic stroke, the only FDA-approved treatment is t-PA, or tissue plasminogen activator. The FDA has approved a three-hour window to treat an ischemic stroke with t-PA, although American Heart Association/American Stroke Association guidelines support treatment within a window of 4.5 hours of stroke onset.

Unfortunately, the majority of stroke patients come to the hospital outside of the time window to receive t-PA. That’s why educating the public about the warning signs of stroke is so important. Nationwide, approximately 5 percent of stroke patients are treated with t-PA. At Suburban Hospital, the number of stroke patients who receive t-PA is twice the national average. This may be the result of increased educational efforts as well as making the county’s emergency medical system aware of Suburban Hospital’s protocols. The Suburban Hospital Stroke Program has been named a specialty referral center for stroke by the Maryland Institute for Emergency Medical Services Systems (MIEMSS).

What does Suburban Hospital’s collaboration with NIH mean for stroke patients?

The NIH Stroke Center at Suburban Hospital is dedicated to researching the most effective ways to diagnose and treat stroke using new technologies and drugs. Physician-scientists from NIH work side-by-side with Suburban Hospital clinicians to provide our patients with the most advanced medical protocols and cutting-edge technology.

One mission of NINDS is to prove that MRI is a better diagnostic tool than CT scan. Most community hospitals use CT scan to diagnose acute stroke. A CT scan can quickly exclude bleeding in the brain, but the resolution is not as high.

At Suburban Hospital, all stroke patients have access to MRI technology (with the exception of those with pacemakers and/or metallic implants). With MRI, we can clearly see the stroke. In addition, we can age the lesions, so we don’t need to rely only on the patient’s description of when the symptoms began. MRI also shows microbleeds (very small hemorrhages), as well as tissue at risk. We can also use an MRA scan to get a picture of the vessels in the brain, allowing us to make safer treatment decisions.

What type of research on stroke are you conducting at Suburban Hospital?

One clinical trial being conducted by NINDS at Suburban Hospital involves “wake-up strokes.” This trial includes patients who wake up with the symptoms of a stroke. Because the time of symptom onset is unknown, these patients are not eligible for t-PA. NINDS researchers previously discovered that certain sequences on the MRI may help to determine if the age of the stroke is within the t-PA time window. Using this approach, doctors can then predict the age of lesions with about 80 percent sensitivity. If MRI characteristics meet these criteria, the patient may enroll in the study and receive t-PA.

A second study underway at Suburban Hospital involves the evaluation of the natural history of stroke. Patients who present to the Emergency Department with suspected acute stroke or TIA may be eligible for this study, which follows individuals to see how their lesions change over time with or without treatment with t-PA. The goal of this study is to better understand the natural history of stroke. Approximately 20 percent of stroke patients are eligible for this study. Those who enroll receive MRI at specific intervals after their strokes to assess changes over time. Through this study, we hope to learn more about stroke and obtain information that may serve as the basis for future diagnostic and treatment strategies.

What happens once a patient has been diagnosed with stroke?

After a stroke, the emphasis is on secondary stroke prevention. Approximately 10 percent of those who suffer a stroke will experience another stroke within a year and, depending on the cause of the initial stroke, this number can be even higher. Therefore, investigating the cause of stroke is extremely important in order to initiate secondary stroke prevention strategies, as recurrent stroke might be devastating. When a stroke patient is admitted to Suburban Hospital, our dedicated Stroke Team begins diagnostic studies to determine the cause and immediately initiates medication therapy aimed at secondary stroke prevention.

Can stroke be prevented?

The American Heart Association/American Stroke Association estimates that 80 percent of strokes can be prevented. Here’s what you can do to protect yourself:

  • Manage blood pressure and cholesterol levels
  • Control diabetes
  • Quit smoking
  • Identify and treat atrial fibrillation (Afib) – an irregular heartbeat
  • Maintain a low-fat, low-cholesterol, low-salt diet that includes plenty of fruits and vegetables
  • Exercise at least 30 minutes per day, five days per week

About Dr. Zurab Nadareishvili

Dr. Nadareishvili joined the Suburban Hospital Stroke Program in 2013. Formerly the assistant director of the Stroke Center at the George Washington University Hospital and assistant professor of neurology, Dr. Nadareishvili is a board-certified neurologist with subspecialty certification in vascular neurology by the American Board of Neurology and Psychiatry. He completed his neurology training at Georgetown University Hospital and a vascular neurology fellowship at the National Institute of Neurological Disorders and Stroke at NIH.

Dr. Nadareishvili is affiliated with Johns Hopkins Community Physicians – Downtown Bethesda. His office is located at 7315 Wisconsin Avenue in Bethesda. The phone number is 240-235-9120.

Clinicians are seeing an increasing number of younger individuals who are having strokes, including those under the age of 45. While this may be due to better diagnostic tools, it is also likely a result of other causes such as drug use, unhealthy lifestyles, and uncontrolled risk factors.

Know the warning signs of stroke. Remember the word FAST: Face, Arm, Speech, and Time.

  • Sudden numbness or weakness of the face, arm, or leg (especially on one side of the body)
  • Sudden confusion, trouble speaking or understanding speech
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of balance or coordination
  • Sudden severe headache with no known cause

If you or a loved one experiences any of these symptoms, do NOT call your primary care physician and wait for a call back. Call 911 and get to a hospital immediately. Time is of the essence when someone is experiencing a stroke.