A popularizing procedure among stroke centers was the basis of clinical research for the medical center, and is now improving in practice.
Daniel Labovitz, MD, MS
Montefiore Medical Center’s designation as an Advanced Comprehensive Stroke Center may have come this September, but the practices that led to the high distinction have been set in place for long before that.
The Bronx-based system’s in-house team of neurosurgeons, physicians, nurses, and specialty care providers have been at the forefront of a stroke care revolution since at least 2015, according to Daniel Labovitz, MD, MS, medical director of the stroke center and an associate professor of Neurology at the Albert Einstein College of Medicine.
In an interview with MD Magazine®, that was the year when published work indicated that patients individually and expeditiously chosen for mechanical thrombectomy of blood clots via catheter were likely to experience radical improvement prior to a stroke, with unlikely damage to blood vessels.
The discovery had punctuated a 20-plus year pursuit for the proper catheter-based stroke treatment, Labovitz said, and debunked more recently held beliefs that such a procedure was even feasible.
“We knew it sometimes made a difference, but sometimes we had trouble choosing who to pick, what intervention to do,” Labovitz explained. “We didn’t have the logistics right. It took some learning.”
Once they had perfected the procedure, the rates of use skyrocketed. At Montefiore, the mechanical thombectomy was used in 47 stroke procedures in 2015. It increased to 77 in the following year, then to 87 the year after. In 2018, the rate should exceed more than 100 procedures. Its success—currently a 97% success rate compared to the national average of 70%, according to Montefiore—and compelling promise in advancing care is enough to motivate the team, Labovitz said.
“Even though it means rousting people out of bed at 3 AM, it’s addictive,” Labovitz said. “We love doing it, because it has potential for such improvement.”
Since 1996, the stroke care team have been treating ischemic stroke patients with tissue plasminogen activator (tPA), the only treatment approved for such patients by the US Food and Drug Administration (FDA). The frequent failure in the procedure is in surgeon’s inability to remove blood clots. Combining procedures has given Montefiore the ability to significantly improve patient recoveries that result in them being responsive and improving within the same day.
Labovitz has noticed other healthcare systems following suit—regions are beginning to divert ambulatory patients to facilities with the team and resources capable of providing the new procedure. Though he noted there being a learning curve in having emergency medical service (EMS) teams correctly identify the right patient cases, Labovitz has faith in the procedure becoming common practice among emergency crews by next year.
“We think, perhaps in the first quarter of 2019, the fire department and ambulance service is going to start sending out cases to our facilities,” Labovitz said. “We’re going to be using a crude but highly predictive Los Angeles Motor Scale (LAMS), a good indicator of blockage near enough for us to reach in with a catheter and pull (clots) out.”
The team is also advancing care enough to learn that immediate, emergency care and diagnosis may not be integral to the process leading to thrombectomy. Since discovering the value of the procedure, Labovitz and colleagues have been capable of extending the window of care to 24 hours-plus. Acute stroke care, he noted, is not really dependent on identifying patients in a certain time window.
“We’ve learned some people progress rapidly and no matter what we can’t just help,” Labovitz said. “Other progress slowly, and we don’t know what the time variable can be.”
The complexities of invasively treating the brain, even when compared to the heart, made this progress far more difficult to master—an omelet that took a lot of broken eggs, Labovitz noted. Even now, it requires a team of highly trained radiologists and neurologists. It’s not something that can be expected of an emergency physician, which puts more stress on a team-based approach.
“It’s thrilling times, and it puts a burden not just on centers capable of thrombectomies, but hospitals unable to handle thrombectomy, to get patients out to right place to get the clot out,” Labovitz said.
The game-changing discovery and embrace of the procedure—both at Montefiore and across the country—makes the medical center’s new Advanced Comprehensive Stroke Center designation the perfect time stamp to advancing stroke care. As Labovitz noted, from humble trial-and-error in the 1990s, to newfound success, it’s an entirely new game they’re playing.