By Wayne Clark, M.D.
Earlier this month, the OHSU Telemedicine Network treated two stroke cases that demonstrate how tele-stroke technology can assist in the development of new therapies and expand clinical research.
Case No. 1
A 51-year-old previously healthy businessman was brought to the Salem Hospital emergency room with stroke symptoms. Salem Hospital’s Peter Killefer, M.D., called OHSU and requested a tele-stroke consultation.
Hormozd Borzogchami, M.D.
Minutes later, OHSU stroke neurologist. Hormozd Borzorgchami, M.D., was examining the patient using a two-way audio-video robot that had been wheeled to the patient’s bedside. The exam showed the patient had suffered a very large stroke. He was unable to speak or move his right side. Dr. Borzorgchami talked to the family and learned they had last seen the patient two nights earlier. Unfortunately, he had been at home paralyzed and unable to seek help for more than 24 hours. He was far beyond the three-hour window for the standard clot buster treatment – t-PA.
The decision was made to transfer the patient to OHSU’s neurologic critical care unit for close observation and evaluation. Therefore, Dr. Borzorgchami discussed a new stroke treatment available at OHSU as part of a national multi-hospital research study.
This clinical trial involves the use of donor bone marrow cells to try and reduce stroke injury and improve patient recovery. The idea is based on the finding that when we are very young, the brain often recovers very well from injuries including stroke. As we get older, our ability to recover from a stroke and other injuries diminishes. The theory is the donor stem cells will travel to the brain and make the environment around the brain cells more like that of a young brain.
The study is testing whether the treatment will improve patient recovery and reduce the area of brain permanently damaged by a stroke. Using telemedicine technology, we were able to obtain an accurate patient history and examination, explain the study in detail to the family and obtain informed consent for the patient to participate in the study. This allowed us to enroll him in the trial and start the potential therapy rapidly upon his arrival at OHSU. The Salem patient has started to talk and can now hold up his right arm.
Case No. 2
A second case last week showed how tele-stroke and clinical trial research work together to offer the best care for the patient. A 82-year-old male with stroke symptoms was brought to Willamette Valley Medical Center. Timothy Brock, M.D., activated the telemedicine call with OHSU’s Andrew Rontal, M.D. Dr. Rontal’s tele-stroke evaluation found the patient was unable to speak and could barely move his right side.
In collaboration with Dr. Brock, a decision was to administer the t-PA clot buster therapy. This was started an hour and 20 minutes after the onset of the patient’s stroke symptoms. Administering t-PA so soon after a stroke occurs greatly improves the chances that the medication will work.
Since the patient was suffering major stroke symptoms, the medical team decided to transfer him to OHSU. Sometimes tPA alone doesn’t do the trick and OHSU has other tools for removing the clot – a process called a thrombectomy. As part of a research study, we also have a new imaging technique called CT perfusion that can help determine the size of the clot causing the stroke and assess whether there is still a portion of the brain that can be safely saved by removing the clot. Dr. Rontal discussed these issues with the family and they gave consent for the patient to be evaluated as part of this study.
Once again, tele-stroke was key to successfully using this intervention. Families usually cannot accompany a patient during the ambulance ride, so telemedicine allows us to immediately discuss the study with family and obtain their consent rather than waiting for them to arrive at OHSU. Fortunately for this patient, CT perfusion showed t-PA had done its job. The clot was gone and the patient’s brain was getting great blood flow. There was no need to use an additional clot removing technique. By the next morning, the patient was walking and talking almost normally.
Future potential applications
In addition to early examinations and speeding up the process of obtaining consents, telemedicine has other potential applications in clinical stroke research. One is to use telemedicine to perform follow up visits in the homes of patients who live too far away to easily return to our clinic. Another idea is to allow local small hospitals to participate in some of these state-of-the-art therapies by using telemedicine to supervise the administration of the study drug at these hospitals. Finally portable telemedicine units are available for ambulances. Novel stroke therapies could be given in the field under the direction of the telestroke specialist. This would really shorten the time after stroke onset to when therapy starts. This could be very important, because in the world of stroke treatment, time is brain.
Wayne Clark, M.D., is the director of the Oregon Stroke Center at the OHSU Brain Institute. Dr. Clark received his medical degree from Oregon Health & Science University and completed his neurology residency and stroke fellowship at the University of California at San Diego. Dr. Clark`s clinical interest is in the acute treatment of stroke, including the investigation of new potential stroke therapies.