For Stroke, 3 Specialized Services
Date: September 1, 2007
The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center may each have a stroke center, but the two operate as one—one exceptionally large, fully integrated cerebrovascular program. Faculty and residents rotate between two stroke clinics and two neuro intensive care units. There’s even a “stroke attending” on call 24/7.
The centers, each certified two years ago by the Joint Commission as primary stroke centers and re-certified this June, are overseen by Eric Aldrich at Hopkins Hospital and Rafael Llinas at Bayview. They provide highly specialized services not routinely available. Here are three examples.
TCD bubble test
About half the patients under 60 with stroke of unknown cause (cryptogenic stroke) have patent foramen ovale, but in a quarter of them, the PFO is insignificant. So who needs to have the hole, a remnant of the normal connection between the two sides of the heart that’s present before birth, closed? A simple outpatient test administered in clinic can determine the presence of a PFO as well as its clinical significance.
The transcranial doppler (TCD) bubble study is an ultrasound test in which agitated saline (micro air bubbles) is injected into an arm vein. If there is a PFO, the bubbles, or embolic signals, can be heard through probes placed at the temples. The test estimates the size of the PFO and thus helps predict its clinical significance as a possible cause of the stroke.
To close the hole, interventional cardiologists deploy a tiny, umbrella-like device (most often CardioSEAL or Starflex occluder) during a conventional cardiac catheterization.
Intra-arterial thrombolysis for CRAO
Central retinal artery occlusion (CRAO), the acute onset of blindness in one eye caused mainly by an embolism lodged in the central retinal artery, is among the most severe of ophthalmic events. Historically, it had been difficult to restore retinal blood flow; outcomes have been poor. “Now, though,” says Eric Aldrich, medical director of the stroke service, “we have the potential to do something about it.”
Candidates for intra-arterial thrombolysis are first evaluated by ophthalmologists at the Wilmer Eye Institute. Eligible candidates are then emergently referred to the stroke service, and interventional neuroradiologists perform a cerebral angiogram within 12 hours of onset of symptoms. Once the CRAO is confirmed, the thrombolytic agent—recombinant tissue plasminogen activator, or tPA—is infused via microcatheter into the proximal ophthalmic artery. “The technique doesn’t work every time,” says Aldrich. “But when it does, we’ve been able to dissolve blot clots and significantly improve vision.”
Comprehensive inpatient rehabilitation has long been a hallmark of stroke care at Johns Hopkins. The missing link—outpatient neuro-rehab—was added in 2006. Based at Hopkins Hospital, this program uses a coordinated, team approach to restore patients’ function and improve quality of life. “Everyone thinks you have a stroke and you’re done,” says Aldrich. “Rehab can help you get your life back.”
For rapid referrals, call the Hopkins Access Line: 410-955-9444 or 1-800-765-5447, and ask for the stroke attending on call. For outpatient cerebrovascular evaluation: 410-955-2228.