Health
Stroke patients reach hospital too late to get drug treatment

By Beverly Creamer
Advertiser Staff Writer

Stroke sufferers in Hawai'i aren't getting a life-saving drug, hailed five years ago as a "miracle" when it was first released, mostly because they are not reaching hospitals in time to receive the medicine.

"The drug TPA (tissue plasminogen activator) has revolutionized our idea of taking care of strokes," said Dr. Cherylee Chang, medical director of the Queen's Medical Center's Neuroscience Institute. "For the few who have gotten it, their lives have been changed dramatically. The problem continues to be we can't reach enough of our stroke patients. They still come in too late."

Fewer than five percent of stroke patients arrive at a hospital within the three hours during which TPA can be used to break up a blood clot, said Karen Seth, programs director for the American Heart Association's Operation Stroke.

The American Heart Association has issued repeated pleas that patients with any kind of stroke symptoms get to an emergency room as quickly as possible. Such symptoms include sudden numbness, especially on one side of the body, as well as sudden confusion or trouble speaking, walking or seeing.

"Stroke is a medical emergency," Seth said. "People need to get in. Every minute counts." Operation Stroke, a national program, is dedicated to educating the public about the importance of getting to a hospital immediately.

Dr. Stuart Pang, chief of neurology at Kaiser Permanente, believes patients who suffer stroke symptoms just aren't recognizing them or may be in denial that something is wrong. As a result, these patients may sit at home waiting to feel better instead of rushing by ambulance to the hospital.

Five years ago, TPA gave doctors their first hopeful medication for the immediate treatment of ischemic stroke, the most common type, which is caused by a blood clot lodged in the brain. Between 73 and 80 percent of strokes are of the ischemic type. With its ability to break up the clot so that brain tissue isn't cut off from a supply of oxygen, TPA can minimize the damage stroke can cause.

"But the impact for the vast number of stroke patients hasn't been as good as we like because we can't treat a large volume," Chang said.

While Queen's has carried the bulk of treatment for stroke because of its Neuroscience Institute that's dedicated to brain disorders, O'ahu's other medical centers also developed stroke teams and procedures for administering the drug.

At Straub Clinic & Hospital, there has been a decline in the use of TPA over the last five years, according to a spokesperson, while at Kaiser Permanente Medical Center the usage has always stayed fairly low.

An estimated 1,700 people suffer strokes in Hawai'i each year, with Queen's seeing about 830 of those cases. But so far this year, only one stroke patient a month has arrived at Queen's in time to receive TPA. Kaiser, too, has generally been able to administer the drug to only about one patient a month since it has been available.

"We continue to use it for people who meet the criteria and come in within three hours, but there's been no increased use of the drug," Pang said.

Physicians note that, during that precious three-hour window, the patient must get to the hospital, be assessed by a physician, receive a brain scan to analyze the type of stroke that's occurring and give a medical history to hospital personnel, to assure that there are no factors that suggest the treatment should not be used.

For example, TPA is not recommended for those who suffer a stroke caused by hemorrhaging — about 20 percent of cases — because it may encourage bleeding that could worsen the effect of the stroke. The treatment also is not recommended for those who:

• Are taking blood-thinning medication.
• Have a history of bleeding or hemorrhaging.
• Have suffered recent head trauma.

But there are other issues that may be keeping patients from getting TPA in a timely fashion.

The treatment can only be administered at hospitals that have CT-scan equipment available to perform a pre-TPA analysis of brain function. On O'ahu, that includes all centers except Kahuku Hospital and the Wai'anae Coast Comprehensive Health Care Center. The Maui Memorial Medical Center also offers TPA treatment on the Valley Isle.

Regulations governing the State Emergency Medical Services system require ambulances to take those suspected of suffering a stroke directly to the nearest medical center with a CT-scan, regardless of whether that hospital has a neurologist available. Patients cannot request a specific medical center unless it takes no more than 20 minutes extra for the round-trip.

Some of those close to the situation believe hospitals have not placed enough priority on the stroke treatment system, which is admittedly an expensive one.

Emergency room physicians may not be comfortable using TPA without the advice of a neurosurgeon, and not all hospitals have a neurosurgeon available 24 hours a day, 7 days a week, said Don Weisman, spokesman for the American Heart Association.

While the early studies showed that TPA must be administered within three hours to improve recovery, the latest wrinkle in treatment involves delivering the drug directly to the clot by use of delicate catheters manipulated by a specially trained neuro-radiologist.

This technique — available now at Queen's and Maui Memorial — stretches the TPA stroke treatment window from three to six hours.