 This is Think Tech Hawaii. Community matters here. Aloha. Welcome to Much More Medicine with Think Tech Hawaii. I'm your guest host today, Tom Forney. I'm an emergency physician with Hawaii Emergency Physicians Associated. And today we'll be discussing stroke care within Hawaii. I would like to introduce our guests, Dr. Kazuma Nakagawa, a neuro-intensivist and director of the Stroke Center with Queens Medical Center. As well as Jennifer Moran, APRN and stroke care coordinator. Welcome. Thank you both for being here. Thanks so much for having us. Yeah, thanks for inviting us. So there's been tremendous advances in stroke care over the past 10 to 15 years or so. But before we get into all the great advancements and everything that we've had, I'd love to hear some of the basics on what is stroke and how, what are some of the basis of it? Yeah, so stroke is a brain attack, it's a medical emergency. And it happens when there's a blockage, a sudden blockage of the blood vessels in the brain. And that part of the brain stops getting oxygen and blood flow and starts to cause this damage, permanent damage. And the thing is that damage can occur very quickly and starts to spread with time. And it's estimated that about 2 million brain cells are lost every minute during the stroke. So just to recap, if there's a blockage, the damage starts to form a very small area and then every minute it grows really fast. So if you can actually intervene and open up the blood vessel right away, that part of the brain can be restored and saved. But if you don't act quickly, there's a large area that could potentially be damaged permanently and cause a chronic disability. Yeah. And if we could load the first two images that we have, it shows a nice picture of... Okay. And it shows some nice pictures of how that goes. But that intervention, tell me more about it and kind of the need for acting quickly. Sure. So most of the blockage usually occurs from a blood clot or thrombus. And then since 1996, there has been an FDA-approved medication called a TPA. It's actually a tissue, a pleasant agent activator, but we call it TPA as abbreviation. And it's a clock-poster medication. It kind of works like a drain when your kitchen sink is clogged. You kind of give that medication and kind of dissolves and melt away the clot. That's how it works. And it works if you give it. The clot actually does sort of dissolve and melt away. But really it's not about whether the medication works or not, but whether we can actually give that medication fast enough. Because if you give it, but the brain tissue is already damaged, it's too late. You know, we can give that medication at most hospitals in the emergency department. And but we have to have a system in place. We have to have the right screening protocol and then the clinical pathway so that we can give the medication to the right people. Here, and I think we're actually bringing that first picture up, showing how many brain cells go. So describe this picture for me. So that is a picture of the brain. And in that bright spot you're seeing is probably the where the clot is located. And then that's the epicenter of the damage. So that's the part that starts the damage. And if you don't treat it, that area can grow with time. And then probably the next picture can show you that again here, immediately at time zero when the clot is formed, that dark area is a small little area that gets damaged. Again, if that's the only damage, then you can potentially walk away with no deficit. You can go back to your life of 100% recovery and move on. But if you don't intervene and give the treatment, that dead tissue grows, gets larger and larger. And then if you don't do anything about it, you're left with that large area of brain damage. And that leads to permanent weakness, speech problem, and disability. And in fact, stroke is considered a second leading cause of death globally worldwide. And in Hawaii, it's the third leading cause of death. And it's the non-grown cause of disability in the United States. And even if you survive stroke, it adds to both financial and emotional burden to the family and to society. And that's truly huge numbers of number three cause of death, number one cause of chronic disability. So it affects a lot of us. And the nice part is there's been tremendous advances over the past 15 years. Jen, I know you've been integral in the development of stroke centers throughout the state. Yeah, so we actually, the Queen's Medical Center in 2004 first became certified as a primary stroke center. We were certified as a primary stroke center for about 10 years and then became a comprehensive stroke center in December of 2016. Some of the differences between stroke centers and the importance of certification are with certification, it really holds you to a higher standard. So every patient every time is going to get that high standard of care. Adhering to clinical practice guidelines that are developed by the American Heart Association and American Stroke Association. And that's one reason it's important to maintain that certification to make sure that we're getting all the patients into the system so that they can get that quality care. Yeah, and so there's the, you said the comprehensive stroke center which you guys have obtained as well as multiple primary stroke centers. Congratulations, my understanding is that it's not easy to obtain. Right, so that's the highest certification that one can obtain and what it really means is that we can not only provide the IVTPA, the clot busting medicine, but also we can provide other forms of treatment. They've really come out with some new forms of treatment and the guidelines are really increasing on which patients we can choose and which patients we can treat. Helping us to determine which patients we can treat and make our patient selection very carefully has really decreased the risk that we're historically associated with TPA. Yeah, and with that, I think that's a nice transition into what is our treatment. And historically, I know you alluded to the thrombolytics being available in the 1990s, sometime in the 90s. And it's really gained more prominence over the past number of years. Tell me more about thrombolytics and its utility as well as some of the risks involved with stroke patients. Sure. So if a patient arrives at the hospital within four and a half hours of time last known well, they are typically able, the correct patients, to get the clot busting medication, the IVTPA that Dr. Nakagawa was speaking about. So it's really important time is brain because as we said, like 1.9 million brain cells are dying every minute that that brain is not getting blood flow or oxygen. So we try to do it very, very quickly. And we are able to give the IVTPA up until four and a half hours of time last known well, hopefully breaking up that blood clot and restoring blood flow to the brain, therefore kind of preventing the disability and death typically associated with stroke. So for our viewers watching this, what science should they watch for? If they're sitting at home watching this, what should they look for and say, OK, now I need to activate EMS and go into the same? Right. So we use an acronym. We use the acronym FAST to help people remember what to look for. So the F stands for facial droop. So you're looking for any asymmetry of the face. Ask someone to smile and see if one side is drooping or not. The A stands for arm. So you ask someone to hold both arms up. If one arm is weak, that could be a symptom of stroke. And S stands for speech. This could be the inability to speak. This could be slurred speech. Or this could be someone that's not understanding what you're saying to them. And the T is one of the most important ones. T is for time. Time to call 911. And we really want to emphasize that. That calling 911 is one of the most important things you can do to get the patient into the medical system, into the system of care. Excellent. Thank you. And so once they get into the medical system and visit an emergency room and see somebody like myself, we have to work together as a team to decide, does this patient need to have the TPA that you were mentioning? Fortunately, we have experts like Dr. Angawa to help us out. Tell me more about, we've talked about all the benefits. Are there any risks involved with the medication? So TPA does have some risk. Since it's a clot-busting medication, it can have the potential to cause bleeding. Like I said, because we are actually much better with our patient selection, then we're having much less risk of bleeding than historically we're done in the initial studies. So that's very good. We've taken away a lot of the limitations of the medication by correctly choosing those patients. And that's the point I'd like to elaborate on. This medicine has been available for 20 years now, but really only the last 10 years or so has it really gained much more momentum. And there was a lot of concern, at least within the emergency medicine world, of are we harming our patients and how much benefit is there? And as we've gotten better at selecting those patients, the risk involved has really plummeted. And so the true benefits to all of our patients has been increasing pretty rapidly. Yes. Yeah, we have seen some amazing results. Right after the medication, the patient starts walking and moving and talking. And like you said, like 10, 20 years ago, we, of course, as a physician, we don't want to harm anyone. So there's that hesitancy to give something that may be potentially harmful. But over the last 10 years, we've gotten so much more comfortable and confident with that medication. We know exactly who's at risk for bleeding. So really realistically, our bleeding rate here in the state is much lower than what's been quoted. And we feel very comfortable. And I also just want to emphasize what Jen had said that it's important to call 911 because a lot of people make a decision to start driving in themselves or drive their loved one in because they feel like, well, each one is wide open. We can start driving and it's only 20 minutes from my house. And then calling the ambulance is going to cause more delays. It's actually not the case. When the EMS shows up, they activate the system. They notify the emergency department physician and they call the stroke team. So when the patient shows up to the ER, there's going to be open. CT scanner's going to be open. The whole team's going to be there waiting for that patient. Whereas if they drive themselves in, they may be placed in the waiting area, be asked to wait in the triage area and so on. And that adds time. That could be five minutes, 10 minutes. And that could be the deal breaker. So I really want to emphasize to the audience here that it's extremely important to call 911. Absolutely. And you touched on a good point of you and your team have helped a number of the hospitals across the state really break down the barriers to that quick treatment of having EMS take the patient directly to the CT scanner to make sure there's nothing else going on to make sure that the patient is a good candidate for stroke, the quicker registration. Everything is happening so much more quickly now than even a couple of years ago that each extra minute that we save is tremendous. And, but all patients that look like they might be having a stroke aren't necessarily. Tell me a little bit more about some of the stroke mimics. Stroke mimics, sure. So sometimes a non-stroke neurological condition such as seizure, migraine or other condition can mimic stroke like symptoms. So that's why it's extremely important for an expert to assess the stroke patients before giving that medication. Like they have stroke mimics and give that medication, we could potentially harm them. That's why we have a clinical exam and also imaging technology to roll these things out. Absolutely. So it's not necessarily always so easy to determine, but using, being involved with experts like yourself to determine, yes, this patient actually has a stroke we need to give the medications versus not. How many patients are going through your department now and kind of how many stroke patients are seeing it on average at this point? So we actually see at Queen's Medical Center, we're seeing about 1,000 stroke patients a year. So quite a few. And I know just throughout the state there's typically about 3,000 stroke patients per year. So Hawaii does have a lot of stroke. Yeah, that's a significant number. And do you know how often you guys are, they get transferred to the Queen's Medical Center versus staying in their local hospitals if they're transferred into you? So we're actually trying to empower the local hospitals if they have the ability to treat, to go ahead and treat those patients and then keep them at their hospitals. We do want to transfer the patients transferred that need the higher level of care, the more advanced technology and services that we can offer. So really like making the proper patient selection is important for those patients. Yeah, and what are some of the criteria for that? When do you determine, say yes, this patient needs to be at the Comprehensive Stroke Care Center versus no, they could stay in their local community, say whether it's in Waimea on the Big Island or Molokai or whatever. Sure, so if the TPL, the clobbusting medications is all they need, they could potentially stay at that local hospital. Some hospitals can, but if they need further treatment, which I'm going to describe now, then they'll be transferred to a higher level of care such as Comprehensive Stroke Center. And just going back about the treatment, the TPA is a great drug, but in reality, only about a 30% of the patients benefit from TPA. So what happens to the other two third of the patients, they don't get better. They don't get worse, but they don't get better. And the question is why? In reality, if the clot is so big, if it's so big, the medication's not enough to dissolve the clot. Back to the plumbing example, if the blockage is so bad, the drain is not going to cut it, you're going to get a rotator to take it out. That's what we need to do. So over the last 10 years, we've developed this technology where we can actually do a minimally invasive, really like a neurosurgical procedure where we can thread a catheter, a wire from the groin, all the way through the body, through the heart, through the neck, to the brain, find the clot, and really grab the clot and yank it out, and we can do that. But that requires an expert who's well trained, long years of training to do that procedure, and only a Comprehensive Stroke Center can provide that 24-7. And so anyone with a severe stroke with a big clot that's seen on the CAT scan gets potentially transferred to a place like ours and provide that service. That's fascinating. I think let's show some images about how that's done after the break and discuss more about that new technology. Sounds great. Thank you all for watching, much more about medicine with Think Tech Hawaii. We'll see you in a minute. This is Think Tech Hawaii, raising public awareness. Children, adults, and veterans of all abilities escape gravity right here on Earth. Search diveheart.org and imagine the possibilities in your life. I just walked by and I said, what's happening, guys? They told me they were making music. Aloha, my name is Mark Shklav. I am the host of Think Tech Hawaii's Law Across the Sea. Law Across the Sea comes on every other Monday at 11 a.m. Please join us. I like to bring in guests that talk about all types of things that come across the sea to Hawaii, not just law, love, people, ideas, history. Please join us for Law Across the Sea, ala. Aloha, welcome back to Much More Medicine with Think Tech Hawaii. I'm your guest host today, Tom Forney. We're having a discussion today regarding stroke care within Hawaii. And I'd like to reintroduce our guests. We have Dr. Kazuma Nakagawa, a neuro-intensivist with the Queen Stroke Center, as well as Jennifer Moran, APRN, who is the stroke care coordinator. Thank you both for being here. As we left to go to the break, we started having a discussion about some of the new treatments for large clots. If we could go ahead and upload the image in Induction Gala, if you could please discuss more, please. Sure. So if there is a large clot that goes into the brain, the medication, the clot buster medication, usually doesn't work. Actually it works about 10% of the time, but most of the time it doesn't. So we can actually go up to the brain through a small guide wire and micro catheter, which we can access from the growing site and basically thread that wire all the way from the growing, through the body, through the heart, through the neck and all the way to the brain and find that clot. And we can deploy a stent retrieval device. It actually acts like a stent and then basically grabs the clot and then we can yank it out. And then this is what the device looks like. And then this is what the actual clot looks like after we pull out the clot in the brain. And if you go to the next picture, you can probably see this CAT scan. Here we go. Before the treatment, so this is the CAT scan in the brain. It's a mirror image. One side is the left. One side is the right. But that yellow arrow points the occlusion, the blockage of the blood flow to that part of the brain. And then after we perform the treatment, you can see the respiration of the blood flow. Now it's symmetric. So now that side of the brain is getting adequate blood flow. And that patient did well, I think was a woman who walked out of the hospital with a minimal deficit, if not 100%. Yeah, that's truly amazing. And there's been some, obviously the new technology of being able to do the thrombectomy. I think the focus on large vessel occlusions has really changed our management of stroke here tremendously. Tell me more about the, both how do we select our patients who potentially are having a large vessel occlusion? How do we find them? And then also some of the time frames for treating them that are different than the typical stroke patient. So until recently, oh, this device existed for, or the older generation exists for about a decade, but we have failed to show efficacy because we weren't very good about choosing the good candidate, the people who'd actually benefit from the procedure. So we often did procedure when the case was too late perhaps. And then over the last five years, we've gotten much better at that. But until very recently, until actually last year, we were offering this treatment up to six dollars from the symptom onset. So, which is actually longer than TPA, so which is great. So if the symptom onset occurred anywhere from four and a half hours, which is a TPA cut off to six hours, we could still provide that treatment. And also some people with a blood thinning medication or recent surgery, which are both contraindication for clot buster medication, we could still do that procedure. So people who had a stroke right after big surgery can still get that procedure, which is great. Unfortunately, there are a lot of people who wake up with a stroke. So they went to sleep around 9 p.m. and woke up around 6 a.m. with a big stroke deficit. So the way we calculate or count the time is from the last time that person was seen normal. So if that person went to sleep at 9 p.m., the symptom onset was counted as 9 p.m. So that person would have been excluded from the procedure. And a lot of people woke up with a stroke and was left out. But now over the last year, we've gotten much better at identifying even people who woke up with a stroke, people who had a deficit 24 hours ago could potentially benefit. And that's through the advancement in the neuroimaging technology. So advanced CAT scan or MRI, where we can truly find out people who still have brain tissue that are alive and salvaged. And by taking out the clot, they can still benefit. So not everyone's gonna get the treatment beyond six hours, but we've learned that even after six hours, there are many, many patients who can still benefit. So now the new guideline came out. Actually, then two trials came out last year that have shown that up to 24 hours people benefit. And then with a 2018 ischemic stroke guideline, they highly recommend considering this procedure to 24 hours from symptom onset. So I mean, that's a tremendous change going from three hours only a few years ago to four and a half hours. And now we're getting it stretched out to 24 hours in the appropriate patient. And no medicine, there's some anatomical differences with the patients for up to 24 hours where there's good collateral blood flow. Is that correct? Right, so our brain blood vessels are formed differently. Everyone's different. And the more overlapping branch vessels we have, more likely you're gonna tolerate the lack of blood flow. So the example I gave is sort of like, if you have a beautiful backyard, you set up a sprinkler system where there's not much overlap. You have one over here, one over there, and then each sprinkler system's barely touching each other. If one goes down, that area dies really fast. But if you put a lot of sprinkler system, a lot of overlap, if one goes down, that grasp will stay clean for a long time. And that's the concept. Our brain has so many blood vessels. Some people have a lot of overlapping branches, some don't, and we can now identify those with a lot of overlapping branches and we provide that treatment to those people. So how do you guys decide? So say somebody shows up within that four and a half hour window. Are there criteria that you use to decide, hey, yes, this person is a thrombectomy candidate versus no, we'll give the traditional TPA? So our patients actually, you can get both treatments. It's not really an either or or. So if a patient shows up and they meet the criteria for getting the IV TPA, they go ahead and get that IV TPA. If they show signs of a large vessel occlusion, like the big bad stroke, both by imaging and also by clinical exam, those are the patients we then take to mechanical thrombectomy. So some patients will actually get both treatments. Some patients may only get one or the other. Excellent. And I think that transitions into some of the telestroke work that your organization has been doing as far as providing services to the rest of the state. Tell me more about the origination and how everything started with that. Sure. So maybe 10, 15 years ago in Hawaii, we really weren't giving a lot of TPAs just throughout the state. And there may be multiple reasons for that. Also, I think with a lack of comfort with that medication back then, but also other factors that are just limited number of neurologists and stroke experts in various hospitals. And without expertise, it was difficult to give that medication or make that decision to give that high risk procedure and whatnot. But with the technology, we can actually connect these hospitals to a tertiary center like Queens and we can access these patients remotely through telemedicine. So currently, we are covering approximately eight hospitals outside of Queens. So if they have a stroke on the big island or North Shore or anywhere, they can go to the closest hospital and if they bring that telemedicine camera, you'll see the stroke neurologist from Queens. So they don't have to drive 30 minutes to get to Queens to see us. That's how it works. And then really the trick is really making that really expert decision to see do the treatment or no treatment. Do we supplement the TPA with a procedure? Those are very advanced decision-making that we need to make and we really need to see the patient. So technology really overcome that barrier. And it honestly has been practice changing for myself working at some of the rural facilities throughout the state of, as you mentioned earlier, there are some risks involved with the thrombolytics. Making that decision to potentially save a patient but also potentially harm them is not an easy one to make. And so having your involvement with helping to make that decision has been very helpful. And I think it's also has reduced the overall variation. No longer is it each hospital, each emergency physician making a decision by themselves, it's making an end coordination with you and your colleagues to give the thrombolytics or not. And it's been an overwhelming success at least for my practice and helping to improve the patients. And if you wanna jump to the next picture, it essentially shows the way that works is there's a camera looking at the patient with you on the other end. And as you're able to actually see and evaluate the patient, it's almost the same as that you're being there in person. And if we go to the next slide, it shows the overall increase and actual telestroke, both the consultations and how often the thrombolytics are given. And the nice part is the overall utilization is increasing and on the rise so that whether you show up at a facility on the big island or Maui or the North Shore of Oahu, you're able to get the same stroke care as you would if you arrived at the Queens Medical Center and actually at the comprehensive stroke care. So it's has made a big impact over the past number of years. Unfortunately, we're running out of time. I would like to thank both of you for being here today. The care that you guys are providing through the stroke center, both at Queens and across the Strait has been truly amazing. Thank you both. I'd also like to thank much more on medicine as well as Think Tech Hawaii and our producers who produce this show. Thank you all. Aloha and Mahalo.