Prompt recognition, imaging, consult to a comprehensive stroke center, and treatment are imperative for saving brain tissue in acute stroke situations.1 Every minute that goes by is a minute that could change a patient's life forever. Every critical care nurse should remember the phrase "time is brain" when caring for a patient with a neurologic emergency such as acute ischemic stroke.
When interventional neurosurgeons began to treat patients with ischemic stroke with endovascular procedures, older, first-generation devices such as coil retrievers and aspiration devices were often difficult to use and caused damage to vessel walls.1 Several studies in 2013 reported that these devices were no more beneficial than medical care in acute stroke.2 However, with new stent-retrieval devices approved in 2012, evidence shows that these second-generation stent-retriever devices decrease disability after stroke.2
A great deal of literature speaks to the technical aspects of acute ischemic stroke intervention, as well as the treatment of acute stroke in the ED. There is a need for research that focuses on the role of the nurse in an interventional neuroradiology department during acute ischemic endovascular stroke intervention.
Background
Acute ischemic stroke occurs when an artery supplying blood to the brain becomes occluded, leading to the death of brain tissue and subsequent focal deficits.1 Alteplase, the I.V. recombinant tissue plasminogen activator (tPA), is indicated for treatment of acute ischemic stroke. The manufacturer's drug label states that alteplase must be given within 3 hours of symptom onset.3 However, recent studies suggest that tPA may be given within 4.5 hours of symptom onset.1,4 Many patients are unable to receive I.V. tPA because of its narrow time window or because they don't meet the eligibility criteria for the drug.1 Prior to acute stroke endovascular intervention, patients unable to receive I.V. tPA had to rely on conservative medical management. Endovascular intervention provides patients with an alternative option and further hope that they will avoid the debilitating effects of an acute stroke.
With the advancement of timely computed tomography (CT) angiography and perfusion studies, it can be determined if there is salvageable tissue, called penumbra. Acute ischemic stroke endovascular interventions can restore blood flow to the penumbra, reversing or limiting the disability that the patient may experience after a stroke.1
Significance
An estimated 700,000 to 800,000 ischemic strokes occur annually in the United States, costing more than $70 billion.1 Improving neurologic outcomes after an ischemic stroke is a major societal priority and has attracted the attention of clinicians and researchers, government funding agencies, and industry.1 But more important, stroke leaves patients with mild-to-severe disability. For every 5-minute delay in endovascular reperfusion, 1 out of 100 patients has a worse disability outcome, as measured by the modified Rankin Scale (mRS), which quantifies the degree of independence a patient achieves in his or her activities of daily living after an ischemic infarct.5
Communities are in need of comprehensive stroke centers with knowledgeable staff who can administer tPA and perform an acute ischemic stroke endovascular intervention if required. These procedures have been shown to reduce disability, but only if they are done in a timely manner.2
Recommendations
In an article by Gross and colleagues, the authors stress the importance of timely referral to stroke centers. They suggest that a telestroke consultation is one way to expedite the administration of fibrinolytic agents and determine whether transfer to a stroke center is necessary. The article also includes guidelines on when to obtain a CT scan; BP parameters; and the timely transfer to comprehensive stroke care if a patient is not eligible for I.V. tPA or the patient does not improve after I.V. tPA.6
Powers and colleagues state that endovascular intervention requires the patient to be at or transported to an experienced stroke center with systems that are designed for expeditious assessment and treatment.4 This focused update also states that reduced time from symptom onset to reperfusion with endovascular intervention is closely correlated with better clinical outcomes.4
A 2015 guideline published by the American Heart Association and the American Stroke Association focused on eight randomized, clinical trials of endovascular treatment and recommended that patients who are eligible for I.V. tPA should receive it. They also recommended patients receive endovascular intervention with a stent retriever as long as they meet certain guidelines (such as a prestroke mRS score of 0 to 1, or a National Institutes of Health Stroke Scale [NIHSS] score equal to or greater than 6) and time of stroke onset was within 6 hours of treatment.4 This study did not recommend the use of first generation devices and recommended that a vascular study be obtained, but did not find benefit of obtaining CT angiography or perfusion when selecting patients for endovascular intervention.
A similar study was performed involving 200 patients who were treated with a stent-retriever device in two trials. Researchers found that accelerated onset to reperfusion was associated with improved outcomes and reduced disability.5
Mehta and Watkins summarized the results of four other trials. All of the studies demonstrated that stent-retrieval devices were safe, highly effective, and reduced disability as long as the treatment could be delivered quickly.2
As members of the healthcare team strive to meet treatment goals for ischemic stroke, nurses serve as timekeepers and provide constant updates throughout the process. Clinical nurses must understand inclusion and exclusion criteria for mechanical thrombectomy and their organization's protocol and treatment criteria. Rapid and astute nursing assessment and preprocedural screening is indispensable for optimal patient outcomes and improved organizational metrics.2
Teamwork and roles in acute stroke care
This section provides an example of acute stroke care in a comprehensive stroke center, which involves a complex and dedicated team with distinctive roles who collaborate to provide timely and seamless care.
Telemedicine
The process begins when one of the community hospitals in the comprehensive network seeks an emergency consult with a vascular neurologist or neurosurgeon concerning a stroke patient. Most of the network hospitals are equipped with a robot that can be wheeled into the patient's room to give the physician visualization and the ability to communicate with the patient and his or her family. The physician can help make recommendations for I.V. tPA and recommend transfer if an endovascular intervention is warranted.
Transfer center
Once the telemedicine physician orders a transfer to the comprehensive stroke facility, the transfer center coordinates the patient's transportation by helicopter or ambulance. The nursing supervisor is notified and he or she initiates the neurovascular intervention team to report to the hospital to prepare for the patient.
INR nurse
The interventional neuroradiology (INR) nurse obtains report from the transferring hospital on the patient and distributes pertinent information to the surgical stroke team. The nurse then receives the patient from the transport team in a holding area that is in close proximity to the CT scanner, magnetic resonance imaging machine, and the interventional suite.
The patient is placed on a monitor to measure BP, pulse, and continuous ECG. The neurology and neurosurgical team complete the NIHSS and the patient is transported to the appropriate diagnostic scan.5 If there is a large vessel occlusion and reasonable penumbra determined by neurosurgery and the neuroradiologist, the patient and family are offered the option of an acute endovascular intervention.
The INR nurse then assists the anesthesia team into the procedure room, positions the patient on the table, and completes the appropriate paperwork. The INR nurse acts in a circulating nurse role, obtaining products for the technologists and surgeons and assisting the anesthesia provider. He or she has also received education in medications used during the procedure such as tPA or nicardipine, and in drawing an activating clotting time test to evaluate the effectiveness of heparin if indicated by the neurosurgeon. Postoperatively, the INR nurse and the anesthesia team transport the patient to the neuroscience ICU.
Neuroradiologic technologists
Neuroradiologic technologists are specially trained in endovascular neurosurgery. When called in for a stroke, they prepare a sterile tray and troubleshoot the biplane image guiding equipment. They assist the INR nurse in receiving the patient and getting the patient to the CT scan, and scrub in and serve as a valuable resource to the surgeon during the procedure. They film the procedure and communicate important times to the circulating nurse.
Neurosurgery
The neurosurgery team includes the in-house neurosurgical resident, the neuroendovascular fellow, and the neuroendovascular attending, who collaborate to read films, decide if an endovascular thrombectomy is warranted, and perform the procedure.
Neurology
A neurology resident and fellow evaluate acute stroke patients and consult with the neurosurgeon. If the patient does not qualify for an endovascular thrombectomy, the patient is managed medically by the neurology stroke team.
Anesthesia providers
The neurovascular anesthesiologist and neurovascular certified registered nurse anesthetist help the neurosurgery team determine whether local, moderate sedation, or general anesthesia is safest.
Neurophysiology
Neurophysiology staff participate in all procedures. Their role is to obtain baseline sensory signals and report deviation from baseline.
Stroke outreach and coordination
Stroke care is constantly evolving and adapting, and with a large program in place, communication is paramount to keep everyone on the same playing field. The stroke outreach coordinator is heavily involved in communicating with the telemedicine hospitals and facilitating patient access to the comprehensive stroke center. The stroke coordinator maintains comprehensive stroke certification, ensures currency with practice guidelines, and focuses on stroke care issues within the hospital. Both of these roles interpret data that are collected and constantly work to improve the stroke program.
Neuroscience ICU
Postoperative endovascular thrombectomy patients are taken to the neuroscience ICU and are cared for by neuroscience critical care nurses, acute care nurse practitioners, and physicians from neurosurgery and neurology. Alternatively, there is a stroke unit where noncritical stroke patients can be cared for by stroke-trained nurses.
Timing: The secret to success
When the acute stroke program was being developed in the interventional neurovascular department of the facility where I work, nurses began to record when stroke patients arrived and their arrival to CT scan time. When the comprehensive stroke certification process began, it started the hospital's mission to record and decrease door to needle times in order to ensure better outcomes for each patient. Keeping a log helped to identify delays in treatment, and nurses could participate in meetings with the stroke coordinator to resolve these barriers to prompt care.
Recording stroke times helps to identify issues in a program, trend success with patients, and assist with research. Currently, nurses in the facility where I work record the following: patient arrival to the interventional neurovascular department, neurosurgery arrival, neurology arrival, CT arrival, CT read time, when the procedure begins, groin sheath time, catheter initiation time, thrombolysis in cerebral infarction [TICI] score prior to treatment, preintervention time, door to treatment time, and the TICI score post intervention.
Conclusion
Endovascular intervention has become a mainstay of treatment for acute ischemic stroke. As facilities work to improve stroke care for their communities, nurses, nurse leaders, and NPs require increased education. It is important for healthcare providers to understand the urgency of acute ischemic stroke care so patients can be transferred to a facility capable of endovascular intervention as soon as possible.
Nurses who participate in acute stroke care need to take ownership of getting patients proper stroke care. As more neurointerventional suites are opened, nurses should feel empowered to take a "time is brain" approach and promote prompt treatment for stroke patients to improve outcomes.
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