toledoblade.com --

Richard Dandino was knocking ice off the eaves of his South Toledo house when a blood clot lodged in the base of his head, causing a stroke.

His wife recognized his symptoms after Mr. Dandino stumbled back inside, and she had him rushed to the Medical College of Ohio Hospitals. Dr. Gretchen Tietjen, an MCO neurologist, said she doubted that he’d make it, but she injected Mr. Dandino with a clot-busting drug, Tissue Plasminogen Activator, more commonly known as tPA.

Within an hour, Mr. Dandino began to improve.

"We know he would have died if he hadn’t gotten it," said his wife, Patricia.

Each year 700,000 Americans have a stroke and 168,000 people die, making it the nation’s third-leading cause of death. A stroke occurs when a blood vessel in the brain either becomes blocked [the most common type of stroke], or bursts. Stroke is the leading cause of long-term disability, with more than 1 million Americans reporting difficulty walking or other problems because of a stroke.

But a review by The Blade found that how patients are treated for strokes can depend on the hospitals they end up at. Because of debates among physicians over proper stroke care, some hospitals follow treatment guidelines endorsed by the American Heart Association; others do not.

The Heart Association and many other organizations and physicians are urging hospitals to improve stroke care so that more patients such as Mr. Dandino make a full recovery.

One goal the organization seeks is the establishment of hospital stroke centers that have agreed-upon treatment guidelines. Another is the wider use of the clot-busting drug tPA. which was given to Mr. Dandino.

But some of the goals for improving stroke care are controversial, especially broadening the use of tPA. The American Academy of Emergency Medicine, representing emergency-room physicians, refuses to endorse tPA use, citing insufficient proof of its safety and effectiveness.

"We don’t know for sure whether the benefit outweighs the risk," said Dr. Tom Scaletta, an official with the academy and an emergency physician in a Chicago suburb.

Dr. Scaletta and many other emergency physicians argue that guidelines pushed by the American Heart Association and others are unproven and driven more by health-care marketing than science.

When the drugs work, "it’s very gratifying. You see [patients] get better in front of your eyes," said Dr. Dawn Kleindorfer, a neurologist in Cincinnati and a member of that area’s well-respected "stroke team."

Given within three hours of a stroke, the drug often dissolves clots and patients can make a full recovery.

In addition to a three-hour window for giving drugs such as tPA, Dr. Lee Schwamm, associate director of acute stroke service at Massachusetts General Hospital, said other therapies must be started as soon as physicians suspect a stroke. Dr. Schwamm said hospitals should have resources and procedures in place to evaluate patients.

"A lot of hospitals, while they have the individual resources, don’t have them set up in a coordinated, systematic approach so patients can get treated rapidly," he said. "Just because you have a CAT scan and a radiologist doesn’t mean you have it warmed up and ready to go and a radiologist there [on site]."

Dr. Schwamm has been pushing an initiative of his own that encourages doctors and hospitals to follow set protocols for every stroke patient. While not every patient will end up getting the same treatment, patients are evaluated the same way each time, he said, which reduces errors.

He follows a checklist when he treats patients. Many physicians frown upon such procedures as "cookie-cutter" medicine, but Dr. Schwamm insists the process works.

"Airline pilots who use a checklist don’t seem to appear to be offended every time they prepare for take off, even though we think they know how to do it after 20 years of practice. One way to ensure quality is redundancy," Dr. Schwamm said.

Some treatment guidelines have been put forward by the Brain Attack Coalition (www.stroke-site.org), a group of professional and government organizations dedicated to improving stroke care. The guidelines, which include a "checklist for communities," are supposed to help patients tell if their community or hospital offers quality stroke care.

Those guidelines include having a dedicated stroke team available at the hospital all day, every day; developing written stroke-care guidelines; having a neurologist on staff at all times, and ensuring that tests, such as computed axial tomography scans or magnetic resonance imaging, or MRI, are performed soon after arrival.

Dr. Scaletta scoffs at much of the Brain Attack Coalition efforts.

"I think creating this notion of a brain attack and stroke centers is a marketing campaign for academic neurologists," he said. "They want you to believe not any hospital is good enough. ... You know what? We don’t have any proof that’s true."

Dr. Scaletta said he views the disagreement as one mainly between neurologists who support tPA use and emergency physicians, who urge caution - or outright refuse to use tPA. However, some emergency physicians are more open to tPA and other Brain Attack Coalition guidelines. The American College of Emergency Physicians urges caution in the use of tPA but says physicians should consider the use of the substance.

A survey of metro Toledo hospitals by The Blade found many meet most of the Brain Attack guidelines for stroke treatment. Of those that do not meet some of the key ones, they have rules in place to allow transfer to hospitals that do.

MCO is the only area hospital that meets every guideline to the letter, Dr. Tietjen said. However, the area’s two largest hospitals - St. Vincent Mercy Medical Center and Toledo Hospital - meet almost all of them.

Right now, some hospitals have designated themselves stroke centers, but those moves are based more on marketing promotions than sound patient-care principles, said critics, including American Stroke Association officials.

Certifying facilities should help ensure stroke patients go to facilities best suited to care for them, said Dr. Robert Adams, a Georgia neurologist who is chairman of the American Stroke Association’s certification committee.

"Right now there’s no real guidance about how a patient might bypass one hospital and go to another one," Dr. Adams said.

Establishing a certification process might make sense, but that doesn’t mean there should be only one or two stroke centers in a community, said Dr. Paul DeSaint Victor, chairman of the emergency department at St. Vincent Mercy Medical Center in Toledo.

"As I look at stroke resources, they’re resources hospitals are already using," Dr. Victor said. "Every hospital can have that."

Dr. James Sander, chief of neurology at Toledo Hospital, agreed.

"I don’t think you can have just one stroke center. You need a bunch of them," Dr. Sander said. "Every hospital should have some capability of taking care of stroke patients."

Dr. Kleindorfer, the Cincinnati neurologist, has reservations about establishing JCAHO-approved stroke centers. "I wonder if proving you have the resources and actually doing it are two different things," she said.

Cincinnati has tried a different approach for stroke treatment, establishing a trained team of neurologists, emergency physicians, nurses, and others who respond to all cases of acute stroke. The team responds to strokes in all 17 hospitals in the Cincinnati metro area.

Dr. Kleindorfer, one of the members of the team, said the program has worked well despite intense rivalry among hospitals in the Cincinnati area.

"They don’t like each other, but ... the patient gets the best care and the hospital gets to keep the patient," Dr. Kleindorfer said, which avoids the fear that hospitals have of losing money to the stroke team. The team just helps coordinate care in the crucial first few hours, and then generally fades away, she said.

One crucial weapon in the team’s medical toolbox is tPA.

"We have lots of people we bring back from the brink of death" using the drug, she said.

But while establishing stroke centers and written guidelines are generally viewed by most physicians as sound moves, doctors such as Dr. Scaletta are deeply skeptical of tPA.

The drug has devastating side effects, including extensive bleeding or death in a small percentage of patients. For physicians trained under the Hippocratic Oath’s mantra of "first do no harm," injecting a drug into a patient that could potentially kill them is a risk some are unwilling to take.

"We’ve all seen people have hemorrhages and die from it," Dr. Sander said, adding that he thinks the importance of the drug has been oversold by some supporters. "It certainly has been shown to have some benefit, but unfortunately it’s not available to the majority of people who have strokes."

The primary reason, he said, is few patients reach the hospital in time to qualify for receiving tPA.

"People don’t understand that stroke is a medical emergency," Dr. Sander said, noting that many patients or their family members ignore stroke symptoms until it’s too late. Symptoms of a stroke include sudden numbness or weakness of the face, arm, or leg; sudden confusion or trouble speaking; vision problems; difficulties walking, or a severe headache with no known cause.

While patient ignorance is a factor, another problem is when strokes often occur, he said.

"What happens is many strokes occur in the morning, like 3, 4, or 5 a.m. So they wake up with a stroke and then we [doctors] don’t have a start time. Without that [a time to begin the three hour countdown for starting tPA] they automatically don’t become candidates," Dr. Sander said.

Because of such delays, the American Stroke Association reports that only 3 to 5 percent of those who suffer a stroke are considered candidates for tPA. Intensive research efforts are now under way to extend the three-hour window to as long as nine hours, as well as work to develop invasive techniques to remove blood clots.

The Blade review found tPA is widely available in the Toledo area, but it is used sparingly by local physicians both because of timing and other patient risk factors.

Permanent Link