Health Quest’s new Division of NeuroInterventional Surgery leverages medical expertise and technological innovation to improve regional access to advanced stroke care and endovascular treatments for aneurysm and vascular malformations of the brain.
With the opening of its new NeuroInterventional Surgery service in February, featuring Alison J. Nohara, MD, Director of NeuroInterventional Surgery, and a multimillion-dollar investment in a Siemens Artis Q biplane angiography suite, Health Quest has radically changed the treatment options for stroke patients in the Mid-Hudson Valley region.
There was a time not too long ago when there was no effective treatment for an acute stroke. If the patient survived the stroke, the focus was on coping with its devastating effects and minimizing the risk of reoccurrence. Starting in the mid-1990s, options for intervening during a stroke became available, beginning with the FDA approval of tissue plasminogen activator (tPA) in 1996 and continuing with the introduction of various neurointerventional techniques for revascularization and thrombectomy of ischemic stroke and coil embolization of hemorrhagic (aneurysmal) stroke. Coupled with biplane angiography, state-of-the art stroke treatment now aims to stop a stroke while it is happening.
Because these treatments require state-of-the art equipment and neurointerventional surgeons, who still number fewer than a thousand nationwide, this high level of treatment has been limited mainly to large university and urban hospitals. In the Mid-Hudson region, those suffering stroke symptoms — approximately 750 people in 2014 — have had to travel to Albany or Westchester for neurointerventional treatment. Given the limited time window for neurointerventional procedures, that drive time alone can make them ineligible for treatment.
To remedy that situation, Health Quest has made a multimillion-dollar commitment to build on its existing stroke services — Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center have all been designated as stroke centers by the New York State Department of Health, and Vassar Brothers Medical Center has been designated a Primary Stroke Center by The Joint Commission — by bringing national-level stroke technology and thoroughly trained and experienced neurointerventional surgeons to the Mid-Hudson region. Regional physicians will no longer have to send their patients out of the region for neurointerventional treatment.
After an extensive nationwide search, Health Quest successfully recruited Dr. Nohara to help guide the development of its stroke program and lead its new Division of NeuroInterventional Surgery. Having completed a full three-year fellowship in neurointerventional radiology at the University of Virginia, Dr. Nohara has more than 10 years experience as a neurointerventional surgeon. She has worked in both academic and private practice settings, including an appointment as an assistant professor at Johns Hopkins University Hospital and five years in private practice in Tacoma, Washington. There, she worked as part of a team of three neurointerventional surgeons that covered two multi-hospital systems and performed approximately 600 neurointerventional procedures and more than 1,000 stroke consultations each year.
“My training and experience enable me to enhance the treatment provided in this community, and the support and commitment of Health Quest’s leadership confirm that I am in the right place,” Dr. Nohara says. “The coalescence of the latest innovative treatment capabilities, administrative support and medical expertise provides the perfect atmosphere for optimizing stroke care.”
To allow Dr. Nohara to make the greatest use of her skills and training, Health Quest has invested in the Siemens Artis Q biplane angiography suite, which provides superior high-contrast resolution.
The Siemens Artis Q, which provides superior high-contrast resolution, is housed in a newly designed space in Vassar Brothers Medical Center.
Introduced at the 2013 American College of Cardiology meeting, the Siemens Artis Q operates with flat emitter technology to produce precise imagery with low-dose radiation, which benefits both patients and clinicians.
Dr. Nohara looks at final images with a technologist after aneurysm coiling.
“Catheter-based stroke treatment relies heavily on the physician’s experience and knowledge of the brain’s anatomy, but the procedure is predicated upon the physician’s ability to see what is happening in the vessels — it’s critical to be in the right location,” Dr. Nohara says. “The biplane angiography suite provides real-time front and side images of the brain, which is a major advantage in these procedures. It reduces our contrast load and increases our speed of action. There is an art to endovascular stroke treatment, and the ability to assess your position in two planes is a necessity.
“This machine is a huge investment in infrastructure,” Dr. Nohara adds. “It speaks volumes about the administration here that they are committed to providing the most technologically advanced equipment on the market.”
The technology — while exciting — is only part of what it takes for a successful outcome. Equally important is the ability to select the appropriate treatment for each patient and make adjustments as the case evolves.
“Geriatric patients understand that stroke can be fatal, but they’re typically more concerned with debilitating consequences, such as being rendered without the ability to speak or move,” she says. “Their worst fear is becoming a burden to their families.”
Dr. Nohara has established protocols to mitigate cognitive and motor deficits and improve outcomes by expediting treatment once patients present at the hospital. TPA, which dissolves the blood clot and restores blood flow to the brain, is the only FDA-approved medication for stroke treatment. But the medication can only be provided within a narrow window of time after stroke.
“Approximately only 10–20 percent of patients suffering a stroke present within the three- to four-hour time window for tPA treatment,” Dr. Nohara says. “We are modifying our stroke protocols to be much more aggressive and deliver lifesaving therapy to more patients.”
When patients enter the hospital within an eight-hour period after the onset of a stroke, Dr. Nohara chooses from a vast armamentarium of treatment options, including intravenous tPA, which can be administered by any physician; intra-arterial tPA, which can only be administered by a neurointerventional surgeon; revascularization through angioplasty and stenting; and clot removal and retrieval.
“In general, any patient who is revascularized has a chance for better outcomes,” she says. “If one approach isn’t working, then I identify factors, such as anatomical irregularities or clot composition, and employ alternative methods to snare the clot. We can use a balloon to open up the vessel if necessary and are approximately 90 percent accurate in being able to take out the clot.”
Each clot-retrieval procedure is performed swiftly, with the procedure itself sometimes lasting less than five minutes.
“From a technical standpoint, these cases are challenging and require surgical excellence,” Dr. Nohara says. “Entering the vasculature and removing the clot must be done carefully to avoid complications. The body starts shutting down quickly after a stroke, and when you remove the clot and restore blood flow, the therapeutic effects are apparent. These interventions require precision and speed, and Health Quest has the physician expertise and technological advancements to provide the highest level of stroke care.”
Dr. Nohara discusses treatment with a patient.
Recent clinical trials validate the effectiveness of acute ischemic stroke treatments that combine tPA with embolectomy. Results of a study published in 2014 by The New England Journal of Medicine, “A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke,” identified positive outcomes in patients receiving tPA and neurointerventional treatments during a five-year trial period.
Researchers evaluated patients by the modified Rankin Score — a measure of disability after stroke or disabling neurological disorder — and found that combined tPA plus embolectomy intervention produced favorable outcomes when compared with tPA treatment alone.
Dr. Nohara (L) consults with a colleague about a patient.
“This study was a head-to-head, rigorous trial of tPA versus tPA plus embolectomy, and it showed that tPA with embolectomy is superior — a finding confirmed by studies soon to be reported from Australia, Canada and the U.S.” Dr. Nohara says. “The results show tPA combined with embolectomy produces positive outcomes in more patients than tPA alone.”
Dr. Nohara adds that treatment approaches are tailored to each patient, so not every stroke is treated with the combined approach.
“Patient selection is how we make the impact at this point,” she says. “We’re making enormous strides in stroke treatment, and I am very encouraged by the progress in the field.”
“The medical team at Health Quest collaborates to provide the highest level of stroke treatment. We’re making a difference, one patient at a time.”
— Alison J. Nohara, MD, Director of NeuroInterventional Surgery at Health Quest’s Vassar Brothers Medical Center
Partnering for Better Patient Care
Dr. Nohara reviews her schedule with an administrator at her office.
The bottom line for Mid-Hudson Valley physicians and their patients is that there is no longer a need to travel outside the region to receive the most advanced stroke and neurointerventional care possible. This can save lives in the case of a time-sensitive acute stroke, but it also can mean a better overall care experience for patients with non-acute conditions, such as intracranial stenosis or unruptured aneurysms, who can now remain within the region, among their network of physicians.
“I am happy to consult any physicians looking to improve the care of their patients, whether they have had a stroke or are at risk for one,” Dr. Nohara says. “We can arrange transfers from other hospitals to our lab and craft treatment plans tailored specifically to their patients. When patients are geographically close to their service providers, they are far more likely to seek and receive the long-term monitoring their conditions require, and referring physicians are better able to stay in the loop.”
Alison Nohara, MD, is the Director of NeuroInterventional Surgery for Health Quest.
Health Quest is constructing an easily navigable referral system that will begin with Northern Dutchess Hospital and Putnam Hospital Center, and will gradually roll out to other facilities.
“We are going to have one phone number for referrals to expedite the process,” Dr. Nohara says. “If a patient needs care, we will make it happen. We are here for that purpose — to best serve the medical needs of patients in the region. We are growing our services beyond our immediate geographic area in order to expand the number of people we can potentially help.”
For more information about neurointerventional surgical services and the stroke center at Health Quest, visit health-quest.org.