"Door-to-needle time" time is common terminology when talking about stroke treatment -- meaning how long it takes to triage, examine, image and start therapy on a patient who has been diagnosed with stroke. "The brain is dying while a stroke is taking place," explains Craig Kemper M.D., neurosurgeon and director of the Brain & Spine Center at Brackenridge Hospital, "which is why a quick and efficient response is critical. There are many conditions that can be confused with an ongoing stroke, and every minute wasted means more brain tissue is being destroyed."

Considering stroke is the third leading cause of death and the leading cause of disability among adults nationwide, clinicians and administrators at Brackenridge Hospital decided six years ago to lead a charge in Central Texas and implement a Stroke Program. That program was recognized in 2003 by the Joint Commission of Healthcare Organizations as the first approved Stroke Center in Texas. Seton Medical Center Austin also has a certified Stroke Program.

"In our program, a patient who is suspected of having a stroke is immediately handed over in the ER to the Stroke Team who specializes in expediting the steps and understands medically exactly what to do. The first step is to figure out if in fact a stroke is taking place, and if so, what kind of stroke, so we can start intravenous treatment or operate if necessary," says Dr. Kemper. The "door to needle" time at the acute care centers in the Seton Family of Hospitals is less than one hour in most cases.

High definition imaging is used to determine the what, where and why the patient is having stroke symptoms. Typically, patients first receive a specialized CT (computed tomography) scan that enables doctors to view the stroke, areas of restricted blood flow, and even visualize clots in an artery that may be causing the stroke.

"The majority of strokes that we treat are ischemic, meaning the blockage of blood flow is caused by a clot of blood and/or tissue. These can be treated with an intravenous medication (t-PA) as long as not more than three hours have passed since the stroke commenced," explains Dr. Kemper. T-PA (Tissue Plasminogen Activator) is a powerful clot-busting medicine given intravenously that was approved for use in 1996. Losing that window of opportunity for treatment because either a patient delayed seeking medical attention or the stroke was not properly and quickly diagnosed is a huge loss, given the high effectiveness of the TPA therapy when used correctly.

The remaining strokes are caused by a cerebral hemorrhage when a blood vessel bursts and causes bleeding inside the brain. These can be repaired with surgery. In addition to surgery or intravenous medication therapy for the treatment of stroke, the area of neuroradiology offers patients many new exciting options that are minimally invasive with great outcomes. "We have been very successful in the Brain & Spine Center of Brackenridge using neuroradiology to treat other conditions of the nervous system such as tumors. It is an area of medical science that offers great potential in evolving treatments for stroke," says Dr. Kemper.

The benefits for having a Stroke Program in place are many for the Seton Family of Hospitals. In addition to having well-documented treatment protocols in place, the presence of the Stroke Program encourages more outreach and research projects. In the area of outreach, "we were approached by hospitals in New Braunfels and Kerrville to help them create a treatment program for stroke," explains Kemper. "We call it our 'Drip and Ship' program."

Research is another important component of the Stroke Program as a strategy to continually seek new, more advanced approaches to care. "We have a clinical trial ongoing that uses Malaysian Pit Viper venom as an alternative to the TPA drug therapy. Using the viper venom doubles the window of opportunity to begin treatment from three hours to six hours," explains Dr. Kemper. The Brain & Spine Center is involved in a variety of clinical trials, collaborating with physician groups and The University of Texas Medical Branch that focus on finding ways to get the nervous system to repair itself and reprogram tissue after a medical emergency or trauma has taken place.

Craig Kemper, MD

Director, Brain and Spine Center, Brackenridge Hospital

Austin Brain and Spine

Dr. Kemper completed his residency at Vanderbilt University in 1994 and has been in private practice in Austin since 1996. He is Board Certified, American Board of Neurological Surgeons, and is a Fellow of the American College of Surgeons. Dr. Kemper is the Medical Director of The Brain & Spine Center, Neurosciences at Brackenridge.

Stroke Symptoms and Warning Signs

• Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
• Sudden confusion, trouble speaking or understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden, severe headache with no known cause

Source: Dr. Darryl Camp, director Stroke Program, Brain and Spine Center of Brackenridge Hospital, Austin, Texas

Drip and Ship programs

The Drip and Ship program was designed by clinicians at the Brain & Spine Center at Brackenridge Hospital. The name refers to the program's most important goals - to ensure that timely treatment is started in the emergency department and patients are rapidly transported to a higher level of care, such as the Stroke Centers at Brackenridge Hospital or Seton Medical Center Austin.

A typical scenario involves a patient who presents in a rural hospital emergency department with stroke symptoms. Staff in that ER conduct a CT scan and those images from the CT scanned are sent digitally to the neuroradiology team in Austin. Treatment options are reviewed and instructions given to the local ER group on how to proceed. Most often, those patients are then air-lifted to Austin while the intravenous treatment is in progress. "Once we are able to treat them thoroughly and stabilize them, they return home for whatever rehab they will need as part of their recovery. The objective is to give them the most advanced care possible, but return them back to their home hospital for follow-up," explains Dr. Kemper.

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