Making San Francisco the Safest Place to Have a Stroke

I’m not the first person to say it: In ischemic stroke, time lost is brain lost. Or, said even more briefly, time is brain.

Each minute of lack of blood flow to the brain kills 1.9 million neurons. More dead brain tissue means greater physical and mental impairment going forward, and, of course, it can also mean death. By quickly treating stroke, we save lives and vastly improve quality of life.

The last decade has seen advancement in stroke triage and treatment, but there’s much room for improvement. The San Francisco Stroke Initiative proposes to link UCSF Moffitt Hospital and Zuckerberg San Francisco General Hospital, network their technologies, and outfit them with cutting-edge stroke treatment capacities. The goal is to radically improve the outcome of 90 percent of patients by treating them within 90 minutes of stroke onset.

Once the Initiative is in place, if someone suffers a stroke in the Bay Area and calls an ambulance, they will be treated by paramedics trained to manage remote visualization technologies linked to UCSF and ZSFG neurologists. For patients out of reach of those trained paramedics, the Initiative will provide dedicated ambulances equipped with CT scanners capable of performing non-contrast and CT protocols and sending those images ahead to UCSF and ZSFG for interpretation. Teleneurology examinations and prehospital imaging will allow intravenous tPA therapy to be initiated in the ambulance. We will develop a smartphone app for EMS to indicate which hospitals (both in- and outside the UCSF/ZSFG network) are capable of delivering comprehensive stroke care have facilities (such as, for example, X-ray angiography suites) immediately available for treatment of stroke patients, ensuring that they receive care as quickly as possible.

Patients will bypass the ER on arrival to the hub hospital and go directly to a “Stroke Suite of the Future” at ZSFG or UCSF. These suites will consist of an ultramodern biplane X-ray angiography machine capable of performing CT scans linked in-line to a 3T MRI scanner, which are scheduled to be installed at ZSFG in early 2017 and are pending for Moffitt. These rooms are unique to UCSF and ZSFG and will be the critical testing facilities for novel approaches to improving stroke diagnosis and treatment.

Instead of the current standard of moving patients around the hospital from imaging modality to imaging modality and department to department, these suites will allow all care to be delivered in one place, saving precious, lifesaving time. X-ray will be used for endovascular and percutaneous intervention and MRI will be used for brain viability assessment with modalities interleaved during the case as needed. This overall approach will minimize time to reperfusion and allow trouble-shooting in difficult cases in order to optimize clinical outcomes. Patients will recover in dedicated neurological intensive care units at the hub hospitals. The episodes of care will be completed either with patients going directly home or to rehabilitation with our partners, for example, at St. Mary’s Hospital or Kaiser.

Together, these steps will cut invaluable minutes from our response time to strokes. They will make our goal of treating 90 percent of patients within 90 minutes of stroke onset not just achievable, but a brain-saving, and potentially life-saving, imperative. Time lost to stroke is brain lost. And time gained in treatment is brain, and lives, saved.

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