Dimitri Sigounas, MD, discusses the new technologies surrounding stroke recognition and treatment, including the future development of portable devices that could assess stroke type and severity before the patient even arrives at the hospital.
Dr. Sigounas also explains the two different types of strokes (hemorrhagic and ischemic), stroke symptoms, and why it's crucial for stroke victims to seek care immediately in order to avoid brain cell death and reduced quality of life.
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Stroke Care: Treatment and Technology Update
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Learn more about Dimitri Sigounas, MD
Dimitri Sigounas, MD
Dimitri Sigounas, MD., is a neurosurgeon and interventional neuroradiologist at The GW Medical Faculty Associates and is affiliated with The George Washington University Hospital and GW Medical Faculty Associates.. He specializes in cerebrovascular disorders, including aneurysms, arteriovenous malformations (AVM's), vascular brain masses, carotid occlusive disease, and stroke.Learn more about Dimitri Sigounas, MD
Transcription:
Dr. Mike Smith, MD (Host): Welcome to GW Healthcast. I’m Dr. Mike Smith. The topic today is stroke care, treatment technology update. My guest is Dr. Dimitri Sigounas, MD. Dr. Sigounas is a neurosurgeon and interventional neuroradiologist and a member of the medical staff at the George Washington University Hospital and is affiliated with The George Washington University Hospital and GW Medical Faculty Associates. Dr. Sigounas, welcome to the show.
Dr. Dimitri Sigounas, MD (Guest): Thanks very much for having me Dr. Mike.
Dr. Smith: So, I have heard this phrase before and I think a lot of people have; “time is brain” when we are talking about stroke. Can you tell us a little bit what that means?
Dr. Sigounas: Absolutely. So, that’s a very, very sort of a short but very true statement. Time is brain, basically means that the cost of not treating a stroke, can be measured in many different ways. If we are talking about actual brain cells, every minute that a stroke is untreated; basically, means that you will lose the equivalent of two million brain cells per minute that is. If a stroke goes untreated, it can basically mean that your brain at the end of a stroke is the same as having a 36-year aging process happen. If you are a 44-year-old that has a stroke, at the end of the stroke; you have the brain of an 80-year-old. So, it is obviously a tremendous, tremendous issue with our population.
Dr. Smith: So we want to make sure that we recognize the stroke fast and we get into the treatment part of that as quick as possible and that’s what that means. Are we getting better at doing this Dr. Sigounas? Are doctors recognizing the symptoms quicker? Are people coming into the emergency room faster? Are we getting to the treatment part of a stroke quicker?
Dr. Sigounas: Dr. Mike, thankfully we are. We are making inroads and as you mentioned, the biggest concern is trying to figure out whether a patient is having a type of stroke that can be treated and that way kind of avoid this brain cell death that we are talking about. There is a big awareness campaign called FAST which is basically if you have a facial droop on one side, if you have weakness on one side of the body versus the other, if you have any slurred speech or speech issues, then it is time to act, then it’s time to get a patient to the hospital. It’s time to call EMS and EMS providers now realize based on the 2017 American Heart Association Guidelines that they need to get a patient to a comprehensive stroke center. A stroke center that can treat these strokes by trying to pull out any blockages in blood vessels and that way they can kind of maximize the chances for a patient to have some kind of recovery.
Dr. Smith: So, obviously, recognizing in the community, recognizing maybe a family member or yourself, right, having some of these symptoms, is really key. So, the patient takes- place an important role in getting to the hospital quickly and getting treated quickly. I think that’s an important point to always bring out and educate, but you mentioned that there were different types of strokes. Can you teach us a little bit about the types of strokes and how they are treated?
Dr. Sigounas: Sure, sure. So, there are two main types of strokes. The first type is called hemorrhagic, which basically means bleeding in the brain. And this basically makes up about 10% of all strokes. The vast majority are called ischemic strokes and constitute about 90% of all strokes and they basically mean that there is some foreign body or a clot which forms in a blood vessel in the brain and blocks blood from going to that part of the brain that it supplies. That basically means that no blood flow to that part of the brain gives no oxygen to that part of the brain and over time, that basically means that that part of the brain is going to suffocate and eventually die. So, those are the ones that we are talking about. We’re talking about going into blood vessels that are blocked with either fiber fatty plaque or some kind of clot and removing it physically.
Dr. Smith: So, when you see a patient, you know being an expert in treating patients with stroke; are you basically just looking at the clinical presentation or are there technologies that you are using in that initial workup to help decide what type of stroke that is and what course of treatment would be best?
Dr. Sigounas: Yes, so the technology that we use currently, are CAT scans and MRIs. CAT scans allow us to see what type of a stroke it is, whether it’s a bleed or whether it is a blockage in the blood vessel and a CAT scan with some kind of dye basically tells us where the blockage is, so we can go after it with what’s called angiography. And that’s a technique that I do where we basically take a small needle and insert it into one of the arteries of the legs and then go up with small plastic tubes called catheters into the blocked vessel and we basically fish out the blockage. We do that with one of two ways. We either use sort of an expandable pipe to kind of block the – excuse me to trap the clot and then pull it out or we use what’s sort of like a mini vacuum where we actually suck out the clot. And I do this in addition to a number of other interventionalists at George Washington to be able to sort of get to these patients quickly and open up the blood vessel in order to be able to restore flow.
Dr. Smith: So, keeping in the same idea of time is brain, right, how long are we talking about here, from the time that you are presented with a patient that you have diagnosed with a stroke and you send them to the CT scan and you diagnosed what type of stroke and then you finally get to treatment? What timeframe are we talking about here?
Dr. Sigounas: We typically try to get a patient in the emergency room, identified and up to the procedure room within anywhere between 15 and 30 minutes is our target. We have done this as quickly as ten minutes from when they hit the door. So, kind of in keeping with the time is brain paradigm, we are trying to get to these patients faster and faster and we are doing a better job of it but, again sort of the holy grail in terms of what we are looking for is to try to get these patients identified before they actually get to the hospital, to try to maybe find technologies which allow us to be able to figure out whether a patient is having a blockage and then we just wheel them straight to the procedure room. And those technologies are definitely in the works and they are something that hopefully will be available in the next few years.
Dr. Smith: And so, Dr. Sigounas, these new technologies would be used as we say in the field by say a paramedic or an EMT, and then they could convey that information to you and you would be ready to go right when they come into that door.
Dr. Sigounas: That’s exactly right. And these technologies would be something that would be portable, something that would basically be placed on a patient’s head to be able to detect where they are having a stroke, where they are having a blockage; to figure out what type of stroke it is and that way the EMTs will know exactly what types of hospitals to take these patients to, to make sure that they can undergo this removal of clot. Unfortunately, there are only select hospitals that have the ability and the resources to be able to treat these patients 24-7.
Dr. Smith: Right. I would like to impress upon the listeners, Dr. Sigounas, about how important time really is here so. Let me give you a couple of different scenarios and you can give us maybe an idea of what the outcomes would be. You have a patient that comes in, definitely it is a stroke. It’s the kind of stroke that’s a blockage. You get them in. You treat them within 10-15 minutes versus somebody who it takes longer to come in, longer to diagnose and maybe it’s an hour, hour and a half later that you finally get the treatment they need. Give us an idea of what is the different outcome between those two patients.
Dr. Sigounas: Sure. So, we talked about the burden in terms of brain cells lost per minute. Let me put it another way. Every hour that passes without a stroke patient being treated; means a 20% decrease in their ability to function independently. So, that hour may mean the difference between being able to get up in the morning, dress yourself, feed yourself, be able to go to work, to interact with family members and not being able to do that. And we are trying to figure out better ways to be able to extend that window, but unfortunately, right now, what we have is that the faster we can get to a patient, the more likely they are to be able to have that independent function.
Dr. Smith: Dr. Sigounas, in summary, what would you like people to know about stroke care?
Dr. Sigounas: I think the most important point is that this is obviously a huge problem with our population aging with having more cardiovascular disease. So, what we need to keep in mind is that stroke isn’t something that can impact a patient and we don’t have any tools to be able to fight back. It’s something that is not a lost cause. We’re basically, we are in the dawn of a new era where we have techniques and we have studies which show that if you get to these patients as quickly as possible in a reasonable amount of time; then we can actually change their outcomes. We can help them live as close to normal lives as we can. And I think that sort of being aware that you need to get to a hospital that can provide this kind of treatment is very key in trying to keep our population as happy and healthy as possible.
Dr. Smith: Time is brain. That’s what we started with and that’s what we are going to end with. Dr. Sigounas, thank you for the work that you are doing and thank you for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Sigounas or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment.
Physicians are independent practitioners who are not employees or agents of the George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians. This is Dr. Michael Smith. Thanks for listening.
Individual results may vary. There are risks associated with any surgical procedure. Talk with your doctor about these risks to find out if surgery is right for you.
Dr. Mike Smith, MD (Host): Welcome to GW Healthcast. I’m Dr. Mike Smith. The topic today is stroke care, treatment technology update. My guest is Dr. Dimitri Sigounas, MD. Dr. Sigounas is a neurosurgeon and interventional neuroradiologist and a member of the medical staff at the George Washington University Hospital and is affiliated with The George Washington University Hospital and GW Medical Faculty Associates. Dr. Sigounas, welcome to the show.
Dr. Dimitri Sigounas, MD (Guest): Thanks very much for having me Dr. Mike.
Dr. Smith: So, I have heard this phrase before and I think a lot of people have; “time is brain” when we are talking about stroke. Can you tell us a little bit what that means?
Dr. Sigounas: Absolutely. So, that’s a very, very sort of a short but very true statement. Time is brain, basically means that the cost of not treating a stroke, can be measured in many different ways. If we are talking about actual brain cells, every minute that a stroke is untreated; basically, means that you will lose the equivalent of two million brain cells per minute that is. If a stroke goes untreated, it can basically mean that your brain at the end of a stroke is the same as having a 36-year aging process happen. If you are a 44-year-old that has a stroke, at the end of the stroke; you have the brain of an 80-year-old. So, it is obviously a tremendous, tremendous issue with our population.
Dr. Smith: So we want to make sure that we recognize the stroke fast and we get into the treatment part of that as quick as possible and that’s what that means. Are we getting better at doing this Dr. Sigounas? Are doctors recognizing the symptoms quicker? Are people coming into the emergency room faster? Are we getting to the treatment part of a stroke quicker?
Dr. Sigounas: Dr. Mike, thankfully we are. We are making inroads and as you mentioned, the biggest concern is trying to figure out whether a patient is having a type of stroke that can be treated and that way kind of avoid this brain cell death that we are talking about. There is a big awareness campaign called FAST which is basically if you have a facial droop on one side, if you have weakness on one side of the body versus the other, if you have any slurred speech or speech issues, then it is time to act, then it’s time to get a patient to the hospital. It’s time to call EMS and EMS providers now realize based on the 2017 American Heart Association Guidelines that they need to get a patient to a comprehensive stroke center. A stroke center that can treat these strokes by trying to pull out any blockages in blood vessels and that way they can kind of maximize the chances for a patient to have some kind of recovery.
Dr. Smith: So, obviously, recognizing in the community, recognizing maybe a family member or yourself, right, having some of these symptoms, is really key. So, the patient takes- place an important role in getting to the hospital quickly and getting treated quickly. I think that’s an important point to always bring out and educate, but you mentioned that there were different types of strokes. Can you teach us a little bit about the types of strokes and how they are treated?
Dr. Sigounas: Sure, sure. So, there are two main types of strokes. The first type is called hemorrhagic, which basically means bleeding in the brain. And this basically makes up about 10% of all strokes. The vast majority are called ischemic strokes and constitute about 90% of all strokes and they basically mean that there is some foreign body or a clot which forms in a blood vessel in the brain and blocks blood from going to that part of the brain that it supplies. That basically means that no blood flow to that part of the brain gives no oxygen to that part of the brain and over time, that basically means that that part of the brain is going to suffocate and eventually die. So, those are the ones that we are talking about. We’re talking about going into blood vessels that are blocked with either fiber fatty plaque or some kind of clot and removing it physically.
Dr. Smith: So, when you see a patient, you know being an expert in treating patients with stroke; are you basically just looking at the clinical presentation or are there technologies that you are using in that initial workup to help decide what type of stroke that is and what course of treatment would be best?
Dr. Sigounas: Yes, so the technology that we use currently, are CAT scans and MRIs. CAT scans allow us to see what type of a stroke it is, whether it’s a bleed or whether it is a blockage in the blood vessel and a CAT scan with some kind of dye basically tells us where the blockage is, so we can go after it with what’s called angiography. And that’s a technique that I do where we basically take a small needle and insert it into one of the arteries of the legs and then go up with small plastic tubes called catheters into the blocked vessel and we basically fish out the blockage. We do that with one of two ways. We either use sort of an expandable pipe to kind of block the – excuse me to trap the clot and then pull it out or we use what’s sort of like a mini vacuum where we actually suck out the clot. And I do this in addition to a number of other interventionalists at George Washington to be able to sort of get to these patients quickly and open up the blood vessel in order to be able to restore flow.
Dr. Smith: So, keeping in the same idea of time is brain, right, how long are we talking about here, from the time that you are presented with a patient that you have diagnosed with a stroke and you send them to the CT scan and you diagnosed what type of stroke and then you finally get to treatment? What timeframe are we talking about here?
Dr. Sigounas: We typically try to get a patient in the emergency room, identified and up to the procedure room within anywhere between 15 and 30 minutes is our target. We have done this as quickly as ten minutes from when they hit the door. So, kind of in keeping with the time is brain paradigm, we are trying to get to these patients faster and faster and we are doing a better job of it but, again sort of the holy grail in terms of what we are looking for is to try to get these patients identified before they actually get to the hospital, to try to maybe find technologies which allow us to be able to figure out whether a patient is having a blockage and then we just wheel them straight to the procedure room. And those technologies are definitely in the works and they are something that hopefully will be available in the next few years.
Dr. Smith: And so, Dr. Sigounas, these new technologies would be used as we say in the field by say a paramedic or an EMT, and then they could convey that information to you and you would be ready to go right when they come into that door.
Dr. Sigounas: That’s exactly right. And these technologies would be something that would be portable, something that would basically be placed on a patient’s head to be able to detect where they are having a stroke, where they are having a blockage; to figure out what type of stroke it is and that way the EMTs will know exactly what types of hospitals to take these patients to, to make sure that they can undergo this removal of clot. Unfortunately, there are only select hospitals that have the ability and the resources to be able to treat these patients 24-7.
Dr. Smith: Right. I would like to impress upon the listeners, Dr. Sigounas, about how important time really is here so. Let me give you a couple of different scenarios and you can give us maybe an idea of what the outcomes would be. You have a patient that comes in, definitely it is a stroke. It’s the kind of stroke that’s a blockage. You get them in. You treat them within 10-15 minutes versus somebody who it takes longer to come in, longer to diagnose and maybe it’s an hour, hour and a half later that you finally get the treatment they need. Give us an idea of what is the different outcome between those two patients.
Dr. Sigounas: Sure. So, we talked about the burden in terms of brain cells lost per minute. Let me put it another way. Every hour that passes without a stroke patient being treated; means a 20% decrease in their ability to function independently. So, that hour may mean the difference between being able to get up in the morning, dress yourself, feed yourself, be able to go to work, to interact with family members and not being able to do that. And we are trying to figure out better ways to be able to extend that window, but unfortunately, right now, what we have is that the faster we can get to a patient, the more likely they are to be able to have that independent function.
Dr. Smith: Dr. Sigounas, in summary, what would you like people to know about stroke care?
Dr. Sigounas: I think the most important point is that this is obviously a huge problem with our population aging with having more cardiovascular disease. So, what we need to keep in mind is that stroke isn’t something that can impact a patient and we don’t have any tools to be able to fight back. It’s something that is not a lost cause. We’re basically, we are in the dawn of a new era where we have techniques and we have studies which show that if you get to these patients as quickly as possible in a reasonable amount of time; then we can actually change their outcomes. We can help them live as close to normal lives as we can. And I think that sort of being aware that you need to get to a hospital that can provide this kind of treatment is very key in trying to keep our population as happy and healthy as possible.
Dr. Smith: Time is brain. That’s what we started with and that’s what we are going to end with. Dr. Sigounas, thank you for the work that you are doing and thank you for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Sigounas or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment.
Physicians are independent practitioners who are not employees or agents of the George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians. This is Dr. Michael Smith. Thanks for listening.
Individual results may vary. There are risks associated with any surgical procedure. Talk with your doctor about these risks to find out if surgery is right for you.