May 21, 2019

Riverside’s Continuing Excellence in Stroke Care

Since its designation in 2015 as a Comprehensive Stroke Center by DNV GL Healthcare – the first health care system in Hampton Roads to earn that distinction – Riverside Health System has continued to expand its ability to offer the highest level of care for stroke patients. Now Riverside Regional Medical Center, the flagship hospital of Riverside Health System, has added another tool to its arsenal in the diagnosis and treatment of stroke patients.  

In the spring of 2018, Riverside acquired the iSchemaView RAPID technology, currently the most advanced visualization software for brain perfusion. “RAPID is a fully automated program that allows us to assess the extent and severity of patients’ strokes far more quickly than ever before,” says Dr. Pankajavalli Ramakrishnan, a Riverside stroke neurologist and neurointerventional specialist. The RAPID software creates high-quality images from CT, CT angiography, CT perfusion and MRI diffusion studies and provides visual results, clearly showing areas of the brain that have been irreparably damaged and areas that might still be saved by restoring blood flow. “It gives us critical information – literally within seconds – that helps us determine which patients would benefit from immediate thrombectomy, even those patients who might be beyond six hours after last-known-well. We can now make that decision within minutes.”

When they acquired the new software, Riverside neurointerventionalists already knew that opening blocked arteries has been shown to favor those patients who still had more brain to lose than had already been lost. The DAWN trial, which came out at the end of 2017, demonstrated that “among patients with acute stroke who had last been known to be well 6 to 24 hours earlier, and who had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone.” A subsequent trial, the DEFUSE 3, published in the Feb. 22, 2018 edition of New England Journal of Medicine concluded that “endovascular thrombectomy for ischemic stroke 6 to 16 hours after a patient was last known to be well, plus standard medical therapy, resulted in better functional outcomes than standard medical therapy alone, among patients with proximal middle-cerebral-artery or internal-carotid arterial occasion and a region of tissue that was ischemic but not yet infarcted.”

RAPID was the exclusive imaging tool used to aid in patient selection in both studies. The results of the studies helped change the American Heart Association and American Stroke Association’s stroke guidelines to include CT perfusion and MR perfusion. 

The question has always been how to quickly determine the ratio of dead to salvageable brain, in enough time to intervene. With the RAPID software, that information is readily available on any screen – computer, tablet or smart phone – the physician has at hand. “It’s obvious and straightforward,” Dr. Ramakrishnan says. “The images show two versions of the brain spheres. On one version, the dead areas show up as pink on the screen, and on the other, the still viable tissue is green. This allows us to determine if there is enough brain available to save, or if removing the blood clot would offer no meaningful chance of restoring blood flow to brain. In stroke cases, when time equals brain function, this is an outstanding advance that will help us extend and even save lives.”

The RAPID software is a tool, Dr. Ramakrishnan emphasizes, and like any tool, it’s only as good as its users. But with the acquisition of this advance in the treatment of both certain and suspected stroke victims, Riverside’s Comprehensive Stroke Center is reducing the “speed to decision” time from hours to generally less than two minutes for actionable results. In stroke care, when time equals brain function, this is an extraordinary benefit to patients in our Hampton Roads communities. In the coming months, Riverside plans to implement this technology in its four community hospitals: Riverside Doctors’ Hospital Williamsburg, Riverside Walter Reed Hospital in the Middle Peninsula, Riverside Shore Memorial Hospital on the Eastern Shore and Riverside Tappahannock Hospital.