Memorial Hermann-Texas Medical Center
EMS FAST LANE
SPECIAL STROKE CARE ISSUE
Our Hospital Earns Recognition as a Primary Stroke Center
The state of Texas has designated the Memorial
Hermann-Texas Medical Center hospital as a “Primary
Stroke Center,” making our hospital the first in the
Texas Medical Center to receive this honor.
“To earn the designation, stroke centers like ours
have to meet certain standards to ensure that any
patient brought to the
Emergency department
will be treated rapidly with
approved therapies shown
to reduce paralysis and
other disabilities caused
by stroke,” said James
Grotta, M.D., co-medical
“Hospitals that are
director of the Mischer
named Primary Stroke
Neuroscience Institute,
Centers will work
chief of neurology at
Memorial Hermannin partnership with
TMC, and chairman of the
Emergency Medical
department of Neurology
Services to improve the
at The University of
timely care for patients,
Texas Medical School
reduce the burden of
at Houston.
stroke and improve
This designation is
survival outcomes.”
part of a new program
created by the Texas
Department of State Health Services to develop a
voluntary, statewide emergency treatment system
for stroke victims.
Hospitals that are named Primary Stroke Centers
will work in partnership with Emergency Medical
Services to improve the timely care for patients, reduce
the burden of stroke and improve survival outcomes.
In addition to our hospital, the department recognized
four other hospitals in the Memorial Hermann system
– Memorial Hermann The Woodlands, Memorial
Hermann Memorial City Medical Center, Memorial
Hermann Southwest and Memorial Hermann Katy.
“This designation speaks to the combination of
innovation and medical expertise from our partners at
the UT Medical School and the caring nurses and staff at
the Mischer Neuroscience Institute, who work diligently
to uphold the highest standards of care,” said Dr. Grotta.
“It reflects our continued commitment to safety and to
creating the best possible experiences for our patients.”
MNI Stroke Field Assessment Guide
Begun in 1988, the Stroke Center at Memorial Hermann-Texas
Medical Center has the longest track record of treating stroke
patients in the region. In 2000, the Center was the first to
advocate for, and work with EMS to establish, other stroke
centers in Houston, and the first to show that patients could
be safely triaged and treated at community hospitals before
being transferred to Memorial Hermann-TMC.
In conjunction with the development of stroke centers
around the city, the stroke team at Memorial Hermann-TMC
developed a field assessment tool to help paramedics
recognize stroke. Our Stroke Field Assessment Guide appears
on the last page of this newsletter.
The University of Texas
Medical School at Houston
4403042
MEMORIAL HERMANN-TEXAS MEDICAL CENTER EMS FAST LANE
Hypothermia May Improve Survival Rates for Stroke and
Other Neurological Injuries
Lowering the body temperature of patients may be an
effective way to reduce brain damage following stroke
and other types of neurological injury, including
trauma, says James C. Grotta, M.D., co-director of the
Mischer Neuroscience Institute, chief of neurology
at Memorial Hermann-Texas Medical Center and
chairman of the department of Neurology at
The University of Texas Medical School at Houston.
Dr. Grotta is principal investigator in a series of Phase
I trials currently under way at Memorial HermannTexas Medical Center to evaluate novel approaches,
including hypothermia, for treating and preventing
acute stroke. Induction of moderate hypothermia
(28°C to 32°C), has been
used successfully since
the 1950s to protect the
brain against ischemia
during open-heart
surgery. Based on its
neuro-protective effects,
therapeutic hypothermia
following cardiac arrest
was attempted in the late
1950s, but the practice
was soon abandoned
Dr. James C. Grotta, M.D.
due to problems with its
use. In 2002, successful
“Dr. Grotta and his
clinical trial results
colleagues are extending
prompted the Advanced
the use of therapeutic
Life Support Task
hypothermia from
Force of the American
Heart Association’s
cardiac arrest to stroke
International Liaison
patients with a five-year
Committee on
grant from the National
Resuscitation (ILCOR)
Institute of Neurological
to recommend that
Disorders and Stroke
patients be cooled to
(NINDS) at the National
32°C to 34°C for 12
Institutes of Health.”
to 24 hours following
cardiac arrest.
At Memorial Hermann-TMC and the UT Medical
School, hypothermia has been under investigation
since 2000, even before it was proven useful in the
treatment of cardiac arrest. “Cooling cardiac arrest
patients to 33 degrees Celsius to reduce brain damage
has been proven safe in studies at Memorial HermannTMC and around the world,” he says. “It’s effective
in reducing the risk of neurological damage and it’s
approved as a therapy, but unfortunately, it’s also
underutilized.”
Dr. Grotta and his colleagues are extending the
use of therapeutic hypothermia from cardiac arrest
to stroke patients with a five-year grant from the
National Institute of Neurological Disorders and
Stroke (NINDS) at the National Institutes of Health.
The grant is part of a NINDS program to establish 10
national centers focused on the rapid diagnosis and
effective treatment of stroke.
Memorial Hermann-TMC’s strong stroke trial
history makes it an ideal location for the NINDS
trials. Based on the success of previous trials of tPA,
a clot-dissolving drug, teams led by Dr. Grotta now
work with the Houston Fire Department and EMS to
administer tPA to more than 20 percent of patients
who present with ischemic stroke, far exceeding the
national average of 2 percent.
For more information about hypothermia as a treatment
for stroke and other neurological injury, e-mail Dr. Grotta
at james.c.grotta@uth.tmc.edu. Hypothermia in Stroke Treatment: Patient No. 14
Thirty-eight-year-old Cheryl Sorak was
securing her newborn daughter in
the rear seat of the car when she felt
something on her leg. “I looked down
and realized it was my hand,” she says.
“Then I realized I couldn’t move my
left arm.”
Sorak’s first thought was to call
her husband. “When I tried to stand
up to get my cell phone, I couldn’t
move my left leg. I fell out of the car
into the street. Someone stopped to
help. I could hear people talking but I
was disoriented. I heard someone say
we need to call 911. The next thing I
remember was the paramedics and the
ambulance.”
EMS rushed Sorak to the Stroke
Center at Memorial Hermann-Texas
Medical Center, where a medical
team led by James C. Grotta, M.D.,
successfully administers intravenous
tPA, a clot-dissolving drug, to 20 percent
of patients who present with ischemic
stroke. Sorak received tPA about
90 minutes after her stroke, well
within the three-hour treatment window.
When Dr. Grotta asked if she would
participate in a study investigating the
neuro-protective effects of hypothermia,
she and her husband agreed.
Funded by a five-year grant from
the National Institute of Neurological
Disorders and Stroke (NINDS), the
study is one of a series of trials currently
under way at Memorial Hermann-TMC
evaluating novel approaches for treating
and preventing acute stroke, including
hypothermia alone and in combination
with caffeine and ethanol.
Sorak was Patient No. 14 of the
20 who received the entire combination
– caffeine, ethanol and cooling – in
the Phase I trial. “I remember being
“I don’t know why I had the stroke. I didn’t have
high cholesterol or high blood pressure. I’d just
had my baby four months earlier, and I knew I was
healthy. I have to thank
the paramedics for correctly
diagnosing a stroke and
taking me to the right
hospital to handle it,
which saved time and
therefore saved me from
a life with disabilities.”
Sheryl Sorak and her family
ridiculously cold,” she says. “My teeth
were chattering. My joints hurt from
shaking so much. The treatment
seemed to last an eternity.”
In reality, Sorak was cooled for 24
hours. “After the cooling, I remember
a doctor coming in and asking me to
raise my left arm. I was fine.”
By the time she was evaluated for
rehabilitation, she had equal strength
in both hands. “I didn’t need rehab,”
she says. “I could tell that I had some
residual facial sagging and my speech
was a little slurred, but only people
who were close to me would have
noticed. After a couple of weeks those
signs were gone. I was able to button
the 15 tiny snaps on my daughter’s
pajamas and I thought if I could do
that, I could do just about anything.
“I don’t know why I had the stroke.
I didn’t have high cholesterol or high
blood pressure. I’d just had my baby
four months earlier, and I knew I was
healthy,” she says. “I have to thank the
paramedics for correctly diagnosing
a stroke and taking me to the right
hospital to handle it, which saved time
and therefore saved me from a life
with disabilities.”
MEMORIAL HERMANN-TEXAS MEDICAL CENTER EMS FAST LANE
Going Home: Dorothy Malone Regains Her Independence
Following acute care for stroke, a Houston woman benefits from innovative neurorehabilitative
technology and integrated care at Mischer Neuroscience Institute and TIRR Memorial Hermann.
Dorothy Malone was devastated when she suffered
a stroke in April 2008. “Before my stroke, I walked
on the treadmill every morning for an hour. I worked
out with a trainer and lifted weights twice a week.
I had a healthy diet and didn’t smoke or drink.
I was a very independent 78 year old.”
Previously diagnosed with atrial fibrillation,
Malone had tried a variety of antiarrhythmic
medications, including anticoagulants. When she
began having dizzy spells, she and her children
knew something was wrong.
“I was sitting on the sofa eating breakfast and
watching TV,” recalls Malone, who lives alone.
“When I tried to stand up, my knees buckled.
Then the phone started ringing. Both of my children
call me every day, and I knew it was one of them.”
When her mother didn’t answer the phone after
three calls, Molly Malone drove to the apartment.
“I knew something was wrong,” she says. “On the
way, I called a very close friend, Sue Porretto, and
asked her to meet me there. Mom had the door deadbolted, so I couldn’t get in. She heard me pounding on
the door and when I heard her voice – and knew she
was alive – I called 911.”
After the ambulance transport and a long wait in
the emergency room of another Houston hospital,
Porretto called Frank Yatsu, M.D., a neurologist
affiliated with Memorial Hermann-Texas Medical
Center and professor of neurology at The University of
Texas Medical School at Houston. Dr. Yatsu facilitated
Malone’s transfer to the Stroke Center at Mischer
Neuroscience Institute, where she was admitted on
April 8, 2008, under the care of neurologist Nicole
Gonzales, M.D., an assistant professor of neurology
at the UT Medical School. She was diagnosed with a
right middle cerebral artery stroke secondary to atrial
fibrillation.
When Malone was stabilized, she was transferred
to the hospital’s 23-bed inpatient neurorehabilitation
unit for comprehensive care and an aggressive
program of physical therapy, occupational
therapy and speech/language pathology. Mischer
Neurorehabilitation’s multidisciplinary team – a
physician, nurse practitioner, neuropsychologist,
rehabilitation nurse, case manager and social worker
for each patient – is led by Elizabeth Noser, M.D.,
medical director of neurorehabilitation for the
Memorial Hermann system. She and Nneka Ifejika,
M.D., directed Malone’s neurorehabilitative care.
“Mrs. Malone came to our service just four days
after her stroke,” says Dr. Ifejika, who is medical
director of neurorehabilitation at Memorial
Hermann-TMC and assistant professor and director
of neurorehabilitation at the UT Medical School.
“We believe the sooner you get to rehab following a
stroke, the better. Once a patient arrives on our unit,
we’re very aggressive with therapy.”
During her recovery, Malone benefited from The
Institute’s innovative neurorehabilitation technology,
including the Bioness® Foot Drop System. “The
Bioness Foot uses mild stimulation to lift the patient’s
foot to aid in walking,” Dr. Ifejika says. “With most
patients, return of use occurs in the leg gradually
from the hip on down. The foot tends to drop, which
puts people at risk for falls. The system helps patients
regain the use of the involved foot faster.”
Malone’s rehabilitation team also used the Bioness
Hand Rehabilitation System to speed the return of
wrist extension. She progressed well, was discharged
to her home in mid-May and began outpatient
rehabilitation at TIRR Memorial Hermann Kirby Glen.
At Kirby Glen,
Malone was one of the
first patients to use the
outpatient rehabilitation
facility’s Lokomat®, the
world’s first driven-gait
orthosis. Designed to
benefit patients with
neurological movement
disorders, the system
consists of the robotic
gait orthosis itself
and the Levi bodyweight support system
used in combination
with a treadmill. The
patient’s legs are guided
on the treadmill according to a preprogrammed
physiological gait pattern, which can be adjusted to
accommodate individual needs and rehabilitation
goals. Advantages of Lokomat-based therapy include
faster progress through longer and more intensive
training sessions compared to manual treadmill
training, ease of monitoring and assessment of
patient walking activity and improved motivation
through visualized performance feedback.
“I am determined to regain my independence,”
says Malone. The therapists at Kirby Glen and my
doctors – Dr. Elizabeth Noser, Dr. Nneka Ifejika and
Dr. Nicole Gonzales – are extraordinary. They are
truly healers of the body and the spirit.”
Molly Malone, who stayed at the hospital during
her mother’s inpatient rehabilitation, considers
it a positive experience. “We marveled at all the
positive things we saw happening around us in the
neurorehabilitation unit. There were many large and
small kindnesses that really make you want to give
back to that hospital. They focused on the entire
person – physically, mentally and spiritually – which
is how the hospital experience should be for everyone.
We would have been happier not to be there, but
we consider it a fantastic experience.”
“Mrs. Malone came
to our service just four
days after her stroke,”
says Nneka Ifejika, M.D.,
medical director of
neurorehabilitation.
“We believe the sooner
you get to rehab
following a stroke, the
better. Once a patient
arrives on our unit,
we’re very aggressive
with therapy.”
Dorothy Malone lives at home and continues to work
toward regaining her independence. A caregiver helps
with her daytime needs.
MEMORIAL HERMANN-TEXAS MEDICAL CENTER EMS FAST LANE
Neurocore: An Innovative IT Application Aids in Research,
Education and Practice Management
Using a specially designed clinical documentation
and communication program called Neurocore,
researchers at the Mischer Neuroscience Institute
are gathering patient data that will improve
knowledge of neurological illness and ultimately
change the way care is delivered.
Developed in Boston
by William Gormley,
M.D., and Dong H. Kim,
M.D., in conjunction
with Clearpath Solutions,
the Neurocore system is
a complete information
system environment
that runs the clinical
services in the ICU.
Neurocore is used to
digitally document
Dr. Dong H. Kim, M.D.
patients’ history,
examination findings,
Neurocore is being
plan of treatment and
put to use in the
outcomes. Neurocore
development of the
also interfaces with the
hospital information
Neuroscience Research
system, automatically
Repository, which will
downloading patients’
collect samples from
laboratory values as well
patients who consent to
as their vital signs. Upon
be included in the study
discharge, Neurocore
for clinical, genomic and
de-identifies patient
proteomic analysis.
data to create a research
database including
patient imaging data.
This capability to collect patient data in a standardized
manner enables researchers to search for patterns in
medical histories and track outcomes. “In addition to
its research platform, Neurocore functions as an acute
care and practice management system that includes
clinical documentation, billing support and workflow
enhancement at the point of care,” says Justin Smith,
president of Clearpath Solutions. “It has the capability
to analyze information with a narrow and deep
focus, making it particularly useful in specialties
like neuroscience.”
The system also offers clinical decision support
through imbedded protocols for the treatment of
specific conditions. “Neurocore facilitates research
and evidence-based medicine and also supports our
mission as a medical school and teaching hospital
to educate future leaders in neuroscience,” says
Dong H. Kim, M.D. “The system helps our residents
advance their knowledge and practice, and offers
us the opportunity to monitor adherence to and
departure from protocols, as well as change existing
protocols and introduce new ones.”
“Neurocore builds on the existing clinical
electronic record of the hospital by bringing us closer
to a larger and more integrated data warehouse,”
Dr. Kim says. “That datamart, along with other
technology improvements on the horizon, will help
us create an environment that promotes the best
delivery of care.”
RESEARCH
Thrombolytic Therapy for Patients Who Wake Up with Stroke
Following a retrospective database
review, researchers at Memorial
Hermann-Texas Medical Center and
The University of Texas Medical School
at Houston have concluded that
thrombolysis may be safe in wake-up
stroke (WUS) patients.1
“About 25 percent of ischemic stroke
patients awaken with their deficits,
which puts them outside the window for
tPA,” says principal investigator Andrew
D. Barreto, M.D., an assistant professor
in the department of Neurology at the
UT Medical School. “The purpose of
our study was to describe our stroke
centers’ experience with off-label,
compassionate thrombolysis for wakeup stroke patients.”
Investigators identified three
groups of ischemic stroke patients
retrospectively: WUS patients treated
with tPA, non-treated WUS patients and
patients treated with intravenous tPA
within the three-hour time window. Safety
and clinical outcome measures included
symptomatic intracerebral hemorrhage,
excellent outcome, favorable outcome
and mortality. Outcome measures were
controlled for baseline National Institutes
of Health Stroke Scale (NIHSS) using
logistic regression.
Forty-six thrombolysed and 34
non-thrombolysed WUS patients were
identified. Sixty-one percent (28 of 46)
of the treated WUS patients underwent
IV thrombolysis alone, and 30 percent
(14 of 46) were given only intra-arterial
thrombolysis. Four patients received both
intravenous and intra-arterial thrombolysis
(9 percent). Two symptomatic
intracerebral hemorrhages occurred in
treated WUS patients (4.3 percent).
Controlling for NIHSS imbalance,
treated WUS patients had higher rates
of excellent and favorable outcomes,
but higher mortality compared to nontreated WUS. A second comparison
controlling for baseline NIHSS between
treated WUS and 174 intravenous tPA
patients treated within three hours of
symptom onset showed no significant
differences in safety and clinical
outcomes.
“Based on the outcomes achieved
at our center, we believe our experience
supports considering a prospective,
randomized trial to assess the safety
and outcome of thrombolysis for wakeup stroke patients.
For more information on the study,
please contact Dr. Barreto at
713.500.7002 or andrew.d.barreto@
uth.tmc.edu. Andrew D. Barreto, M.D., Sheryl Martin-Schild,
M.D., Ph.D., Hen Hallevi, M.D., Miriam M.
Morales, B.S., Anitha T. Abraham, M.D., Nicole
R. Gonzales, M.D., Kachi Illoh, M.D., James
C. Grotta, M.D., and Sean I. Savitz, M.D.,
Thrombolytic Therapy for Patients Who Wake
Up with Stroke, Stroke. 2009;40:827.
1
Clinical Trials Extend the Stroke Treatment Window
The Stroke Center at Mischer
Neuroscience Institute (MNI) at Memorial
Hermann-Texas Medical Center and
The University of Texas Medical School at
Houston were the first in Texas to test and
use tPA for stroke patients within 3 hours
of onset. Today, the Center is extending
the window for stroke treatment to up to
3 days through a variety of clinical trials.
“Our Center is the only one in the
region conducting a large number of
research trials with two important goals
– amplifying what we can accomplish
using tPA and treating patients with
tPA beyond the 3- to 4.5-hour window
now established as safe and used at
most major stroke centers,” says James
C. Grotta, M.D., professor and chair of
the department of Neurology at the UT
Medical School and co-director of the
Mischer Neuroscience Institute. “We’re
also the only center in Houston doing
research focused on the treatment of
hemorrhagic stroke.”
Researchers at the Stroke Center are
investigating how to improve the benefit
of tPA by adding other agents and
procedures to the treatment regimen,
including argatroban, ultrasound,
mechanical clot extraction and brain
cooling. Clinical trials currently open
for enrollment include:
Stem Cells in Stroke Patients
Sponsored by the MNI Stroke Center,
this study is investigating the safety
of IV administration of stem cells taken
from the patient’s own bone marrow
in adults who have suffered an acute
ischemic stroke. Treatment must take
place within 72 hours. This is the first
human study of stem cells in stroke
RESEARCH
“Our Center is the only one in the region conducting
a large number of research trials with two important
goals – amplifying what we can accomplish using
tPA and treating patients with tPA beyond the 3- to
4.5-hour window now established as safe and used
at most major stroke centers.”
patients, an approach that has been
shown to reduce injury and promote
recovery in animal models.
Argatroban tPA Stroke Study (ARTSS)
Researchers are investigating the
safety of adding an IV infusion of
argatroban, a direct thrombin inhibitor,
in patients who qualify to receive tPA
within 4.5 hours of stroke onset. In
early studies, argatroban has doubled
the rate that a blocked artery opens.
The agent appears to be safe, but
more investigation is needed before
researchers can plan an efficacy study.
The trial is sponsored by the MNI Stroke
Center and the National Institute of
Neurological Disorders and Stroke
(NINDS)
The Interventional Management of
Stroke Trial (IMS-III)
Sponsored by the NINDS, this efficacy
study adds intra-arterial, catheter-based
clot removal to IV tPA compared to
standard IV tPA alone. Patients must
be treated within 3 hours of symptom
onset. IMS-III is the final, pivotal step
in determining if the combined IV and
intra-arterial approach is effective in
improving clinical outcomes.
Desmoteplase in Acute Stroke (DIAS 4)
This efficacy study is determining
whether the potent IV clot-busting drug
desmoteplase improves outcomes in
patients who arrive in the emergency
department too late for IV tPA but within
9 hours of stroke onset. Desmoteplase is
derived from vampire bat saliva; previous
studies suggest a benefit in patients with
normal CT scans and arterial blockage
that lasts beyond 3 hours. The trial is
sponsored by Boehringer-Ingelheim.
Albumin in Acute Stroke Trial (ALIAS)
Sponsored by NINDS with UT Emergency
Medicine, this multi-center Phase III
clinical trial is testing whether highdose human serum albumin given
intravenously to acute ischemic stroke
patients protects the brain over and
above the current standard of care.
A Pilot Study of Caffeinol and
Mild Hypothermia
This study is investigating the safety
and feasibility of treating stroke patients
with caffeinol, a proprietary blend of
ethanol and caffeine that helps protect
the brain, and mild hypothermia within
5 hours of symptom onset. Researchers
are evaluating whether caffeinol will
positively affect the patient’s tolerance
of cooling of the body, diminishing the
need for surface warming or medication
to reduce shivering.
Safety of Pioglitazone for Hematoma
Resolution in Intracerebral
Hemorrhage (SHRINC)
The MNI Stroke Center is conducting a
safety study of the diabetes medication
pioglitazone in patients within 24
hours of hemorrhage onset compared
to standard care. Pioglitazone speeds
removal of blood from the brain and
improves outcomes. This is the first and
only study in Houston for patients with
intracerebral hemorrhage.
Mechanical Retrieval and Recanalization
of Stroke Clots Using Embolectomy
(MR RESCUE)
MR RESCUE compares intra-arterial,
catheter-based mechanical embolectomy
clot removal to the standard of care in
patients up to eight hours after stroke
onset who are ineligible or have failed
treatment with tPA. The trial is sponsored
by NINDS.
STROKE FIELD ASSESSMENT GUIDE
SCREENING CRITERIA
1) Symptom duration < 24 hours
2) Blood glucose between 60 – 400
3) Physical Exam: LOOK FOR OBVIOUS ASYMMETRY
NORMAL Facial Smile/ Grimace
Arm Strength Speech RIGHT LEFT
Droop Droop
Drifts down Drifts down
Slurred, hesitant or absent
4) If items 1 and 2 are “YES” (or unknown), and at least one finding in item 3 is not normal,
the stroke screening criteria has been met.
5) Call base station to alert stroke team at stroke center hospital.