Putting Georgia on the path toward improving outcomes for stroke patients 

By Guest Columnists JONATHAN A. GROSSBERG, MD, MBA, FAANS and C. MICHAEL CAWLEY, MD, FAANS on behalf of the Society of NeuroInterventional Surgery (SNIS). Both perform mechanical thrombectomy procedures at Emory University Hospital and Grady Memorial Hospital and are members of SNIS, supporting its Get Ahead of Stroke campaign to improve systems of care.

As most fellow Georgians are aware, our state has the dubious geographic distinction of being the “belt buckle” of America’s “Stroke Belt.” This is an area of the southeastern United States where stroke death rates are approximately 30 percent higher than in the rest of the nation.

According to the Georgia Department of Public Health, our state had the eighth-highest stroke death rate in the U.S. in 2019. Alarmingly, 19 percent of those stroke deaths occurred in people younger than 65. The research also revealed tremendous disparities in stroke outcomes, with an age-adjusted stroke death rate among Black residents that is 33 percent higher than for White residents in Georgia.

Dr. Michael Cawley is a Professor at the Emory University School of Medicine and Director of the Emory MBNA Stroke Center. 

Nationwide, strokes cost the United States nearly $53 billion each year, primarily due to rehabilitation and long-term care costs when stroke survivors are no longer functionally independent. These costs also factor in the “butterfly effect” when family members of stroke survivors need to leave the workforce to become full-time caregivers to their loved ones. Between 15 and 30 percent of stroke survivors remain paralyzed for the rest of their lives. The best outcome will ensure the patient will go on to live a longer, productive life as opposed to depending on around-the-clock care for the rest of their life.

The reason a stroke has such a devastating impact is that it is often the result of a blood clot blocking a brain artery, which deprives the brain of oxygen and can kill up to two million brain cells each minute. Until stroke patients are properly treated, particularly if they are experiencing an emergent large vessel occlusion (ELVO), the deadliest form of stroke, they will experience paralysis, speech problems, imbalance, or worse. Every minute of delay before the patient receives appropriate care will mean an extra week of recovery. Time is brain.

That is why we have strongly supported the efforts underway in Georgia and across the entire country to improve and update stroke systems of care to align with modern treatment. Specifically, we have worked in collaboration with the EMS community and other key stakeholders to adopt a triage and transport model for stroke based on the trauma system. Just as critically injured patients are transported by EMS directly to Level 1 trauma centers for lifesaving care, we want to ensure critical stroke patients are similarly taken to Level 1 stroke centers.

Level 1 stroke centers, including Emory University Hospital, are staffed with specialized neurointerventional care teams who are trained to provide lifesaving care for critical cases of stroke such as ELVO. The most effective treatment for ELVO is mechanical thrombectomy, a minimally invasive procedure that uses small catheters to reopen blocked arteries in the brain and restore the flow of blood and oxygen. Recent studies confirm that 65 percent of stroke patients treated via mechanical thrombectomy achieve recovery without long-term disability.

As physicians, we have witnessed an incredible medical revolution in stroke treatment that is saving lives and vastly improving patient outcomes. But this treatment is effective only if patients who would benefit from it are triaged and immediately transported to a hospital that has the appropriate capabilities to treat them.

Dr. Jonathan Grossberg is an Associate Professor of Neurosurgery at Emory University School of Medicine

A team of our colleagues reaffirmed this in a recent study in which they compared the stroke triage and transport protocols of two states over 5.5 years. “State 1” had adopted an updated system to ensure critical stroke patients – including those with ELVO – were immediately triaged and transported to Level 1 stroke centers. “State 2” continued operating under its standard protocol of transporting patients to the nearest hospital – and then transferring them to Level 1 stroke centers. Over the duration of the study, our colleagues reported a reduction of 43 minutes in time to treatment for patients along with lower rates of disability following a stroke in “State 1.” No changes were reported in “State 2.”

We cannot emphasize enough that “time is brain” when it comes to critical cases of stroke. The longer it takes for a patient experiencing a severe stroke such as ELVO to receive the appropriate care he or she needs, the greater the likelihood of a negative outcome – such as long-term disability.

In recent years, states like Florida, North Carolina, Tennessee, Arizona, Colorado, Ohio, and others have adopted the triage and destination-transport protocols necessary to improve outcomes for critical stroke patients. This year, we look forward to seeing Georgia join these states.

We are encouraged by the progress Georgia has made over the past year as health officials and stakeholders from across the state’s medical community have come together to work toward improving the statewide systems of care for medical emergencies, including stroke. The dedication of everyone involved with the process has been inspiring and we could not be prouder of this effort to help improve patient outcomes, including for stroke. We commend our colleagues and fellow stakeholders for their time and commitment to helping save more lives here in Georgia.

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