REAL® System: Supporting The Rehab Patient Journey
Cooper University Health Care Experience
Tudor G. Jovin, MD
Chief of Neurology
Cooper University Health Care, Camden, NJ
Chief of Neurology
Cooper University Health Care, Camden, NJ
Hello everybody and thank you for joining us, it’s a great pleasure to be here. I would like to thank Penumbra for giving us the opportunity to highlight the elements of stroke care at Cooper and in general.
I’ll give you an overview of what rehabilitation and new rehabilitation technologies mean for stroke care. My name is Tudor Jovin, I am a neurologist and interventionist at Cooper University Hospital. I’m delighted to be joined today by Dr. Rohini Kumar who is an assistant professor of physical medicine and rehabilitation at Cooper University Health Care, and by Dave Owens who is the director of Cooper University Health Care Rehabiliatation Services here at Cooper.
We will provide an overview of stroke in general, and the challenges that we have with stroke rehabilitation. An increasingly important component of stroke care as we are more and more finding out now.
So it is really important to understand that stroke care is a very complex undertaking that requires participation of multiple services. It starts with the prehospital area with really the call that the patient makes for acute stroke care. It starts with the dispatch call, the paramedics, EMS, the emergency department care and the stroke team. If need be, not all patients are candidates but if need be, if the patients are elegible for these advanced treatments like intravenous thrombolysis or thrombectomy, the whole acute stroke team including for thrombectomy intervention, radiology, angiosuite and the whole personnel. Then post procedure care that usually takes place in the neuro ICU or stroke unit. The admission in the hospital, which really focuses on understanding why the stroke occurred, stabilizing the patient, make sure that they’re safe to continue on their recovery journey, and then rehabilitation. And we are finding out more and more that this component, this last component, rehabilitation, is a critical component, as important as all the other elements.
I personally am a vascular neurologist and an interventionist. I do thrombectomy. I take clots out of people’s brains, but over the years I've been doing this for 20 years and I have been increasingly impressed with the power of rehabilitation. In fact, the REAL System was sort of the vision of the CEO of Penumbra, Adam Elsesser who really had dealt initially just with acute stroke devices. Devices that were for many many years, devices that were designed to take out blood clots from people’s brains, very intense, acute type of treatments. And Adam realized that we were sort of missing an important link, and that of recovery and rehabilitation and has dedicated a lot of his and the company’s resources to finding ways for better addressing this element that is often neglected of rehab. So we’re very excited, excited to share with you how we think the rehab component and the new technologies that are part of rehab are tying into the continuum of stroke care in the modern era of stroke treatment.
These are my disclosures but important to note that I don’t have any formal relationship with Penumbra.
So as mentioned I am a vascular neurologist and interventionist. I have been involved in research in acute stroke trials. In 2015, there was a landmark moment in acute stroke care, because within a space of six months, five, no less than five randomized trials were published attesting to the sort of overwhelming benefit of thrombectomy for acute stroke due to large vessel occlusion. I was fortunate to be one of the principal investigators of one of these trials and was involving others of these five trials as well. and then two years later another landmark moment occurred in acute stroke treatment with a publication of the DAWN and DEFUSE 3, which basically showed that the time window for acute stroke interventions extended up to 24 hours, pretty much doing away with the concept of time-based selection for thrombectomies. So now we have a door-to-door time window of 24 hours but in actuality we treat patients even beyond 24 hours based on the physiological principle of having a salvageable brain that can be recovered with restoration of flow to the brain, and that can occur even beyond 24 hours.
Just a quick overview of our hospital Cooper University Health Care. It’s a healthcare system. We’re a comprehensive stroke center, certified by the Joint Commission, Level 1 Trauma Center, and in general a tertiary referral center for Southern New Jersey. It’s a 635-bed academic tertiary care hospital, and the only level one trauma center in Southern New Jersey.
We have in the last year and a half, two years, have steadily increased our acute care footprint in the region. Our target populations are patients who from the standpoint of a stroke program, non-pediatric population, sometimes also pediatric, suffering from signs and symptoms of acute stroke, whether it’s ischemic, hemorrhagic, TIA, from the standpoint of recovery, we don’t make a big difference between ischemic and hemorrhagic stroke recovery, at least for now, follows the same path. Everything that we are going to be talking about today in terms of acute stroke recovery applies equally to ischemic and hemorrhagic stroke. We have a large population of patients over 65 years of age with a very high representation of African American and Hispanic. It’s a typical inner city population in 2019, we had 563 stroke patients and numbers are steadily growing. A couple of words about stroke in general and there’s about 800,000 new strokes every year in the United States. The majority are ischemic, which means blockage of a major artery feeding the brain, with resulting death of the brain territory that is supplied by this vessel. It’s the leading cause of adult disability in the United States and the fifth leading cause of death in the United States and much higher on this list in other countries.
It’s important to know the typical stroke symptoms and make sure that emergent or urgent medical attention is sought. The typical signs, this so-called FAST acronym: facial drooping, arm weakness, speech difficulty and time to call 911. This is an emergency. Even if it’s a TIA, emergent care should be sought.
As I mentioned since 2015, we have been practicing acute stroke interventions, meaning thrombectomy, for a long time but these treatments have been FDA approved and established as level one evidence only relatively recently, about five years ago. There is advances in triage and transfer paradigms that allow us to get patients earlier, hopefully we’ll see that developing even more, and in parallel, there are clot-removing tools, many of them pioneered by Penumbra, and that’s how Penumbra as I mentioned started, with clot-removing tools and now it’s diversifying its portfolio very appropriately in my opinion, and there’s a lot of progress made in triage and transferring the field, in the fields to get the right patient to the right hospital, in the fastest possible manor because time is brain is an important mantra that is very actual and something that we need to live by. With all our efforts however, we still have good clinical outcomes, which would be fine as patients are being independent, these are typically untreated such bad problems, that we consider that if somebody is not back to normal but back to being independent at home functioning independently, we consider that a good outcome, so I’m sure many of you are familiar with a modified Rankin Scale, from zero to six, zero being normal, six being dead, one is not having any restrictions compared to the prior level of activities, two being independent, and so zero, one and two after an acute stroke interventions for large vessel occlusion stroke, the worst type of stroke, there is considered a good outcome, but for the patients that is not good enough, they want to be back to what they were before and that’s where new breakthroughs in rehab I think will play a big role.
A lot of these good clinical outcomes require rehabilitation. I should also mention that if these patients are not treated, if the vessel does not open up, if the large vessel blockage is not addressed, these outcomes are dismal. I mentioned in the low 50s, good clinical outcomes, post-stroke intervention, if you don’t treat the patient, the good clinical outcomes are in the 20 percent, and it’s usually the young people who still can have a chance of a good outcome if untreated. Twenty percent or less, so these outcomes are dismal without treatment, that’s why it’s so important to very rapidly identify patients who need these treatments, get them through their hospitalization, their procedure, then moving on to rehabilitation.
I mentioned the continuum of stroke care, it’s really a chain of structures of services that have to be provided and every stroke center is as good as the weakest link of this chain. So it doesn’t matter that much if you’re a stellar thrombectomy center, if you’re not good at rehab, you’re not gonna have the outcomes that you should have. So many patients require rehab and that’s in stroke alone, there’s a lot of other neurological conditions and non-neurological conditions that will also obviously benefit from rehab.
This is a schematic drawing that shows the people that benefit from intravenous tPA that’s another tool that we have in our armamentarium, especially good for patients without large vessel occlusion, but even in those with large vessel occlusion there is benefit. You can see here out of these are 100 people, out of 100 people these are the people who are able to live independently. These have other improvements and these have no major change compared to no treatment at all. This is the benefit that you get with thrombectomy, you see there’s a lot more patients who compared to no treatment at all are able to live independently, and others who have some other type of improvement. So clearly thrombectomy is a big deal, a big advancement in treatment.
Here is a patient who has blockage of the internal carotid artery, you can see here this is where the blockage is, blood flow is restored after the JET 7, a Penumbra catheter is placed in this blood clot here and sucked out, and you can see the clot here in this picture, that’s kind of how we do these procedures. This is a patient who has a large vessel blockage, here, this is the carotid artery, it should terminate in the brain, it should branch out into multiple branches, that’s not the case. There’s a blockage there. This area here in dark blue is the territory of the brain that will infarct, will undergo permanent damage if the vessel is not opened up.
The patient undergoes treatment, thrombectomy, this is again, a blocked vessel here, this is the blockage, the vessel is opened up, after two passes of aspiration and stent retrieval, then this is the final MRI and you can see that on the MRI these white spots are strokes, are areas of dead brain, but they’re actually much smaller, again I’m going back to this area here, this is how the brain would have looked if the vessel didn’t open up. This whole area would have been white on MRI, instead because the vessel was opened up, you can only see these spots here, so a large area of the brain was salvaged, was spared. So that’s kind of the principle. This is the patient, 75 years old, was treated this way but despite the fact that we saved a lot of brain, there’s still these infarcts that are there, still this area of damaged brain, that causes disability and requires treatment. This patient had a good outcome, we consider at 90 days was independent, a Rankin score of two, but it could be better. We’d like to see a Rankin of one or even zero. That’s where we have the big role of rehab, we were very lucky that Cooper University Hospital was chosen by Penumbra to be the testing site, the beta site, for the REAL System, this is the REAL System, you’ll hear more from Dr. Kumar and Dave Owens about this system, how it exactly works.
This is me wearing the system and being immersed in that real world of the virtual world of rehab. Patients with multiple deficits as you will hear can benefit from this treatment. Finally I’d like to show something that was very touching to me, this is an email that people from Penumbra who were with these patients while we had this testing phase received from the daughter of a patient of ours, who tried this device, this technology for several days while at Cooper, and I’m gonna read it to you. I think this letter basically tells you everything you need to know about the impact that it makes on patients and its potential for progress with stroke recovery.
Hello, my father was at Cooper Hospital for a stroke for which you came in with physical therapy and test out a new virtual reality device. I just wanted to let you know I thought it was great and I thought you would have gotten a lot more improvement out of it, should he be using it for any period of time and I could see the results right in front of me compared to normal movement at the time. My father is now at so and so facility for rehab, and I wish they had the availability to use that device, but anyway I just wanted to let you know how wonderful I thought it was, and that I could see the improvements that my dad had when he was using it. My father is doing very well and after four days they had him up and walking, just so you know. Keep up the great work.
And with that I’m gonna end and give the microphone to my colleague Dr. Rohini Kumar, who we are very fortunate to have here at Cooper, who is spearheading the stroke rehabilitation and REAL System efforts for our stroke patients at Cooper. Thank you very much.
Video recording used with permission. Consent on file at Penumbra, Inc. The opinions and clinical experiences presented herein are for informational purposes only. The results may not be predictive for all patients. Individual results may vary depending on patient-specific attributes and other factors. Any treatment decision must be made in consultation with a healthcare provider based on a complete discussion of risks and benefits. The views and opinions expressed herein are those of the presenter and do not necessarily reflect the views of Penumbra, Inc. or its ailiates. The featured presenter is consultant for Penumbra, Inc.
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