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Phelps’ State of the Art Stroke Center Saves Time–and Thus Lives

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November 7, 2022

By Barrett Seaman–

Michael Stillman, 79, a retired dermatologist in Waccabuc, NY woke up early on a Wednesday morning last spring with a feeling of great discomfort yet he was unable to identify its source. “My wife realized that there was something major wrong,” he recalls. He couldn’t speak; he was paralyzed on his right side. “She got me dressed and took me to the emergency room” at Northern Westchester Hospital in Mt. Kisco. Alerted to his impending arrival and the likelihood that he was a stroke victim, the hospital’s emergency staff took him in and immediately did a CAT scan, which revealed a large clot on the left side of his brain.

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Small brain clots can usually be treated chemically, using an intravenously delivered clot-busting drug called TPA (for Tissue Plasminogen Activator) that has been available since the 1990s. Larger clots, like the one in Dr. Stillman’s brain, required surgery—either by opening the skull or with a relatively new surgical procedure called a mechanical thrombectomy. In this procedure, a catheter about the diameter of a pen nib is inserted into the body (usually through an artery in the groin) and then navigated up through the body’s vascular maze into the brain. When it reaches the clot, a tiny pump at the head of the catheter sucks the clot out (or chews it up), restoring blood flow to the occluded areas of the brain.

Both TPA injections and thrombectomies are appropriate treatments for “ischemic” strokes, caused by a blockage, as opposed to “hemorrhagic” strokes, resulting from bleeding in the brain. Says Dr. Ramandeep Sahni, stroke director at Phelps and effectively the quarterback of the hospital’s stroke team: “87% of strokes we see in this country are ischemic. Only a small fraction are due to bleeding.”

A schematic showing a catheter navigating through an artery towards a blood clot

While Northern Westchester is capable of handling stroke cases, it does not have the capacity to offer mechanical thrombectomy as a treatment for larger clots. However, its sister hospital in the Northwell Health system, Phelps, does, which is why Dr. Stillman was immediately transferred there by ambulance. When he arrived, the Phelps stroke team, consisting of between 12 and 20 designated personnel, ranging from EMTs and nurses in the ER to radiologists and specialized neurovascular surgeons, was already in place. Dr. Stillman was rushed to an operating suite specifically equipped to perform this procedure.

The thrombectomy is achieved by sucking out the offending clot

While the Phelps stroke team has been performing thrombectomies for a while, it was only recently certified by the American Medical Association as an “Advanced Thrombectomy-Capable Stroke Center” (TSC). The only other hospital in the county so designated is the Westchester Medical Center in Valhalla. In a county with a population now over one million, having two TSCs dramatically improves the odds that a victim of stroke—the leading cause of disability and the number five cause of death in the U.S.—will be able to recover.

Phelps’s Stroke Team celebrated their certification, its leaders remarking on the rigor of the audit in which examiners from The Joint Commission, which assesses medical practices worldwide, ran through a checklist of standards and procedures contained in 400 pages of data points. Other medical centers in the region and the network of Emergency Medical Technicians/ambulance corps are now aware that Phelps is a go-to destination when stroke is indicated.

In stroke cases, time is of the essence, or as Dr. Yafell Serulle, director of neuroendovascular surgery at Phelps and the surgeon who operated on Michael Stillman, put it, “Time is brain.” The faster the intervention, the fewer number of nerves are damaged and the more likely the patient will regain lost function. Acting within 24 hours of a stroke onset is critical. Intervention after that, says Dr. Serulle, “is more of a complicated problem.” “Sixty percent of patients who undergo mechanical thrombectomy,” he explains, “will be back to functional baseline three months after the thrombectomy. Not perfect,” he concedes, “but I would rather take 60% than no percent.”

All hands on deck–Each member of Phelps’ stroke team has a customized cell phone app. When a stroke victim is brought in, team members’ phones are pinged. “Whenever there is a stroke code,” says Dr. Sahni, “it’s all hands on deck.” The naval analogy is apt. Just as when General Quarters is sounded on a naval vessel, everyone on board knows to go to his or her designated station with specific responsibilities. Following ER admission, a CAT scan is taken and the resulting images are uploaded to every team member’s app. In the OR, says Dr. David Gordon, chair of Northwell Neurosurgery for Westchester and, like his colleague Dr. Serulle, a thrombectomy specialist, “we use fluoroscopy images of brain in real time.”
“We try to do it with the patient awake,” says Dr. Serulle, “although we have an anesthesiologist in the room. In over half our cases, the patient is awake.” It is not unusual to complete the procedure within 15 or 20 minutes; suctioning out the clot takes about 90 seconds. In Dr. Stillman’s case, the insertion took longer because, as often happens with older patients, there were anomalies in his vascular architecture that took more time to navigate.

Following protocols, patients are closely monitored in the Intensive Care Unit (ICU). Michael Stillman spent two nights at Phelps following his thrombectomy. “Within 24 hours, I was alert and regaining cognitive functioning,” he recalls. His grandson Alex was due to be bar mitzvahed on Friday, and Stillman lobbied to be released in time to make it. Dr. Sahni examined him and gave him the green light. Friday morning, Michael Stillman walked out of Phelps Hospital unassisted and was there in Connecticut that evening for Alex’s ceremony.

Dr. Michael Stillman with his grandson Alex

Once home, he started walking four miles a day and has gradually regained all of his cognitive functions. “I basically do not have any residual problems.”

The Phelps Advanced Thrombectomy-Capable Stroke Center is state of the art, but its medical staff sees more improvements in the future. In February, they are hosting a stroke symposium for EMTs throughout Westchester, so that these first responders have them top of mind when they are transporting a major stroke case. Eventually, they would like to have a mobile stroke unit—a traveling radiology and surgical suite that could reduce the lag time between onset and surgery even further. That, says Dr. Sahni, “would be a game-changer.”

In the meantime, Phelps is constructing a Center for Advanced Procedures (CAP) adjacent to its Emergency Room so that everything can take place in one location. “The machine we will be using there will be state of the art,” says Dr. Gordon, “and it will be the standard of care for delivery of the most complex cerebrovascular care.” Most of all, it will be yet another time saver in a drama that is, at heart, all about time.

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In other Phelps news, Northwell Health has appointed Binoy Singh, MD, FACC, as chair of department of cardiovascular medicine at Phelps Hospital and will oversee all cardiac services at the hospital, as well as practice at Northwell Health Physician Partners – Cardiology in Yorktown Heights. In this new role, Dr. Singh will help develop and expand the cardiovascular services in southern and northern Westchester County.

Dr. Binoy Singh

Dr. Singh has been a practicing cardiologist in Yorktown for the last 20 years and has additionally spent the past decade as the associate chief of cardiology and director of clinical business development at Manhattan’s Lenox Hill Hospital, which is also part of Northwell Health. While there, he helped establish and enhance Lenox Hill’s footprint in cardiology in New York City and advanced the cardiology in Westchester County. Today, that cardiac program is ranked among the top 5% of hospitals in the nation by Healthgrades for overall cardiac service.

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