The Stroke & Brain Aneurysm Center at Good Samaritan offers comprehensive neurointerventional treatment and critical care for vascular diseases of the brain, resulting in complete resolution of stroke symptoms and minimally invasive therapies for brain aneurysms for certain patients who have experienced large vessel occlusions, as well as shorter stays for those with brain aneurysms and more.
The Stroke & Brain Aneurysm Center at Good Samaritan treats the most complex stroke cases by combining the area’s most advanced imaging capabilities and the experience and skill of the center’s specialized team.
The acronym F.A.S.T. has long been used as a mnemonic device to help people recognize stroke symptoms, as well as a reminder to immediately dial 911 upon recognition of those symptoms, allowing emergency services to intervene as soon as possible and administer tissue plasminogen activator (tPA) within the recommended three-hour window. Though tPA has a significant success rate, patients who have experienced a large vessel occlusion may not fare so well with medication alone.
“Patients with large vessel occlusions still face high rates of mortality and debilitation even if tPA is administered in time,” says Kimon Bekelis, MD, Director of the Stroke & Brain Aneurysm Center at Good Samaritan, Chair of Neuro-interventional Services at Catholic Health Services (CHS) and Director of the Population Health Research Institute of New York at CHS. “While administering tPA is considered the best first line of treatment for people experiencing an ischemic stroke, it cannot be given to patients who have a propensity for bleeding or to patients who wake up with stroke symptoms, since the time of onset of stroke cannot be determined.”
To better assist this subset of patients — as well as all those who have strokes — and improve outcomes, the team at the Stroke & Brain Aneurysm Center at Good Samaritan takes a proactive, minimally invasive approach to intervention. Using coordinated care and proven best practices, they help reduce the amount of time it takes to intervene, thereby improving survival rates and duration of life-impacting side effects.
A neurointerventional treatment called mechanical thrombectomy can provide better outcomes for people with large vessel occlusions, regardless of whether they have received tPA. The procedure is successful at opening large vessel occlusions over 85 percent of the time, resulting in the decrease or reversal of stroke symptoms for many patients.
With faster image acquisition, biplane technology represents an improvement over single-plane angiography systems and enables the performance of complex neurointerventional procedures.
“If you re-vascularize the brain in time, the patient may shake your hand with the same side that wasn’t moving before the procedure,” Dr. Bekelis says. “We’ll keep the patient at the hospital for a workup to understand why the stroke occurred, but the patient can go home relatively shortly thereafter.”
Mechanical thrombectomy is an endovascular procedure that involves inserting a catheter into the groin and threading it through the aorta to the brain. Once the catheter reaches the site of the occlusion, a stent is used to suction the clot out of the vessel and restore blood flow to the affected area of the brain. The procedure can take 20 to 45 minutes to complete. Similar endovascular procedures can also be used to treat brain aneurysms, tumors, arteriovenous malformations and other conditions.
“We recruited staff from all over the country that included physicians fellowship-trained in neurology, neurosurgery, endovascular surgery and stroke care. We had the team in place in July 2017, and we spent time setting up further training, policies and procedures for the staff before the Stroke & Brain Aneurysm Center opened in September.”
— Kevin Mullins, MD, FACS, FAANS, Chair of the Neuroscience Service Line, Catholic Health Services and Chief of Neurosurgery at Good Samaritan Hospital Medical Center
“Traditionally, the treatment of brain aneurysms involved performing a craniotomy and placing a pin at the site of the aneurysm to clip it,” Dr. Bekelis says. “We still clip aneurysms, but instead of opening up the skull, we can thread a catheter through the groin and insert coils to clot off the aneurysm.”
Rather than the lengthy hospital stay associated with craniotomy, patients receiving endovascular treatment for brain aneurysms can leave after an overnight visit with nothing more than a small incision in their groin.
“These techniques have been available for many years, but their indications and applications have expanded dramatically, thanks to technology,” says Kevin Mullins, MD, FACS, FAANS, Chair of the Neuroscience Service Line, Catholic Health Services and Chief of Neurosurgery at Good Samaritan. “These advancements allowed us to create the Stroke & Brain Aneurysm Center.”
The Right Tools for the Job
The creation of the Stroke & Brain Aneurysm Center at Good Samaritan began long before it opened, with Dr. Mullins initiating and overseeing all aspects of its development. An extended planning period preceded the program’s successful launch in September 2017.
Under the leadership of Kimon Bekelis, MD, the Stroke & Brain Aneurysm Center’s neurosurgeons, neurointensivists, neurologists, nurse practitioners, physician assistants and nurses with extensive training in neurological critical care provide comprehensive and continuous bedside care to patients during their recovery.
“There were approximately three years of preparation to set up the center and the program,” Dr. Mullins says. “Beyond receiving approval from the state of New York and coming up with the architectural plans, we needed to choose the right equipment and build the right team.”
Among the most important pieces of equipment procured for the Stroke & Brain Aneurysm Center are a 512-speed low-dose CT scanner and a biplane angiography system. The biplane angiography system was incorporated into its own specially outfitted room — where neurointerventional procedures take place — shortly before the center’s opening. Together, the CT scanner and biplane angiography system allow Dr. Bekelis and his team to determine the proper candidates for neurointerventional procedures and perform treatments that would be difficult or impossible using other imaging methods.
“Not having a biplane machine is a significant impediment to performing these procedures,” Dr. Bekelis says. “The brain has complex vasculature, so we need detailed 3-D imaging in order to properly see the blood vessels and direct our catheters to the affected sites. Otherwise, there’s a risk of the vessels rupturing.”
In order to determine a patient’s eligibility for mechanical thrombectomy in the case of a stroke, the 512 speed low-dose CT scanner is used to find out if the patient is experiencing a large vessel occlusion and whether or not the surrounding brain tissue is still alive. If the brain tissue is still living, this treatment can be administered regardless of the time of ischemic stroke onset.
“We don’t want to intervene if the particular part of the brain in question has died, since that would only increase the risk of bleeding in the area,” Dr. Bekelis says. “The high-speed, low-dose scanner allows us to perform CT perfusion, which shows us the perfusion properties of the brain. From there, we can determine how well the brain is receiving blood and find the ischemic penumbra. This doubles our capacity to offer life saving treatment to patients.”
Good Samaritan acquired the CT scanner in July 2017, allowing the machine to be optimized for procedures that would be performed in the Stroke & Brain Aneurysm Center and giving the team time to train with the machine.
A Specialized Team
Much of Dr. Mullins’ time and effort in crafting the program was spent recruiting neurologists, nurses, physician assistants and other personnel.
Good Samaritan’s Imaging Services Department features Long Island’s only Revolution 512-Speed CT Scanner (one of only two in New York state), enabling clinicians to deliver uncompromised image quality for some of the most challenging clinical applications.
“All in all, we recruited about 60 new personnel to build out the Stroke & Brain Aneurysm Center,” Dr. Mullins says. “We recruited a well-trained staff, from our interventional neurosurgeons performing the procedures to our nurses assisting in the neurological intensive care unit.”
Though similar programs may share some of the mentioned components, the staff at Good Samaritan is unique in that all members of the Stroke & Brain Aneurysm Center have dedicated training in a field of neuroscience. Beyond the fellowship training completed by neurointensivists like Dr. Bekelis, all support staff — including nurses and advanced practice providers — have experience working with neurological patients.
During a typical neurointerventional procedure, Dr. Bekelis receives assistance from a nurse practitioner with a long history of neurological expertise. In addition, a technologist is on hand who serves as an expert on the biplane angiography machine. A neurophysiologist is present to monitor the brain activity of the patient, who is usually awake during the procedure. An anesthesiologist is also present during interventions. One or two additional nurses round out the team during procedures.
“Good Samaritan made a great commitment to building a neuroscience program,” Dr. Mullins says.
Post-treatment Care and Transition
The five-bed neurosurgical intensive care unit (ICU) at Good Samaritan provides follow-up care for patients who have undergone neurological interventions or require ongoing neurocritical care.
Through neurointervention, conditions such as strokes, brain aneurysms and tumors that are present in the delicate areas of the brain, neck or spine can be treated in a minimally invasive procedure.
“Patients with neurological conditions can see their situations deteriorate very quickly and quietly, which is why it’s important to have a specialized team that can recognize signs and get them treated immediately,” Dr. Bekelis says. “We want patients who receive neurointervention to be monitored for at least 24 hours to make sure there is no additional clotting or bleeding before they are discharged.”
“The Stroke & Brain Aneurysm Center has been a great success thus far. In the first three months of the program, we performed over 120 procedures. Around 40 percent dealt with brain aneurysms, another 40 percent with ischemic strokes, and the remaining dealt with issues like carotid disease and intractable nose bleeds.”
— Kimon Bekelis, MD, Director of the Stroke & Brain Aneurysm Center at Good Samaritan Hospital Medical Center, Chair of Neuro-interventional Services at Catholic Health Services and Director of the Population Health Research Institute of New York at Catholic Health Services
Patients may also need to stay in the neurological ICU if they have undergone treatment for a ruptured brain aneurysm, since the effects of bleeding in the brain can be sustained for days after the incident. The intense monitoring in the neurological ICU helps make sure that any complications can be swiftly prevented or managed.
Patients who have spent time in the neurological ICU require a careful transition to rehabilitation or life at home. To aid in this transition and provide continuity of care from the critical care setting, a four-bed step down unit is located adjacent to the neurological ICU within the Stroke & Brain Aneurysm Center. The same nurses and advanced practice providers from the neurological ICU staff the step down unit in rotating shifts, with neurointensivists providing oversight for both units.
“If we see any change in a patient with the step down unit, that patient can immediately be moved back into the neurological ICU,” Dr. Bekelis says. “This bridge between the critical care setting and the hospital floor allows us to safely transition patients and can be lifesaving in many cases.”
Time Is Brain on the South Shore
To ensure that patients receive care as quickly as possible, team members at the Stroke & Brain Aneurysm Center are available 24/7 via cell phone and pager. Lines of communication remain open at all times, and the team meets frequently to discuss patient cases.
Director of the Stroke & Brain Aneurysm Center and Co-director of the Medical Center’s Neurological Intensive Care Unit, Kimon Bekelis, MD, is one of the most prominent researchers in stroke care, treatment and population health in the nation.
“We have access to all the highly trained specialists that practice at Good Samaritan, such as neurologists, cardiologists, emergency room physicians, internists, general surgeons and more. This allows us to safely take care of these very complex patients,” Dr. Bekelis says. “We’ve also expanded our stroke neurology component with more specialized stroke-certified neurologists on call who can assess patients before they go to neurointervention to further streamline the process.”
Collaboration isn’t confined to the walls of Good Samaritan. Other institutions in the area that are part of CHS, such as St. Joseph Hospital, St. Charles Hospital and St. Catherine of Siena Medical Center, operate on a hub-and-spoke model that funnels neurological patients to the Stroke & Brain Aneurysm Center. The model ensures patients in the area receive care in the quickest manner possible.
“Because Good Samaritan is part of the CHS system, we can create programs that allow us to transfer patients without roadblocks,” Dr. Bekelis says. “We want to expand the program as much as possible in our area and create mechanisms so that patients can receive care within minutes.”
The initiative to provide more rapid neurological interventions to South Shore residents was one of the main reasons that the Stroke & Brain Aneurysm Center was developed and why it was planned at Good Samaritan.
Thanks to successful recruitment efforts, methodical planning and the dedication of dozens of professionals, the Stroke & Brain Aneurysm Center at Good Samaritan offers critical, high-quality neurological care to the community, and the team hopes to incorporate more hospitals in its hub-and-spoke model in the future.