EP Perspectives

Comprehensive Cryptogenic Stroke Patient Care: A Multidisciplinary Stroke Team Approach

Interview with Stephanie Rubenstein, RN, SCRN, Stroke Program Coordinator, and Brian M. Snelling, MD, Medical Director of the Marilyn & Stanley Barry Center for Cerebrovascular Disease & Stroke at Boca Raton Regional Hospital in Boca Raton, Florida

Interview with Stephanie Rubenstein, RN, SCRN, Stroke Program Coordinator, and Brian M. Snelling, MD, Medical Director of the Marilyn & Stanley Barry Center for Cerebrovascular Disease & Stroke at Boca Raton Regional Hospital in Boca Raton, Florida

What challenges exist in the diagnosis and treatment of stroke?

Personalized health assessments and treatment strategies are critical to long-term prevention of stroke recurrence. According to the Centers for Disease Control  and Prevention (CDC), approximately 795,000 people suffer from a stroke annually in the United States. Stroke is the fourth leading cause of death in the country, and remains the leading cause of serious long-term disability worldwide. Nearly 1 in 4 strokes occur in people who previously suffered a stroke. Timely recognition of symptoms and activating emergency medical services is critical to quick treatment of stroke, and timing can mean the difference between a good and bad outcome. 

While stroke teams across America work tirelessly to provide lifesaving treatment to acute stroke patients, they also work hard to uncover the cause of each stroke. They work diligently with patients post stroke to rehabilitate and provide thorough education to help patients optimize recovery and functionality. Our goal as a Comprehensive Stroke Program is to get patients back to what they were doing before their stroke. We work hard to identify opportunities to help our patients in the best and most thorough way.

One of the major challenges we as clinicians face in stroke is trying to find answers in a “grey zone” where the etiology is not clear cut. In fact, one in three patients who suffer ischemic stroke may be discharged from the hospital without a cause for their stroke. More than one in six ischemic strokes can be traced to atrial fibrillation, but an even larger percentage of ischemic strokes — between 20% and 40% — occur without any explanation at all.1 These strokes are referred to as “cryptogenic”, or, “of unknown origin.” Cryptogenic stroke is a widely used term, but clinicians often use it without truly understanding its meaning and what implications it has for secondary stroke prevention. 

At least 2.7 million Americans live with atrial fibrillation (AF), an irregular heartbeat that can cause stroke. AF is also challenging because it can be transient; therefore, relying on conventional ECGs or monitoring at doctors’ offices often misses AF. Patients that have suffered cryptogenic stroke often have undiagnosed, asymptomatic atrial fibrillation which can be the cause of their stroke. They may also have other cardiac complications months after being discharged from the hospital. Traditional programs typically end weeks or even days after the initial stroke, but not with us — the Marcus Neuroscience Institute (MNI) at Boca Raton Regional Hospital is committed to doing more.

What can you tell us about the Cryptogenic Stroke Pathway program at MNI?

In March 2018, MNI at Boca Regional became the first hospital in Palm Beach County to launch a long-term monitoring program for cryptogenic stroke patients to help reduce their risk of a secondary stroke and help them uncover the cause of their stroke. This monitoring program effectively identifies which patients should consult with a specialized electrophysiologist to determine if an implantable cardiac monitor (ICM) is indicated. The ICM can continuously monitor heart activity to capture abnormal heartbeats and rhythms — when these remain undetected, it can increase the risk of stroke fivefold. This data is relayed quickly to specialty cardiac physicians so that they can promptly initiate treatment when necessary. The ICM is inserted under the skin on a patient’s chest through an incision less than a centimeter long. The procedure itself takes less than 10 minutes. It is minimally invasive and can be done painlessly at the hospital bedside. 

What members of the staff are part of the multidisciplinary stroke team in the Cryptogenic Stroke Pathway program? How many staff members are part of the program? 

From the minute a stroke patient enters our hospital, whether through the front door or by an ambulance, a dedicated specialty stroke clinician guides the patient through the entire process. Staffing structures around the stroke patient are implemented using a “time is brain” mentality. We have our neurology team, stroke clinician team, and emergency department teams working closely together from the beginning. Following the acute treatment phase and into admission and then stroke diagnostics, we unite our neurology, cardiology, and electrophysiology teams to cross-coordinate care. The cryptogenic stroke patients are identified, and the necessary cardiac teams are brought in right away so that care can be delivered and hospital admission is not extended. Our goal is to optimize patient care and communicate effectively through the process, as this saves time. The stroke clinician team is made up of 6 rotating nurses who work with the physicians and medical teams to design plans of care around each patient. Multidisciplinary rounds are held to discuss plans of care with these teams, so everyone is on the same page and shares the same priorities. 

How many patients have you treated on average since the start of the program in March 2018? Also, approximately how many stroke patients does MNI treat annually? 

On average, our program sees more than 550 acute ischemic stroke patients on an annual basis, and that number grows each year. Based on the data, roughly one-third of those patients have a cryptogenic stroke diagnosis, and of those patients, 25-30% will have undiagnosed, asymptomatic atrial fibrillation as the cause. Since the beginning of our pathway implementation, we have inserted over 150 ICMs. Not only are we finding AF in these patients, but we are also detecting other serious cardiac arrhythmias that require medical attention. 

How do you measure success? Discuss a 100% stroke pathway percentage at MNI. 

With access to third-party data, we quantify success based on our patient volumes compared to available data, and then monitor patient feedback and results. We also closely track readmission rates, and have seen a reduction in our stroke readmission rates. We ensure that if a patient may benefit from this option, that they are connected directly with the electrophysiology team, who have reported that greater than 30% of patients were found to have AF when they had an ICM implanted for cryptogenic stroke. 

How does the Cryptogenic Stroke Pathway program at MNI differ from other hospital protocols in place for treating cryptogenic stroke? 

Currently, there is no requirement for hospitals or stroke programs to have a cryptogenic stroke pathway. Nationally speaking, this is a highly overlooked area, and although programs may want to have a pathway in place, it becomes exceedingly difficult to coordinate the communication and delivery of care in the short time a patient may be admitted. We utilize strict and carefully designed comprehensive order sets and protocols aimed to ensure that things move quickly. Our stroke clinicians work 24/7, 365 days a year to ensure that individualized and thorough patient care is delivered, no matter the time of day or night. 

What patient feedback have you received so far?

As a result of this program, we have some very happy patients. One of our first patients in the Cryptogenic Stroke Pathway program at Boca Regional credits his life to the program. The patient came to MNI in July 2018 with a life-threatening large vessel occlusion without a known cause. He was treated with mechanical thrombectomy and was implanted with a long-term cardiac monitor prior to discharge. Nearly a year later, the Boca Regional team detected atrial fibrillation, which required that the patient immediately switch medications to effectively prevent another large stroke. The change paid off. The patient now reports feeling better, adding that he plays tennis 4 days a week and goes to the gym to stay active.

What are the keys to a successful program?

The true key to success of this initiative is the collaboration and communication between the medical disciplines. When everyone works together for better patient care, everyone wins. If we didn’t have the neurology team communicating with the electrophysiology team in a timely way, we wouldn’t be successful in uncovering appropriate candidates for this long-term monitoring device. Having patients be discharged without a clear answer for their stroke or stroke symptoms causes anxiety and unwanted stress. We want to make sure patients feel secure and confident that even if we can’t figure it out immediately, we are taking extra measures to find the cause and prevent secondary stroke. 

Disclosures: The authors have no conflicts of interest to report regarding the content herein.

  1. Uncovering a hidden cause of stroke. Harvard Health Publishing. Published September 2014. Available at https://bit.ly/30YWyg2. Accessed June 17, 2020.