Time is brain: Baltimore VA earns primary stroke center status

Baltimore VAMC is redefining stroke care for Veterans

When it comes to stroke, every minute counts. “Time is Brain” remains the most critical medical mantra for stroke treatment because the longer it takes to recognize stroke symptoms and access treatment, the greater the adverse effect on the brain.

Rapid medical intervention can make a huge difference in minimizing long-term brain damage from stroke and in saving lives. Now, Veterans presenting with stroke symptoms at the VA Maryland Health Care System’s Baltimore VA Medical Center (VAMC), either in the emergency department (ED) or as an inpatient, can rest easy about the care they will receive: In 2024, the medical center was designated a primary stroke care center, upgraded from its previous status as limited stroke center.  

“This means that we are ready and prepared to rapidly treat someone with a stroke when that individual comes to the ED with stroke symptoms or when an inpatient starts showing symptoms of stroke,” said Dr. Jackqueline Easley, an advanced nursing educator and lead nurse for stroke care at the Baltimore VA Medical Center.

Fact: In the US, someone suffers a stroke every 40 seconds, with more than 795,000 new or recurrent strokes annually.

Fact: In Maryland, recognized as a “Stroke Smart State,” stroke remains the third leading cause of death, despite 95% of its residents being within a 30-minute drive to a stroke center.

Fact: Studies indicate that Veterans face an elevated risk of stroke due to the compounding physical and psychological factors unique to military service.

As a primary stroke center, the Baltimore VAMC partners with the VA National Telestroke Program (NTSP) which links to a 24/7/365 telehealth service connecting Veterans at VA emergency departments and medical centers with remote stroke specialists.

“This VA program provides acute stroke evaluation and treatment to more than 80 VA medical centers nationally through telemedicine,” said Dr. John W. Cole, a vascular neurologist and stroke researcher at the Baltimore VAMC who leads the Baltimore VA Stroke Program. “More VA medical centers are being added each year. This locally implemented and nationally driven relationship dramatically reduces treatment times and has been shown to decrease unnecessary patient transfers by more than 60 percent.”

Easley explained that there are two kinds of stroke, ischemic and hemorrhagic, and identifying which type a patient is having as rapidly as possible determines the next treatment steps. “If they are having a hemorrhagic stroke, also called a bleeding stroke, the last thing you want to do is give a clot-busting medication,” she said.

Each clinician working on the stroke response team is trained on the facility’s stroke protocol, following steps precisely to help them identify the kind of stroke occurring so that they can confidently proceed with next steps. When a stroke code is called, that is the sign for every department in the medical center to get ready to take action, including radiology, which will urgently perform a brain CT scan, and the hospital’s laboratory, which will be receive the patient’s blood for rapid measurements.   

“A hemorrhagic stroke is a life-threatening medical emergency that means bleeding is occurring in the brain, and the patient may require emergency surgery,” said Easley. “Only a comprehensive stroke center is equipped for emergency surgery on the brain. We partner with University of Maryland Medical Center and with Johns Hopkins, both designated comprehensive stroke centers capable of performing emergency surgery 24/7.”

Ischemic strokes occur when a blood vessel supplying blood to the brain is blocked or severely narrowed, thereby limiting blood flow and depriving the brain of oxygen and nutrients. Ischemic strokes can be deadly and account for roughly 85 percent of all strokes. They are a medical emergency requiring immediate treatment to prevent brain damage, permanent disability or death.

“On average, we treat 10 to 15 strokes per month, as well as a similar number of transient ischemic attacks (TIAs) and also stroke rule-outs,” Cole said. “These numbers remain relatively consistent year to year. It is important to note that when treating stroke, time to evaluation and treatment is the most important factor.”

How the stroke response protocol works

Easley explained how early the stroke code is called: “If someone is presenting with stroke symptoms, the code gets called, alerting everyone that they need to be prepared for their part in the protocol. If the CT scan shows no bleeding in the brain, we follow the protocol to begin administering the clot-busters and other appropriate drugs as soon as possible,” she said. “This medication is administered using a well-defined protocol and is kept in sufficient supply to make it accessible during a stroke code, regardless of where in the medical center the stroke is taking place.”

Stroke care and treatment are not static. The stroke team holds quarterly meetings during which every stroke case is reviewed and evaluated with an eye toward optimizing metrics. The stroke team participates in periodic stroke code exercises in the facility’s medical and intensive care units (ICUs), and in the ED, to evaluate treatment responses, algorithms and logistics to address any issues that stand in the way of rendering care within the “golden hour.”

“These mock codes provide real-time training and allow the Baltimore ED and ICU team staff members to feel comfortable with the logistics across all the various disciplines involved and it includes NTSP providers, radiology and the clinical laboratory,” Cole said. 

Both Easley and Cole agree: The most important part of stroke treatment is recognition of symptoms. “Everyone, meaning the entire U.S. population, should be familiar with the rapid identification of stroke via the B.E.F.A.S.T. mnemonic,” said Cole. “Early recognition in the pre-hospital setting activates the emergency medical system.”

While Easley believes that everyone ought to be familiar with B.E. F.A.S.T, she highlights that “stroke is preventable and patients can significantly reduce their risk by managing their underlying medical conditions and making necessary lifestyle changes.”

“Everyone should know their numbers. Knowing your blood pressure, sugar and cholesterol numbers and getting them out of the risk range is key. Eat a balanced diet low in trans and saturated fats and sodium,” she said. “Not missing health screenings is key. A big risk factor is smoking. There are many programs that help people to stop smoking, which damages blood vessels, thickens the blood and leads to clots and stroke.”

B.E. F.A.S.T.

1. Balance: Sudden loss of coordination or walking ability.
2. Eyes: Sudden vision change or loss of vision.
3. Face: Uneven smile of facial droop.
4. Arm: Arm or leg weakness, often on one side.
5. Speech: Slurred speech, difficulty repeating phrases, or confusion.
6. Time: Time to call 911 immediately

While preventing stroke is key, Veterans suffering from stroke can know that at VA, they are in well-trained and capable hands.