A clinical resource by the MERCY NEUROLOGICAL INSTITUTE OF GREATER SACRAMENTO Volume one | Issue two Register to receive Synapse electronically at mercyneuro.org. A Life-Saving Example of How Mercy’s Neurological Network Can Help Northern California Hospitals When 56-year-old patient Diane Bouge left Mercy Medical Center Redding with a subarachnoid hemorrhage from a cerebral aneurysm on Valentine’s Day, Emergency Department physician Jesse Wells, MD, didn’t hold high hopes. “I didn’t think she was going to make it through the transport,” he said. Dr. Wells had been on the phone, seeking the specialized care Diane Bouge needed. In the past, he had referred such patients to University of California in San Francisco. This time, he found the help he needed at the Mercy Neurological Institute of Greater Sacramento. Dr. Wells connected with George Luh, MD, an interventional neuroradiologist. Dr. Luh’s specialty is one that rarely exists in rural communities. A jet ride and an ambulance later, Dr. Luh performed a coil embolization in Mercy General Hospital’s biplane suite that saved Bouge’s life and started her on the road to recovery. “That’s amazing,” Dr. Wells said, learning for the first time that his patient had survived. “This is a success story and I want to continue and strengthen this relationship.” Dr. Luh and Mercy Neurological Institute are equally anxious to get better acquainted with hospitals in surrounding areas. “This is a good example of the importance of networking with other hospitals,” he said. “We use the analogy of the wheel, spoke and hub, with Mercy San Juan and Mercy General being the hub and outlying hospitals being the spokes. We can provide the access to the next level of care when they need it.” Needless to say, Diane Bouge and Don Eaken, her partner of eight years, are thrilled with the collaboration. “I’m sure she would not have survived a more invasive procedure,” Eaken said. Bouge has stopped smoking as a result of her near-death experience. She still faces outpatient physical therapy as part of her recovery. Preparing for her March 23 discharge home to Platina (a small town near Redding), she said she looked forward to more familiar surroundings and making organic soap as a thank you for her caregivers at Mercy General. If you have a patient who would benefit from the varied specialties of the Mercy Neurological Institute of Greater Sacramento, call the 24-hour toll-free number of 1.888.Mercy41 (1.888.637.2941). For your convenience in neurological admissions, a dedicated toll-free number is available 24/7: 1.888.MERCY41 (1.888.637.2941) Right carotid angiogram of patient Diane Bouge with coils in aneurysm and balloon catheter in artery.
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A clinical resource by the
Mercy Neurological iNstitute of greater sacraMeNto
Volume one | Issue two Register to receive Synapse electronically at mercyneuro.org.
a life-saving example of How Mercy’s Neurological Network can Help Northern california Hospitals
When 56-year-old patient Diane Bouge left Mercy Medical
Center Redding with a subarachnoid hemorrhage from
a cerebral aneurysm on Valentine’s Day, Emergency
Department physician Jesse Wells, MD, didn’t hold
high hopes.
“I didn’t think she was going to make it through the
transport,” he said.
Dr. Wells had been on the phone, seeking the specialized
care Diane Bouge needed. In the past, he had referred
such patients to University of California in San Francisco.
This time, he found the help he needed at the Mercy
Neurological Institute of Greater Sacramento.
Dr. Wells connected with George Luh, MD, an
interventional neuroradiologist. Dr. Luh’s specialty is one
that rarely exists in rural communities. A jet ride and an
ambulance later, Dr. Luh performed a coil embolization in
Mercy General Hospital’s biplane suite that saved Bouge’s
life and started her on the road to recovery.
“That’s amazing,” Dr. Wells said, learning for the first time
that his patient had survived. “This is a success story and I
want to continue and strengthen this relationship.”
Dr. Luh and Mercy Neurological Institute are equally
anxious to get better acquainted with hospitals in
surrounding areas. “This is a good example of the
importance of networking with other hospitals,” he said.
“We use the analogy of the wheel, spoke and hub, with
Mercy San Juan and Mercy General being the hub and
outlying hospitals being the spokes. We can provide the
access to the next level of care when they need it.”
Needless to say, Diane Bouge and Don Eaken, her partner
of eight years, are thrilled with the collaboration. “I’m sure
she would not have survived a more invasive procedure,”
Eaken said. Bouge has stopped smoking as a result of her
near-death experience. She still faces outpatient physical
therapy as part of her recovery. Preparing for her March 23
discharge home to Platina (a small town near Redding), she
said she looked forward to more familiar surroundings and
making organic soap as a thank you for her caregivers at
Mercy General.
If you have a patient who would benefit from the varied
specialties of the Mercy Neurological Institute of Greater
Sacramento, call the 24-hour toll-free number of
1.888.Mercy41 (1.888.637.2941).
For your convenience in neurological admissions, a dedicated toll-free number is available 24/7: 1.888.MERCY41 (1.888.637.2941)
right carotid angiogram of patient Diane Bouge with coils in aneurysm and balloon catheter in artery.
CT perfusion is a relatively new imaging technique that
helps characterize blood flow dynamics of the brain tissue
itself. Using intravenous contrast as a surrogate for blood,
perfusion imaging obtains serial images of the contrast
injection into and out of a section of brain tissue.
Perfusion imaging can not only help define areas of
ischemia, but also differentiate between areas of dead
tissue (infarct core) and tissue at risk of dying (penumbra).
The penumbra is theorized to progress to infarct if no
intervention to reperfuse the ischemic area is taken.
However, unlike the infarct core, if blood flow is restored to
this area, then the tissue may be saved. This information can
potentially help clinicians select patients that may benefit
most from thrombolytic therapy (i.e. those that demonstrate
penumbral tissue) versus those that benefit less and are at
greater risk of adverse consequences from therapy.
Only 30% of patients with an acute stroke demonstrate
findings on a noncontrast CT, CT perfusion also improves
diagnostic confidence. The perfusion images are
more sensitive in identifying an area of abnormal
blood flow dynamics. In many instances, an
abnormality is seen on perfusion images, which
was not evident on the standard CT.
In the treatment of stroke, every minute is
crucial. With the stroke protocol in place,
all the radiological diagnostic information
for both intravenous and intra-arterial
thrombolysis can be obtained all at
once enabling decisions to be made and
treatment plans initiated as expeditiously
as possible, saving both time and brain.
imaging advances save time… and Brain
John Winn, MD
“Time is brain” is the mantra of stroke medicine. At the
Mercy Neurological Institute of Greater Sacramento,
neuroscience clinicians are at the forefront of stroke
management: minimizing time and maximizing brain.
More than 600,000 cases of ischemic stroke occur annually
with less than 10% receiving emergent reperfusion treatment.
Thrombolytic therapy is constrained by time. Currently,
intravenous thrombolytics must be initiated within 3 hours,
although recent data suggest an expanded window up to
4.5 hours from symptom onset. Intra-arterial thrombolytics
and mechanical thrombectomy have time limits of 6 hours
and 8 hours respectively.
One of the major factors that prevents many stroke patients
from being treated is that the window for treatment closes with
time lost when the symptoms of stroke are not recognized and
acted upon urgently by the patient or family.
Advances in radiological imaging have streamlined part
of the process by providing important and necessary
information for the diagnosis and treatment of stroke in a
rapid manner with only one trip to the imaging department.
With the Mercy Neurological Institute stroke imaging protocol,
three separate computed tomography (CT) examinations are
performed in succession: noncontrast CT of the brain, CT
angiogram of the head and neck, and CT perfusion. Utilizing
our 64-slice scanners (Siemen Somatom Sensation 64), all
three studies can be performed within 10 minutes. Each study
provides key pieces of information that allows clinicians to
decide if and how a stroke patient is treated.
The standard noncontrast CT is used to evaluate the presence
of hemorrhage, exclude non-stroke causes of symptoms such
as tumors, and assess the extent of the infarction.
The CT angiogram helps identify a thrombus in a proximal
vessel of the middle cerebral artery, which is necessary for
treatment by intra-arterial means. In addition, it provides
anatomic evaluation of the carotid arterial system which may
contribute to or be the etiology of impaired cerebral blood flow.
John Winn, MD
72-year-old patient acute left-sided weakness and left facial droop. noncontrast ct (a) shows no findings of an acute stroke. ct perfusion (b) demonstrates a large area of abnormal blood flow to the right cerebral hemisphere. cta (c) demonstrates a clot in the right middle cerebral artery (arrow) accounting for the perfusion abnormality.
page 6 | Mercy Neurological iNstitute of greater sacramento
inpatient rehab unit Meets the Needs of Mercy’s Neuro Patients
albert Hwang, MD
The American Heart Association estimates that there are
currently 6.4 million Americans who are stroke survivors.
There are about 800,000 new stroke patients annually.
Although stroke is still the third-leading cause of death,
there have been several breakthroughs in medical
technology, such as the use of tissue plasminogen activator
(tPa), that have greatly increased stroke survivorship.
Unfortunately, stroke survivors are often faced with
functional impairments that if left untreated, can lead to
long-term medical complications.
Mercy General Hospital is equipped with a 24-bed
dedicated inpatient Rehabilitation unit designed to
treat patients with stroke, spinal cord injury, brain injury
and other neurologic diseases that create functional
impairments. The unit has been in operation for 25 years
and is currently in the process of seeking certification
by the Committee on Accreditation of Rehabilitation
Facilities (CARF), which will make it the only accredited
inpatient rehabilitation unit in the Sacramento area. The
Rehabilitation unit works closely with hospital medicine,
neurology, neurosurgery and interventional neuro-radiology
to provide seamless healthcare for stroke patients.
Patients admitted to the inpatient Rehabilitation unit
generally stay two to three weeks. During that time,
they receive physical therapy and occupational therapy
treatments. If needed, a speech therapist can also see
the patient for cognition or swallowing difficulties. The
therapy staff is trained in the latest stroke rehabilitation
techniques, such-as constrained-induced movement
therapy (CIMT), and neuro-developmental treatment
(NDT). In addition to these modalities, Mercy’s
Rehabilitation unit has a full-time neuropsychologist who
can perform in-depth cognitive testing, a necessity for
patients planning on returning to work or school. The
rehabilitation program has also recently partnered with a
neuro-optometrist, who can provide specialized eyewear
for those patients with visual deficits. The team is rounded
out by a case manager, social worker and rehabilitation
nurses. A physiatrist coordinates the interdisciplinary care
and examines the patient every day.
Inpatient rehabilitation patients receive at least three
hours of therapy per day, which makes it a more aggressive
level of care than a skilled nursing facility (SNF), where a
patient may only receive up to an hour of therapy a day.
Full-time therapy is offered six days a week, and limited
therapy is available on Sundays. A community outing to
a local business is scheduled every week for patients to
attempt to navigate in the “real world.” The treatment goal
for these patients is to have them discharged to home,
often with the help of family members, so that they can
return to productive living. Patients will often continue with
outpatient therapy treatments after discharge.
Because the inpatient Rehabilitation unit is hospital-based,
patients have access to advanced imaging such as MRI
or CT scan, and full-time laboratory services. In addition,
should medical complications arise, hospitalists and
intensivists are on-call 24 hours a day and specialists can be
consulted to provide additional care.
The Mercy General Rehabilitation unit works closely
with educational institutions in the Sacramento area to
foster learning in several different knowledge areas. A
partnership has been established with UC Davis Physical
Medicine & Rehabilitation to make Mercy inpatient
Rehabilitation one of the required
resident rotations. In addition, the unit
frequently hosts nursing students and
therapy students who have an interest
in rehabilitation. Continuing medical
education lectures are offered
on a regular basis, and area
healthcare providers from all
modalities are invited
to participate.
albert Hwang, MD
1.888.MERCY41 | page 7
more abrupt onset and termination. NES occur when awake,
while real seizures can occur while awake or asleep. Pelvic
thrusting is seen in NES, but is uncommonly seen in true
epileptic seizure which emanate from the frontal lobes.
While tongue biting is occasionally seen in patients with
NES, they tend to bite the tip of the tongue, while epileptics
bite the side.
On examination, NES is associated with active resistance to
eyelid opening. Persistent eyelid closure during the seizure
is more common with NES, while eyes are usually open in
patients with epileptic seizures. This is a helpful feature that
the clinician can discuss with family members.
The definite diagnosis of non-epileptic seizures is possible
with VEEG, monitoring in which video analysis of the
abnormal behavior is performed along with the EEG. VEEG
is used not only to differentiate epileptic from non-
epileptic seizures but also to localize seizure onset
and to evaluate whether the patient is a candidate
for other therapy, such as the Vagal Nerve Stimulator
or resective epilepsy surgery.
WHEN TO REFER: Patients with intractable
seizures, spells of uncertain cause and those
having multiple seizure types should be
referred for Video EEG.
VEEG monitoring is available at Mercy
General Hospital. For details, please call the
Neurodiagnostic Lab at 916.453.4471 or
fax 916.453.4040.
epilepsy: advancements in recognizing Non-epileptic seizures
edwin cruz, MD
EPILEPSIA is Greek for “seizing.” A SEIZURE is a symptom,
a clinical manifestation of an abnormal neuronal discharge.
EPILEPSY is a disease, characterized by unprovoked and
recurrent seizures. Accurate diagnosis and classification is
the first step in the treatment of this condition.
In most patients, a routine EEG gives sufficient information
about seizure type to guide in initiation of treatment. In
patients with recurrent seizures or unconfirmed seizure
diagnosis, further testing is needed to exclude non-epileptic
spells (NES). Misdiagnosis of epilepsy is common, and
20–30% of patients with intractable epilepsy who are
referred to an epilepsy center are found to have NES.
Non-epileptic spells may mimic epileptic seizures but are not
due to abnormal brain activity. They can be classified into
two types: PSYCHOGENIC (malingering, somatization, or
conversion disorders), or ORGANIC (sleep disorder such as
cataplexy, movement disorders such as dystonia, migraine,
TIAs, syncope or breath-holding spells).
“Red flags” for NES include continuing seizures despite
being on multiple or high-dose AED (antiepileptic drugs)
and specific triggers such as stress or getting upset, or
occurring only in the presence of an audience. NES also tend
to be gradual in onset with asynchronous limb movements,
in contrast to true epileptic seizures, which tend to have
New study finds Wii-hab May Help stroke Patients
New research presented at the American Stroke
Association’s International Stroke Conference in San Antonio
found virtual reality game technology using Wii may help
recovering stroke patients improve their motor function.
The study found the virtual reality gaming system was a safe
and feasible strategy to improve motor function after stroke.
The pilot study focused on movements with survivors’
impaired arms to help both fine and gross motor function.
“It’s a very simple game, but yet it gets patients involved
and gets them going and very excited about activity,” says
David Ferneau, Director of Mercy General Hospital’s Acute
Rehabilitation Department, which routinely uses Wii-hab
therapy with its stroke patients.
Shortly after the study report came out on Feb. 25, KXTV
News10 and KCRA Channel 3 ran stories of stroke patients
using Wii as part of their physical therapy at
Mercy General.
edwin cruz, MD
page 8 | Mercy Neurological iNstitute of greater sacramento
The CNRN credential represents specialized experience
and knowledge in the care of patients with neurological
trauma and illness. Nurses who have CNRN certification
demonstrate a unique body of knowledge and are
dedicated to the highest standards of neuroscience nursing
care and excellence in clinical practice. The institute is
planning to host another CNRN exam on Oct. 29 and looks
forward to more nurses obtaining this certification. To sign
up for the October test, nurses can contact Patty Thomas,
Mercy Neurological Institute, at 962.8711, by Aug. 6.
For more information about CNRN, go to the American
Association of Neuroscience Nurses at aann.org/credential/.
tHe PeoPle BeHiND Mercy’s focus oN
cliNical researcH
The Mercy Medical Group welcomes Caroline Lenaerts,
RN, MPH, CCRP, as a new clinical research coordinator.
Lenaerts, who joined Mercy in January, is a registered
nurse with a master’s degree in Public Health, with eight
years of experience in clinical research. She has led clinical
trials in internal medicine, mainly cardiology (patients with
cardiac arrhythmias, CHF, HTN, CAD, diabetes, etc…) and
in drug and device studies. Research allows her to use
a variety of her skills, from regulatory responsibilities to
patient care and patient education. She is certified through
the Society of Clinical Research Associates (SOCRA). With
a vast interest in other disciplines and a belief in a holistic
approach to patient care, Lenaerts says she is excited
to join the research team at Mercy Medical Group. She
looks forward to further developing Mercy’s research
department and research activities.
Her office is located in Mercy’s Midtown location at
is scheduled for May 6 at Arden Hills Country Club. Register
today at mercyneuro.org/cme or 916.851.2582.
Join us Monthly for Neuro grand roundsMercy general Hospital (first Thursday each month)
May 6: Common Intracranial Tumors, Kavian Shahi, MD
June 3: MS Center Update, M. Karsten Dengel, MD
Mercy san Juan Medical center (first Friday each month)
May 7: Intracerebral Hemorrhage, M. Asim Mahmood, MD
June 4: MS Center Update, M. Karsten Dengel, MD
Questions or program suggestions can be directed to Candy Collins in Mercy’s CME office at 916.733.6334.
UPCOMING EVENTS
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