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Focus on stroke: Out of the dark

1 May, 2012

Stroke stamp

Stroke can have devastating and long-lasting impacts on the lives of patients and their relatives. In this article, the first in the Wellcome Trust’s Focus on stroke, Nic Fleming talks to leaders in the field to hear how this condition has finally begun to be recognised as the medical emergency it is.

‘The dark ages’ is how Lalit Kalra describes the state of stroke care before the past three decades. Patients were abandoned at the back of hospital wards. Little was known about the condition and treatment essentially involved bed rest. Close to one-third of patients died within a month and half died within a year.

“I remember as a junior doctor going on ward rounds where consultants didn’t even look at stroke patients,” says Kalra, Professor of Stroke Medicine at King’s College London. “The attitude was that it was something that happens to older people, and there’s not a lot that medicine can do about it. Some recovered and went home, no thanks to the medical profession, some were sent to nursing homes and, unfortunately, a lot died.”

Since 1980 the advances in our understanding of stroke have been have been dramatic. These have been translated into improved public awareness, diagnosis, emergency treatment and patient outcomes. Comparing prognosis across time is difficult; however mortality is now below 20 per cent within a month of having a stroke.1 Yet patients’ prospects still vary widely depending where in Britain they have their stroke, and those in the field agree there is still great scope for further improvements.

Gaining some insight

The roots of modern stroke care cannot be isolated to one cause; however, the development of computed tomography (CT) in the 1970s was certainly of fundamental importance. The technique produces a three-dimensional image of the inside of an object from two-dimensional X-ray images.

“Before this it was like having the brain in a closed box,” says Kalra. “Suddenly we could actually see the brain, the amount of damage, what sort of damage it was, see the swelling, the bleeding, and we started understanding what happens to the brain in a stroke.”

CT scanning crucially allowed doctors to distinguish between ischaemic strokes, in which patients suffer blockages in arteries carrying blood to the brain, and haemorrhagic strokes caused by bleeds. Brain cells need the oxygen and glucose they get from blood to function and stay alive. When deprived of these they rapidly start to die, causing the loss of functions such as movement and speech.

Brain imaging techniques made it possible to identify ischaemic strokes, which constitute almost nine out of ten of all strokes, and therefore determine which patients might benefit from the use of thrombolytic, or clot-busting, therapy. Such treatment carries with it a risk of bleeding, something that must be avoided at all costs in haemorrhagic stroke patients.

The most influential of the trials that demonstrated that the benefits of thrombolysis outweighed the risks for some patients was the US National Institute of Neurological Disorders and Stroke (NINDS) trial published in 1995.2 This showed that treatment with clot-busting tissue plasmogen activator within three hours of acute ischaemic strokes increased the proportion of patients with minimal or no disability from 38 per cent to 50 per cent compared with placebo. One per cent of patients had a severely worse outcome because of a haemorrhage. Overall, for every 100 patients treated, outcomes were improved for 32 and worsened for three. Other trials have shown thrombolysis can yield more moderate benefits if given between 3 and 4.5 hours.

“The NINDS trial was critical because it meant there was now an acute treatment that could be given and that in order to give it we had to get people to hospital urgently,” says Tony Rudd, Consultant Stroke Physician at St Thomas’ Hospital, London. “This provided a rationale for setting up acute stroke units capable of responding quickly.”

Specialist units

At around the same time, separate research identified significantly improved outcomes for patients treated in specialist stroke units. One key paper3, published in the Lancet in 1993 by Peter Langhorne of the University of Glasgow and colleagues, combined data from ten trials and found stroke unit patients were 28 per cent less likely to have died four months on from their stroke compared to those admitted to general wards. At 12 months, the figure was 21 per cent. Later studies confirmed the findings and showed stroke units also reduced disability, dependency and length of hospital stay.

The complex nature of both the condition and interventions has made it difficult to pin down precisely why stroke units are so successful. “The general consensus is that it is about multidisciplinary teams working effectively together, having stroke specific staff, easy access to imaging and other necessary investigations, as well as involving patients and their carers in rehabilitation,” says Rudd.

Other research advances around this time included work showing that giving aspirin as soon as possible following ischaemic stroke led to a small reduction in related deaths and dependency and studies showing that transient ischaemic attacks (TIAs), or mini-strokes, were often precursors of full-blown strokes and shown be treated accordingly. Various studies, culminating in a Cochrane systematic review in 2005, found that discharging patients early from hospital and providing home-based rehabilitation improved outcomes.

Although research advances have been fundamental, they represent only one side of the coin. The significant improvements in patient outcomes would not have been possible without associated changes in policy and service organisation. At the start of the 1980s, public and media opinion was increasingly hostile to the long-stay hospitals and institutions to which many people with mental health and physical disabilities, including stroke patients, were sent. The government began a programme of closing long-stay hospitals, advocating care in the community as an alternative. The policy was controversial, yet one consequence was that it created a need for the redesign of stroke care and management.

However, health managers and government ministers did not get behind the idea of specialist stroke services until the work of Langhorne and others during the 1990s, which showed the significant improvements in outcomes associated with them. The National Service Framework for Older People of 2001 reported that although the evidence of benefits was clear, only around one-quarter of patients were being treated in specialist units. In the same year, the Department of Health in England set a target that all general hospitals in the country should have specialised units that would seek to prevent strokes in those at risk and provide acute care and rehabilitation, as well as long-term support, by 2004.

A highly critical report was published by the National Audit Office in 2005. It stated that effective, integrated emergency responses to stroke were rare, only 63 per cent of patients were attending stroke units, what constituted a stroke unit varied widely and many were too small, most patients were waiting two days for brain scans, thrombolysis was rarely used, access to key rehabilitation professionals was patchy, and public awareness was low.

“The report demonstrated how poor English stroke services were and what poor value they were,” says Damian Jenkinson, Interim National Clinical Director for Stroke, Department of Health. “We were spending £7 billion per year ineffectively, and that’s what made the Government really listen and commit to making a difference.”

Strategic thinking

Next came the publication of the National Stroke Strategy in 2007, setting out what good quality care, from prevention and acute care to rehabilitation and other long-term support, should look like. It presented 20 quality markers for the assessment of services.

It is seen by many in the field as a turning point. “It laid out what should be done, and set out quality markers, not just for acute medical care but for longer-term care too,” says Eileen Gambrell, Services Manager at Different Strokes, a national charity for stroke patients of working age. “That allowed people to go back and see what progress had been made. It set out a lot of challenges and kick-started a lot of improvement. There is still a long way to go, but it was certainly a good starting point.”

The Department of Health’s £11.5 million Act FAST advertising campaign, launched in 2009, was widely acknowledged as a success in improving public awareness and understanding of stroke. A series of television advertisements featured shocking images of flames spreading across patients’ foreheads and facial slackness. The number of emergency calls categorised as suspected stroke jumped by 54 per cent in 2009, compared to 2008.4

In a follow-up report in 2010, the National Audit Office acknowledged that significant improvements had been achieved in acute stroke care, with more patients spending more time in specialist units, greater and faster use of brain scanning, and the number of patients receiving thrombolysis doubling between 2007–08 and 2008–09. It applauded improved public and professional awareness of the symptoms of stroke but noted less progress had been made in longer-term rehabilitation and care. A review by the Care Quality Commission last year pointed to failures including in access to therapy, psychological support, and help with returning to work and family life, as well as in post-hospital care reviews.

“Things have improved but it is patchy, and it is still a bit of a postcode lottery,” says Gambrell. “The longer-term, emotional aspects of recovery, such as dealing with depression, anxiety and fatigue, are still very much neglected. People are getting short allocations of physiotherapy and speech therapy. A lot of people are basically left to their own devices once they are out of acute care.”

Such views are widely shared. “What we are really not that good at is the longer-term management,” says Rudd. “Patients come into hospital, get into the stroke units, but then actually spend most of their time sitting around not really having very much happening to them. There is, I think, evidence of a link between the intensity of therapy and the speed of recovery people make, so we have to think about how we get more therapy for people without necessarily saying we need staff.”

Jenkinson, part of the team that drew up the Stroke Strategy, acknowledges these failings. “The reason we have not made so much progress in the post-acute parts of the pathway is because the evidence base is less robust, and the care is provided by lots of different agencies. That has been and continues to be more of a challenge, although we have got plans and schemes that continue to run to address this.”

There is also still a lot of geographical variability in the quality of treatment and care. London now has a network of eight hyper-acute stroke units with extra specialist staff around the clock and the ability to rapidly assess, diagnose and treat patients, as well as additional therapists. Consequently, people who have strokes in the capital are around 20 per cent less likely to die of them. Bringing the rest of the country up to the same standard is a key challenge facing today’s health managers.

Many believe that translating advances in knowledge about longer-term recovery from stroke will be more difficult than the recent breakthroughs in acute care. “We converted new knowledge into practice very well with stroke units and thrombolysis,” says Kalra. “Implementing what we are going to discover about recovery and rehab will be a bigger challenge because it is more ill-defined.”

Future research

On the research side, there is a lot of interest in whether thrombolysis could be given to more patients, extending its use beyond the current 4.5-hour post-onset treatment window. Animal studies show that cooling body temperature can significantly reduce the area of brain affected by strokes. In March, funding was announced for EuroHYP-1, a study due to involve 1500 ischaemic stroke patients in 15 European countries that aims to determine whether cooling can improve outcomes.

“Deprived of blood flow, both blood vessels and nerve cells will degrade,” says Anthony Strong, Emeritus Professor of Neurosurgery, King’s College London. “The idea is that by cooling these patients, we may be able to slow down these degradation processes and give ourselves more time in which to reperfuse.”

Researchers are also looking to develop more advanced imaging techniques with the aim of finding a way to allow physicians to tell which patients can still benefit from treatment, perhaps beyond the 4.5-hour time limit. There is a lot of ongoing work investigating how the brain heals, which markers could be used to measure the amount of recovery following injury and on potential therapies to promote brain healing, including drugs and stem cells.

“I’ve witnessed a lot of change in the stroke field,” says Kalra. “To a certain extent it is very reassuring to see, but by no means have we got to where we need to be. We are learning very quickly. The challenge now is whether we can keep up the momentum and convert this new knowledge into practice to the greater benefit of all patients.”

References

 1. Intercollegiate Stroke Working Party. Sentinel Stroke Audit 2010. May 2012.

2. National Institute for Neurological Disorders and Stroke rt-PA Study Group. Tissue plasminogen activator for the treatment of acute ischaemic stroke. N Engl J Med 1995;333:1581–88.

3. Langhorne P et al. Do stroke units save lives? Lancet 1993;342(8868): 395–8.

4. Mead-Robson A. ‘Significant’ improvement in stroke care in England. GPonline.com. Accessed 20 April 2012.

Nic Fleming

Nic Fleming is a freelance writer based in London.

This article is part of the Wellcome Trust’s Focus on stroke, a series of articles, interviews and videos running throughout May 2012, which is the Stroke Association’s Action on Stroke Month.

For more information on stroke, visit the Stroke Association’s site or call its helpline on 0303 303 3100. If you or someone with you is suspected of having a stroke, call the emergency services immediately.

9 Comments leave one →
  1. Jon Barrick permalink
    1 May, 2012 10:08 am

    Excellent article, well done to the Welcome Trust for highlighting stroke. The challenge as Professor Kalra has stated is to keep up the momentum for improvement in Stroke care. We in the Stroke Association believe that continued investment of energy, resources and time into prevention, stroke research and ensuring better quality of life after stroke will challenge the publics old fashioned view that nothing can be done about stroke. A huge leap forward has occurred over the last 10 years, but so much more can be achieved. Stroke is now the second biggest killer in the world. We believe the next 10 years are an era of opportunity in the fight against strokes, this is a cause we must give more prominence.

  2. 1 May, 2012 3:00 pm

    The emergency response to stroke has improved over the last decade (we still get the occasional caller to the StrokeLine saying that the ambulance crew or A & E staff thought they were drunk, but it used to be very common) and as the article makes clear there have been huge advances in acute care. But younger stroke survivors often tell us that once they are discharged from hospital they feel “dumped”. They need ongoing rehabilitation services, guidance and support in returning to work or other meaningful activity, and psychological support, for them and other family members, as they come to terms with the consequences of their stroke. More still needs to be done and so we will continue to help them push for the individualised rehabilitation and recovery that they need to be able to return to a full and active role within their community.

  3. Chrissie Giles permalink
    2 May, 2012 8:14 am

    Thanks Jon and Debbie for your insightful comments. We’ve got a whole series of articles around stroke coming throughout May, which will cover many more aspects of stroke care and research. This Friday we hear from a number of professionals in the field about what they think has been the biggest advance in their career so far and, towards the end of the month, we’ll be hearing what they think are the key challenges that remain in stroke.

    Debbie, the personal accounts we’re planning to publish from people who have had a stroke echo the need for support you mention. We’ll also be taking a look at some of the research underway and technology in development to help people rehabilitate and adapt to life after stroke.

  4. camarades1 permalink
    2 May, 2012 9:32 am

    Further details of the EuroHYP-1 cooling trial are available at http://www.eurohyp1.org

  5. 8 May, 2012 5:16 pm

    The IST-3 trial, funded by the MRC, is the world’s largest-ever trial of clotbusting treatment for acute ischaemic stroke with the drug rt-PA will release its results at the European Stroke Conference on May 23rd, with simultaneous publication in the Lancet. Follow IST-3 on our website http://www.ist3.com and on twitter @IST_3

  6. 31 Jul, 2012 7:39 pm

    I had a stroke some eight months ago. Suddenly with no warning except for headaches. Lots of long distance flights, lots of stress but fit and not used to being unwell. Yes I am 65 but look and feel ten years younger. Young kids under twelve and a beautiful wife. Life was good with holidays and no worries.. Then very quickly it all changed. Stroke and having to close down my brand consultancy after fourteen years. Too much aggravation from a director and staff that were more interested in them selves.
    Today I’m happier to leave that world behind me. More time with the family and just thinking of starting to do some consultancy. On my own !!!
    jeff klein

Trackbacks

  1. Focus on stroke: Making a campaign out of a crisis « Wellcome Trust Blog
  2. Focus on stroke: Treating stroke « Wellcome Trust Blog
  3. Focus on Stroke « Wellcome Trust Blog

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