Fast action on stroke is saving lives

Great strides have been made in the diagnosis and treatment of stroke, but there is still room for improvement, writes CLAIRE O'CONNELL

THERE’S A SAYING in stroke medicine that “time is brain”. In other words, get medical attention as quickly as possible for a stroke, where a blood clot or bleed is damaging brain tissue. Because the longer it goes on, the more potential there is for that precious tissue to be damaged.

So when patients get to hospital quickly, what kinds of recent advances in treatment await them?

“There have been gigantic steps forward in terms of treatment of stroke over the past four or five years,” says consultant physician in geriatric and stroke medicine, Dr Rónán Collins, who directs stroke services at Adelaide and Meath Hospital in Tallaght.

Technology and new medications have important roles to play, but developing more stroke units in hospitals has been one of the major recent changes in Ireland, he notes.

“Stroke patients are now being treated in dedicated units, with organised protocols of care and with staff who are both trained and interested in stroke as a disease,” he says.

“I think that has been a huge development. In 2005 we would have had one stroke unit and maybe three organised services in the country, which weren’t dedicated stroke units. Now we have in the region of 14 or 15 stroke units.”

More generally, one of the most high-profile developments in treating patients who come in with stroke has been the availability of “clot-busting” or thrombolytic drugs. But they aren’t suitable for all stroke patients, and those who could benefit from them need to be assessed by a physician quickly.

Having stroke experts on a rota around the clock is challenging for an individual hospital, so Tallaght, Naas General Hospital and the Midland Regional Hospital in Mullingar have been running a telemedicine project to allow stroke physicians to be on call across all hospitals at once.

A robot (RP-7, from InTouch Health) allows a doctor at one hospital to videoconference with a patient and medical team at another site.

This means that patients can be assessed quickly when they come in, and this speed is important if their cases are suitable for clot-busting medications. “You have a limited time window in which this drug can be given, but almost as important a message is that the sooner you give this drug the better,” says Collins.

The year-long pilot telemedicine programme saw rates of thrombolysis – the breakdown of blood clots by drugs – increase at all three hospitals. Patient feedback has been positive and the robots are still in action across that network of hospitals.

Another approach to getting rid of a clot is to go after it with a medical device that is threaded up into the affected blood vessel itself. It’s an emerging area, says Joe Woody, president of vascular therapies at Covidien, a healthcare products company.

One of its products, Solitaire, can be guided up into the blood vessels of the brain to retrieve a clot and allow blood to get flowing again, and it is being trialled at Irish sites.

Such devices are likely to play an important role in stroke treatment, says Collins.

“If you give intravenous thrombolysis and it doesn’t work, it makes intuitive sense that you should try to remove the clot from the artery and restore circulation to the brain if you can. But we will need to see formal trial results,” he says.

“I would be saying to my younger colleagues coming along in stroke medicine that part of stroke care will involve this in the future, so some of you might like to start training as interventional stroke physicians; that your country will need these skills.”

Collins also draws attention to emerging medications for preventing stroke, particularly for people with an abnormal heart rhythm called atrial fibrillation, which is a risk factor for severe strokes.

The traditional treatment has been the blood-thinner warfarin, he explains. But while warfarin is cheap, it’s not always an easy drug to manage.

“It has the potential for many interactions with drugs and some foods. It can be affected by antibiotics, by alcohol, and for certain individuals the constant variation in warfarin levels can result in undertreatment, so there’s no protection, or overtreatment so there’s a risk of bleeding.”

Newer medications are likely to offer alternatives to warfarin, says Collins. “It’s going to make our decision-making better and it’s going to improve patient compliance with the drugs – and hopefully that will result in greater efficacy in preventing stroke.”

Ireland’s first National Stroke Week, hosted by the Irish Heart Foundation and supported by Covidien, runs until March 31st. See stroke.ie

LEARN THIS: THE SIGNS OF A STROKE

Could you recognise the symptoms of a stroke?

Last year the Irish Heart Foundation launched its FAST campaign on TV to increase awareness of possible stroke symptoms – face fallen on one side, inability to keep both arms up, slurring of speech – and to act fast on them by phoning for help.

The first phase of that campaign saw 59 per cent more stroke victims getting to hospital in time to receive potentially lifesaving clot-busting treatment, according to a study at Beaumont Hospital and Connolly Hospital carried out by the Royal College of Surgeons in Ireland.