Stroke strikes like a thun­der­bolt

With such a high rate of dis­abil­ity and death from stroke in Ire­land, a new clin­i­cal trial and a new form of in­ter­ven­tion aim to re­duce the hu­man cost. But more in­vest­ment is needed

The Irish Times - Tuesday - Health - - Front Page - Michelle McDon­agh

When Prof Peter Kelly was a med­i­cal stu­dent there was a great sense of ni­hilism around the treat­ment of stroke as there was lit­tle or noth­ing that could be done for pa­tients in terms of med­i­cal in­ter­ven­tion. How­ever, since then there have been some ma­jor ad­vances in the treat­ment of stroke­and to­day, he and his col­leagues are en­sur­ing that Ir­ish pa­tients are some of the first in the world to ac­cess the most in­no­va­tive new treat­ments avail­able.

With stroke the third lead­ing cause of death in Ire­land (and se­cond lead­ing glob­ally) and the lead­ing cause of dis­abil­ity in this coun­try, Prof Kelly, con­sul­tant neu­rol­o­gist and di­rec­tor of the stroke ser­vice at the Mater Hos­pi­tal, says there is barely a fam­ily in the State that has not been touched by this dis­ease.

“In hu­man terms, it is an ab­so­lutely dread­ful dis­ease. Stroke is the ap­pro­pri­ate name be­cause it strikes like a thun­der­bolt. One minute you are well and the next minute you can be paral­ysed, or have have lost your speech, mem­ory or sight. A stroke can rob some­body very quickly of their in­de­pen­dence and au­ton­omy. There is a huge cost to the in­di­vid­ual pa­tient at a hu­man level, and to the health sys­tem, and a great deal more needs to be done around stroke,” he says.

Stroke is a dis­ease that af­fects the ar­ter­ies lead­ing to and within the brain. A stroke oc­curs when a blood ves­sel that car­ries oxy­gen and nu­tri­ents to the brain is ei­ther blocked by a clot (is­chemic stroke) or rup­tures (haem­or­rhagic stroke), lead­ing to the death of brain tis­sue and cells.

The first ma­jor de­vel­op­ment in stroke treat­ment came in the mid-1990s when it was found that if pa­tients were given the clot-bust­ing drug Al­teplase quickly enough af­ter hav­ing a stroke, some of the dam­age could be re­versed and the pa­tient’s chances of re­turn­ing to full or near-full in­de­pen­dence in a mat­ter of weeks im­proved. The se­cond ma­jor de­vel­op­ment came when it was shown that or­gan­is­ing the care of pa­tients into stroke units clearly im­proved out­comes in the short and long term.

“A lot of us who had just be­gun our ca­reers in the field were en­er­gised by these de­vel­op­ments, and many of us de­cided to ded­i­cate our ca­reers to im­prov­ing care for peo­ple with stroke,” says Prof Kelly.

Kelly heads up the Health Re­search Board (HRB) Stroke Clin­i­cal Trial Net­work Ire­land which is made up of of eight Ir­ish hospi­tals, six lead­ing uni­ver­si­ties and all seven hos­pi­tal groups. The net­work has strong links with in­ter­na­tional re­searchers in the UK, Europe and North Amer­ica, and in the past 18 months has joined sev­eral new in­ter­na­tional tri­als of new treat­ments for emer­gency care, pre­ven­tion and re­cov­ery af­ter stroke.

In a ma­jor first for Ire­land, the net­work is lead­ing a new in­ter­na­tional clin­i­cal trial aim­ing to pre­vent sec­ondary strokes and heart at­tack af­ter a first stroke. The Con­vince trial is in­ves­ti­gat­ing the po­ten­tial of re­pur­pos­ing an anti-in­flam­ma­tory that has been around for hun­dreds of years to treat gout and arthri­tis, and us­ing it in low doses with standard treat­ments such as as­pirin, statins and smok­ing ces­sa­tion, to pre­vent re­cur­rent stroke and heart at­tack in pa­tients who sur­vive a first stroke.

In re­cent years there has been much re­search in­ter­est in the role of in­flam­ma­tion in trig­ger­ing heart at­tack and stroke. Prof Kelly ex­plains that just as a pim­ple or boil can be­come red and in­flamed, so too can the lin­ing of the blood ves­sels. This in­flam­ma­tion can trig­ger the rup­ture of plaque and can lead to clots break­ing off. The Con­vince trial has started in Ire­land and is be­ing rolled out in nine other Euro­pean coun­tries. This re­search is of no in­ter­est to in­dus­try, as there is no profit in it, Prof Kelly says, but could be of ma­jor ben­e­fit to pa­tients.

“A first stroke is an im­por­tant risk fac­tor for fur­ther strokes even if you are on the best treat­ment. Un­for­tu­nately, if you have a stroke, your risk of another in the first year af­ter­wards is 6 per cent, which is far higher than the back­ground pop­u­la­tion. That risk is cu­mu­la­tive over the next five years up to 15-25 per cent for a fur­ther stroke, heart at­tack or other vas­cu­lar event. If you have a stroke, your risk of heart at­tack is higher and vice versa.”

While the HRB is the pri­mary fun­der of the Stroke Net­work, the Ir­ish Heart Foun­da­tion will fund new Stroke Re­search Nurses, and there is a very small amount (5 per cent) of fund­ing from in­dus­try part­ners for ed­u­ca­tion and train­ing ac­tiv­i­ties.

Prof Kelly says: “Ir­ish pa­tients will be some of the first in the world to have ac­cess to in­no­va­tive new treat­ments which may pro­vide us with ev­i­dence to change global guide­lines and prac­tice in stroke treat­ment.”

Atrial fib­ril­la­tion

New global re­search sug­gests that up to one-third of strokes may be pre­vented with proper screen­ing for the com­mon heart con­di­tion asymp­to­matic atrial fib­ril­la­tion

(AF) in peo­ple aged 65 and older. Dr Rónán Collins, di­rec­tor of stroke ser­vices at Tal­laght Hos­pi­tal, who was one of the key re­searchers in­volved in this study, points out that these find­ings have im­pli­ca­tions for stroke pa­tients around the world.

Asymp­to­matic AF is the most com­mon­cause of heart rhythm dis­tur­bance and can be eas­ily de­tected by sim­ply tak­ing the pulse, or by us­ing hand­held ECGs, which pro­vide a di­ag­no­sis in less than a minute. On the back of this re­search, the or­gan­i­sa­tion AF-Screen has been es­tab­lished to push for the in­tro­duc­tion of na­tional screen­ing pro­grammes for this con­di­tion.

Dr Collins ex­plains: “AF is an age-re­lated con­di­tion that you are more likely to de­velop as you age. While younger peo­ple will usu­ally have symp­toms like pal­pi­ta­tions or short­ness of breath, in most older peo­ple AF is in­ter­mit­tent. The risk of stroke is five times greater if you have AF and very of­ten the first time peo­ple know they have it is when they have a stroke. These strokes tend to be big­ger, more se­vere, and more likely to be fa­tal – and, if you sur­vive, are more likely to be dis­abling.”

The re­search group looked at peo­ple aged over 60 with a num­ber of fac­tors for stroke – in­clud­ing hy­per­ten­sion, di­a­betes

and heart fail­ure – and recorded their heart rate over five days. They found ev­i­dence of AF in more than 14 per cent of peo­ple liv­ing in the com­mu­nity with no aware­ness of their con­di­tion.

“This is clearly a big bang for your buck. You would not find a rate of 14 per cent through screen­ing for breast or cer­vi­cal can­cer. It’s a very plau­si­ble tar­get to look at a high-risk group for screen­ing when stroke kills so many peo­ple. There is a whole range of sim­ple light­weight wear­able de­vices that mea­sure your heart rate on the mar­ket now, and the tech­nol­ogy is get­ting cheaper and eas­ier to use,” Dr Collins says.

He is call­ing on the Depart­ment of Health to give AF screen­ing the same fund­ing and pro­mo­tion as it gives to Breastcheck, given the se­ri­ous per­sonal con­se­quences for the in­di­vid­ual stroke suf­ferer and the mas­sive fi­nan­cial cost of car­ing for stroke pa­tients.

Halv­ing stroke mor­tal­ity

More and more Ir­ish pa­tients are now also avail­ing of a ground-break­ing new treat­ment that has been shown to re­duce stroke mor­tal­ity by half and to al­most dou­ble the rate of pos­i­tive life-chang­ing out­comes for stroke vic­tims. The thrombec­tomy pro­ce­dure in­volves skilled neu­ro­ra­di­ol­o­gists in­sert­ing an ul­tra-thin tube into the artery in the groin and up through the body into the brain ves­sels. The clot is then re­moved from the brain ves­sel by a re­triev­able stent, restor­ing blood flow to the brain.

This pro­ce­dure is be­ing per­formed at Beau­mont Hos­pi­tal, Dublin, the na­tional cen­tre for neu­ro­surgery, and Cork Univer­sity Hos­pi­tal.

Dr John Thorn­ton, con­sul­tant neu­ro­ra­di­ol­o­gist at Beau­mont, who has led the de­vel­op­ment of the thrombec­tomy ser­vice in Ire­land, says the clot-bust­ing med­i­ca­tion used to treat stroke pa­tients does not work for larger clots that typ­i­cally re­sult in the most se­vere strokes. If a thrombec­tomy is car­ried out on time, and blood sup­ply re­stored to the af­fected brain tis­sue, this tis­sue can ac­tu­ally re­cover.

“Ev­ery minute, two brain cells die once blood sup­ply has been blocked off, so time is brain. Pre­vi­ously, stroke was re­garded as a non-ur­gent sce­nario, as there was not much that could be done for pa­tients, but now it’s one of the most ur­gent con­di­tions on a par with acute heart at­tack and needs to be treated with the same ur­gency. Thrombec­tomy can be to­tally suc­cess­ful in some pa­tients and can im­me­di­ately and to­tally re­verse the ef­fects of a ma­jor stroke,” says Dr Thorn­ton.

Some pa­tients do not get any re­cov­ery when the clot is re­moved if too much brain tis­sue had died, while oth­ers may get only par­tial re­cov­ery or re­cov­ery may be slower, says Dr Thorn­ton.

With­out thrombec­tomy, these pa­tients would re­ceive the best med­i­cal treat­ment avail­able, but many would be left per­ma­nently dis­abled.

The thrombec­tomy ser­vice was es­tab­lished at Beamount in 2010, and has grown rapidly since 2015, treat­ing 170 pa­tients in 2016 and an es­ti­mated 250 pa­tients this year. The ser­vice at Beau­mont is avail­able 24/7 and treats pa­tients from all over the coun­try.

Dr Thorn­ton points out: “The chal­lenge is to get more rapid and ef­fi­cient as­sess­ment and di­ag­no­sis of acute stroke pa­tients who may be suit­able for this pro­ce­dure in more hospi­tals all over the coun­try. The more ef­fi­cient hospi­tals be­come at di­ag­nos­ing acute stroke and do­ing CT scans, the more pa­tients we will find within a suit­able win­dow for treat­ment.”

Stark sta­tis­tics

The fig­ures are stark. Stroke is the third-largest killer in Ire­land and the most com­mon cause of ac­quired, se­ri­ous phys­i­cal dis­abil­ity. Some 10,000 Ir­ish peo­ple will have a stroke-re­lated event this year, and a fur­ther 30,000 are liv­ing in the com­mu­nity with a dis­abil­ity as a re­sult of stroke.

Prof Joe Har­bi­son, head of the HSE’s na­tional stroke pro­gramme, has warned that Ire­land’s stroke ser­vices are head­ing for a cri­sis, and are un­able to cope with the num­ber of pa­tients who need them now, never mind the pre­dicted surge in cases as the pop­u­la­tion ages.

Since the cre­ation of the na­tional stroke pro­gramme in 2010, deaths from stroke have dropped by more than 15 per cent, while the num­ber of those left with se­vere dis­abil­ity has fallen by more than 20 per cent. The emer­gency care for stroke pa­tients pro­vided in most Ir­ish acute hospi­tals has im­proved sig­nif­i­cantly, and we are at the cut­ting edge of de­liv­ery of some new ther­a­pies such as thrombec­tomy.

How­ever, the HSE’s Na­tional Stroke Au­dit 2016 showed that while the in­ci­dence of stroke is rising 4-5 per cent per year, we still have a se­vere short­age of stroke unit beds and spe­cial­ist nurs­ing, ther­apy and med­i­cal staff.

We have only about half the acute stroke unit beds we need to meet in­ter­na­tional stan­dards and an even lower pro­por­tion of spe­cial­ist re­ha­bil­i­ta­tion beds. Stroke units have been shown to be twice as ef­fec­tive as coro­nary care units in re­duc­ing death and se­vere dis­abil­ity, but no hos­pi­tal in the coun­try has a unit that is re­sourced to min­i­mum in­ter­na­tional stan­dards.

And we still have only three small, un­der-re­sourced Early Sup­ported Dis­charge teams for stroke which, Prof Har­bi­son points out, are con­sid­ered a ba­sic el­e­ment of care in most western Euro­pean coun­tries.

Har­bi­son re­cently an­nounced that the out­comes for stroke pa­tients were in de­cline, re­vers­ing the ma­jor im­prove­ments that had been made in their care in re­cent years. The av­er­age length of stay for stroke pa­tients is in­creas­ing, and more pa­tients are be­ing dis­charged to nurs­ing homes.

Dr Collins, head of stroke ser­vices at Tal­laght Hos­pi­tal, says it’s not fair to be too ni­hilis­tic, point­ing to the huge progress that has been made by the stroke com­mu­nity – in­clud­ing nurses, clin­i­cians and al­lied pro­fes­sion­als – and the Ir­ish Heart Foun­da­tion over the past decade.

“We have achieved an aw­ful lot in the past 10 years: things are 10 times worse in the UK and equally bad in France. Now 90 per cent of our acute hospi­tals have a stroke unit, we have 24/7 throm­boyl­sis to treat stroke pa­tients and in­creas­ing avail­abil­ity of thrombec­tomy for those who need it. This is a huge sea change from 2005 when we had no acute stroke units and no throm­bol­y­sis.”

Dr Collins high­lights the need to de­velop the thrombec­tomy cen­tre at Beau­mont Hos­pi­tal fur­ther, to en­sure the cen­tre at Cork Univer­sity Hos­pi­tal is prop­erly re­sourced and to open a cen­tre on the western seaboard and the south side of Dublin within the next 10 years to cover the whole coun­try prop­erly.

“We need to fu­ture-proof ser­vices, there’s no point in just build­ing what we need now. We need to tackle stroke on two fronts, through pre­ven­tion in the first place and through faster ac­cess to di­ag­no­sis and treat­ment of stroke pa­tients in our hospi­tals.” he says.

While the in­ci­dence of stroke is rising 4-5% per year, we still have a se­vere short­age of stroke unit beds and spe­cial­ist nurs­ing, ther­apy and med­i­cal staff


Top, Vin­cent Byrne, who had a stroke five years ago; right, Dr Rónán Collins, head of stroke ser­vices at Tal­laght Hos­pi­tal; far right, Dr Joe Har­bi­son, head of the HSE’s na­tional stroke pro­gramme.

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