The Future of Stroke Care

1
The Future of Stroke Care

• Anil Sharma
• University Hospital Aintree
• Liverpool

2
Stroke

• Third most common cause of death
• Commonest cause of severe disability
• 110,000 people in Wales and England have first
  stroke per year
• 30,000 go on to have further strokes
• Stroke costs about 2.4 billion in direct care
  costs

3
Age and Stroke

• Half of stroke patients are under 75 yrs of age
• 25 under 65 years
• 5 under 50 years
• Ageing population especially the increases in the
  numbers of the very elderly will counterbalance
  the benefits of primary prevention interventions
  and the numbers of stroke patients will continue
  to rise

4
What can we improve on?

• Public health information
• Diagnosis
• Stroke is an emergency
• Better in hospital care
• Rapid access to CT Scanning
• Rapid access to specialised acute stroke units
• More Thrombolysis

5
Time is Brain

• Key features of effective stroke care are
• Rapid access to specialised stroke services
• Early CT Brain scanning

6
Where are the delays?

• Patient or family did not recognise symptoms or
  seek urgent help
• Patient or family did not call an ambulance
• Paramedics did not triage stroke as an emergency
• Delays in imaging
• Inefficient process of in-hospital emergency
  stroke care

Kwan J et al. Age and Ageing 2004 33 116
7
Referral

• The response to the diagnosis of stroke should
  be
• Urgent Referral to an acute stroke unit

8
Time Dependent Services
9
Pre-hospital Services

• Rapid access across the UK is well established
• National ORCON standard for stroke
• - Category B
• - 14/19 minutes
• Category A is 8 minutes

10
Pre-hospital Services

• Stay and Play
• Versus
• Scoop and Run

11
Which Hospital

• The nearest
• The nearest with a stroke unit
• The nearest with a stroke unit that is able to
  thrombolyse if this is necessary.

12
Pre-Hospital Solutions

• Reclassify acute stroke as Category A
• Scoop and run when A and B are sorted
• Use most appropriate means of transport
• Go to hospital which can thrombolyse which has a
  stroke unit

13
Time is Brain
14
FAST

• Paramedics correctly recognised stroke 79 of the
  time

Harbison, J. et al. Stroke 20033471-76
15
Imaging

• CT scan
• Diffusion/perfusion MR
• MRA
• CTA
• DSA- occasionally only

16
Urgent CT Head Scan
17
Intra-cerebral haemorrhage
18
Diffusion / Perfusion Mismatch and
MRAStaroselskaya Arch Neurol. 2001581069
19
What is the pathological type of stroke?
Haemorrhage
Infarct
20
What disease process caused the stroke?

• Large artery disease
• Cardioembolic
• Small vessel disease

21
Ischaemic Penumbra
22
Time is Brain

• Thrombolysis
• Optimising homeostasis
• Neuroprotection

23
Early Treatment Remains Essential

• The effect size (OR 1.4) in the 3-4.5h is
  confirmed by ASS III, and the confidence
  intervals will significantly narrow in the new
  pooled analysis, however, the differnce in effect
  size compared with early treatment (OR 2.8)
  remains

OR, odds ratio
Hacke et al. Lancet 2004 363 76874
24
Remote Hospital
Stroke Center
Regional stroke ward
Up to 2 Mb/sec
CT/MRI
DICOM-Data
25
Thrombolysis Rates for stroke

• UK lt 2
• Australia / USA 9
• Current rates at UHA 11

26
MCA patency other methods

• Intra arterial tPA
• MERCI devices
• Sonothrombolysis

27
Intraarterial thrombolysis

• PROACT II

28
Improvements in Diffusion and Perfusion
Abnormalities after Intra-arterial
tPA 27-Year-Old Woman with Left Hemiparesis
Brott, T. et al. N Engl J Med 2000343710-722
29
Intra-arterial Thrombolysis (PROACT II n180)
JAMA 19992822003
30
Hemicraniectomy/Decompression

• Recent trials have shown that hemicraniectomy in
  patients with Malignant MCA syndrome is effective
  
• Close working with the neurosurgeons is essential
• Posterior fossa haemorrhage as well as infarcts
  need close observation to consider early
  decompression if necessary

31
Stroke strategy

• Stroke networks
• Paramedics
• Regional stroke units 0.5-2 million pop.
• Hub and spoke
• Neuro units and role vis a vis regional units
• Stakeholders meetings

32
SU versus conventional care

• Numbers needed to treat to prevent
• 1 death 32 (18-200)
• 1 new institutional admission 16 (10-43)
• 1 failure to regain independence 17 (11-45)

33
Are there other factors that can predict the risk
of stroke in TIA?

• The ABCD2 Score
• Age
• Blood Pressure
• Clinical features
• Duration
• Diabetes

Rothwell PM et al. The Lancet 200536629
34
ABCD2 score

• A- age 60yrs or more
  1point
• B- BP (at presentation) 140/90 or higher 1point
• C- Clinical features
• unilateral weakness
  2points
• speech disturbance without weakness
  1point
• D Duration
• 60 minutes
  2points
• 10-59 minutes
  1point
• Diabetes 1 point
• Low risk0-3
• Moderate risk4-5
• High risk6-7

35
Cumulative risk of stroke after TIA
Definite TIAs
14
OXVASC
OCSP
12
10
8
All referrals
Risk of stroke ()
OXVASC
6
Hospital clinic
4
2
0
0
7
14
21
28
Days
Lancet 2005 366 29-36
36
Imaging in TIAs

• Urgent CT scan adds little to the diagnosis and
  management of TIAs in the absence of specific
  features
• MR diffusion weighted imaging

37
DWI positivity in 175 TIA patients according to
ABCD score
p (trend) 0.008
38
Carotid Endarterectomy

• Conventional wisdom
• /gt70 ICA stenosis operate/stent
• Newer evidence
• If done quickly, males with 50-70 stenosis with
  multiple risk factors benefit from CEA

39
The future - 1

• Primary prevention of vascular disease
• AF and anticoagulation newer agents
• Public awareness and education key to action
• Regional Specialist Stroke Units receiving stroke
  patients from population base of 0.5 -2.0 million
• Receiving units very closely linked with
  Interventional Neuroradiology and Neurosurgery

40
The future 2

• Specialist stroke team on duty 24/7
• No differences in approach to TIA or stroke
• Imaging modalities must be rapidly available
  including 24/7 CT and MR perfusion and diffusion
  imaging and treatment based on these as much as
  on time windows
• Rapid access to intraarterial treatment and clot
  removal
• Future use of sonothrombolysis may have a role to
  play

41
The future 3

• Immediate stroke unit care for all essential and
  very effective
• Stroke rehabilitation short and long term - and
  carer support essential
• Regular MDT review of patients and identification
  of newer needs

42
Conclusions

• Stroke/TIAs are an emergency
• Ambulance scoop and run blue light to nearest
  APPROPRIATE stroke unit
• 24/7 thrombolysis and more with cutting edge
  imaging
• Pathway for those who fail to recanalise at 1
  hour
• TIAs risk stratify and admit those who need
  immediate assessment
• TIA clinics daily and as one stop
• Urgent carotid endarterectomy not elective!