Specialist Registrar Stroke Unit University Hospital Aintree UK.
Consultant Physician Divisional Medical Director for Medicine RCP Regional Advisor for Stroke University Hospital Aintree UK.
The World Health Organization (WHO) estimates that worldwide 15 million people suffer a stroke each year. Within the UK, stroke is the third most common cause of death and the single largest cause of adult disability. It is estimated that 110,000 new strokes occur within the UK annually and currently there are 900,000 people living in England who have had a stroke. It has long been recognised that rapid and accurate stroke assessment and management improve patients’ outcome from stroke. However, there have been many obstacles to this in the past, some of which persist today.
Rapid recognition of stroke enables rapid treatment of stroke. In ischaemic stroke, thrombolysis is proven to be the most effective initial treatment reducing the number of patients with long-term disability from stroke by 30 per cent. The faster this is delivered, the greater the chance of reducing long-term disability and death given that the potential benefit from thrombolysis decreases over time. The need to treat stroke as a medical emergency is key, time delay costs neurones!
Alteplase is currently the only licensed drug for thrombolysis in the UK. It was first licensed in the US in 1996, a restricted license was granted in Europe in 2003. Several landmark thrombolysis trials, including the NINDS trial in 1995, have proved the efficacy of the drug.
More recently, the ECASS III trial published in September 2008 established a favourable outcome with thrombolysis delivered within 4.5 hours of stroke onset.
The National Sentinel Audit for Stroke 2008 assessed stroke care within the UK over the previous two years (2006-2008). Currently, 215 hospital sites offer thrombolysis within the UK. However, only 72 of the 215 relevant sites gave Alteplase to one or more of their patients. During this period, 204 patients were thrombolysed, i.e. only 1.8 per cent of patients with ischaemic strokes. Clearly we have a long way to go to improve stroke care within the UK.
The National Stroke Strategy was published in December 2007. Its aim was to improve stroke care across the UK and outlined 10 key goals to help achieve this. The need to improve awareness of stroke symptoms by the public and health professionals, the need to treat stroke as a medical emergency involving specialist teams, 24-hour access to specialist care and early transfer to a stroke unit were all key goals highlighted in the document. The target for thrombolysis for acute ischaemic stroke within the UK is 10 per cent by 2011. However, this is unlikely to be achieved.
Public recognition and perception of stroke remains a significant factor in the delay of initial stroke assessment and transfer to hospital as an emergency. Although most patients are able to identify the symptoms of a myocardial infarction, a MORI poll performed by the Stroke Association UK in 2005 revealed only 50 per cent of patients were able to identify what a stroke is and only 40 per cent were able to name three stroke symptoms. The FAST test, a validated stroke recognition tool, was developed in 1998 from the Cincinnati Prehospital Stroke Scale. It was initially designed to assist ambulance technicians in the recognition of acute stroke and aid rapid transfer to hospital. Nor et al., Stroke 2004, assessed the agreement between ambulance technicians and paramedics and stroke specialists when using the FAST tool to identify neurological signs in 278 patients with suspected stroke. They concluded that the use of FAST by ambulance technicians and paramedics showed moderate to excellent agreement with stroke physicians.
The FAST test comprises four elements (F) facial weakness, (A) arm weakness, (S) speech problems and (T) time to call 999. The Act FAST campaign was commenced across the UK in February this year. It compromises adverts on TV, radio and in print and aims to raise public awareness of the symptoms of stroke and that emergency stroke treatment can limit stroke damage and save lives (see Image 1). It’s hoped that this campaign will increase the number of patients contacting emergency services and therefore arriving at Accident and Emergency within 1-3 hours.
The rapid and accurate assessment of stroke by emergency physicians within the A&E department is vital in aiding appropriate and emergency referral to the stroke team. The ‘Recognition of Stroke in the Emergency Room’ or ROSIER tool is used by emergency physicians to aid stroke diagnosis (see Table 1). It is proven to help differentiate stroke from common stroke mimics, such as seizure and syncope, with a score of greater than one necessitating urgent stroke referral. Initially developed and validated by Nor et al. the tool was found to have a 92-93 per cent diagnostic sensitivity and 83-86 per cent specificity for the diagnosis of stroke. It has now been widely adopted by A&E departments throughout the UK. The development of an effective model for stroke care within individual trusts is the key to providing a comprehensive stroke service. Immediate blue-light transfer by ambulance to a hospital with hyper-acute stroke services, with a stroke triage system, 24-hour access to specialist stroke team assessment, 24-hour access to thrombolysis and early transfer to a designated acute stroke unit are vital to delivering effective stroke care. There is overwhelming evidence in support of acute stroke unit care. In 2007, a systematic review of stroke unit care was performed by the Stroke Trialists Collaboration, Cochrane database. It concluded that patients treated within an organised stroke unit are more likely to survive their stroke, return home and become independent in looking after themselves and that the benefits are proven over five and ten years. The National Sentinel Audit for Stroke 2006 estimated that if 75 per cent of stroke patients had timely access to stroke unit care 500 deaths per year would be prevented and 200 more individuals would live independently per year. The key to stroke unit success is a multidisciplinary approach, including early rehab assessment, goal setting and discharge planning, early swallow assessment and dietician review, as well as access to stroke specialist medical input and specialist nursing care.
The Stroke Unit in University Hospital Aintree was established in 1993 and started offering thrombolysis in 2004, 24-hour thrombolysis has been available since September 2008. The stroke service starts at the front door of the hospital having established links with our local ambulance trust to ensure rapid transfer to hospital and a pre-alert system to A&E Resus and the stroke team for suspected thrombolysis cases. The stroke team comprises four stroke nurse clinicians, who triage and coordinate all new suspected stroke cases, three consultant stroke physicians and one consultant neurologist, two specialist registrars and a team of nurses and therapists specialising in stroke who are based on the stroke unit. The stroke nurse clinicians work closely with the radiology services to ensure a rapid CT brain scan and with the unit as a whole to ensure rapid transfer of patients to the acute unit.
The Stroke Team for Audit and Research (STAR) is an integral part of the system enabling data collection and analysis to inform service developments. We have thrombolysed 79 patients to date—4 patients in 2004, 20 patients in 2008 and 13 since Christmas 2008. Our target for this year is 50 patients, which is around 12 per cent of the total number of stroke patients admitted to Aintree.
It is vital that we continually strive to improve the care we deliver to stroke patients within this rapidly evolving speciality. Basic principles, however, are the key. The rapid assessment, recognition and triage of stroke are all fundamental factors to enable effective management of stroke and improve patients’ outcome. The need to raise public awareness of stroke as an emergency is also crucial in order to increase the number of patients arriving to hospital within 4 hours of stroke to enable thrombolysis for ischaemic stroke within 4-5 hours to be an option for these patients.
Anil Sharma has been a Consultant Physician at University Hospital Aintree since 1980 and is in charge of the Clinical and Research Stroke Unit at Aintree. He has been the Divisional Medical Director of Medicine since 2003 and the RCP Regional Advisor for Stroke and has lectured widely at national and local meetings.
Hannah Cronin graduated from the University of Leicester in 2002. She has been working as a Specialist Registrar within the Mersey Deanery since 2006 and is currently working as a Specialist Registrar within Stroke Medicine at University Hospital Aintree, Liverpool.