Treatment of Stroke

Acting on the symptoms

Stephanie Jones

Stephanie Jones

Research Fellow Clinical Practice Research Unit Department of Nursing University of Central Lancashire, UK

Michael Leathley

Michael Leathley

Senior Research Fellow

Caroline Watkins

Caroline Watkins

Professor, Stroke and Older People\'s Care

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Prompt recognition of suspected stroke symptoms and immediate activation of Emergency Medical Services (EMS) are crucial to effective pre-hospital stroke care, early access to stroke specialist services and successful management.

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A stroke has been defined as “a focal, or at times global, neurological impairment of sudden onset, lasting more than 24 hours or leading to death, and of presumed vascular origin”.1 However, this definition has, as a result of time-dependent treatment and management, become redundant.

Stroke is the third most common cause of mortality in the developed world and is also the leading cause of adult neurological disability. Due to ageing populations worldwide, it has been estimated that by 2020, stroke will be the leading cause of lost healthy life-years. Not only does stroke have a devastating impact on both patients and their families, there are also financial implications for society as a whole. Stroke costs the National Health Service (NHS) in the UK approximately £ 2.8 billion a year in direct costs. Moreover, an additional cost of £ 1.8 billion is incurred in terms of loss of productivity and disability. Annual informal care costs of home nursing are estimated to be at £ 2.4 billion.2

Considering Transient Ischaemic Attack
A Transient Ischaemic Attack (TIA) is often, mistakenly, described as a mini-stroke and has until recently been defined as “a neurological deficit caused by focal brain ischaemia that completely resolves within 24 hours”.3 According to a newly proposed definition by the TIA Working Party Group, TIA is “a brief episode of neurologic dysfunction caused by neurologic dysfunction or retinal ischaemia, with clinical symptoms lasting less than one hour, and with no evidence of acute infarction”.4

During the vascular event, of stroke or TIA, the symptoms would be the same. Unfortunately, as TIA symptoms resolve quickly, TIA is often perceived by the public as unimportant, and does not warrant any treatment.5 However, the evaluation and diagnosis of TIA should mirror that of stroke and so suspected stroke (regardless of whether the eventual diagnosis turns out to TIA or stroke) should result in immediate access to EMS and be treated as a medical emergency.6

The variation in signs and symptoms from person to person depending on the areas of the brain affected often creates problems in recognising stroke. Stroke classically presents with sudden onset of neurological loss and can include one or more of: limb weakness, speaking difficulty or understanding speech, loss of vision, clumsiness or numbness of the arms or legs. Symptoms most commonly described by stroke patients include weakness, numbness or paralysis.

Treatments for TIA and stroke
The recommended assessments and treatment for TIA patients include brain imaging, carotid imaging, antiplatelet and antihypertensive therapy and statins.7,8 For stroke, effective and cost-effective investigation and treatment options include immediate brain scanning9, thrombolysis and organised care in a specialist unit,10 as well as secondary prevention therapies as for TIA.7,8

Rapid access is the key to maximise the benefits from these investigations and treatments. To provide rapid access, the time from the onset of stroke symptoms to hospital arrival must be kept to a minimum. Studies have shown that activation of the EMS is the single most important factor in the rapid triage and treatment of acute stroke patients.11 Individuals who activate EMS arrive at Accident and Emergency Departments (A&E) earlier and are evaluated faster—particularly when EMS is the first point of medical contact—and hence it is the provider of fast transportation to hospital. For example, one study showed that for patients who contacted the EMS first, the mean time from stroke onset to arrival was 2.7 hours compared to 6.3 hours for patients who contacted their community physician in the first instance. Similar delays were also found for patients who contacted EMS (3.8 hours) and for those who did not (7.5 hours).11

Many factors contribute to delays in seeking treatment including poor awareness of stroke symptoms, reluctance to seek medical help and stroke not being viewed as a medical emergency. Of these factors, the principle ones are believed to be lack of public knowledge regarding stroke symptoms and the need for a rapid response. A recent campaign by the Stroke Association in the UK promoted the use of the Face Arm Speech Test (FAST) to inform symptom recognition and facilitate the rapid access for people with suspected stroke to the appropriate services. However, the effectiveness of this campaign has not yet been evaluated. Stroke screening, educational programmes and first aid training are some of the effective ways to increase knowledge about stroke.
Educational tools have also been shown to increase stroke awareness across diverse populations. While it is appreciated that increasing knowledge does not necessarily lead to a change in behaviour, it could facilitate behavioural change. When people were asked about what action they would take if they suspected that they or one of their relatives was experiencing a stroke, approximately 50 per cent said that they would call the EMS or would visit a hospital emergency department. However, when stroke patients were asked about what they had actually done at the onset of symptoms, only 18 per cent said that they had called EMS immediately.12

Those with lower levels of education have consistently shown poor levels of stroke knowledge. Participants who had higher levels of education are more likely to name at least one symptom of stroke or risk factor or to provide a correct explanation of the physiological processes of stroke. Higher levels of education and upper socio-economic status have also been associated with the increased ability to identify the brain as the organ affected by stroke. Other factors that affected knowledge are age and ethnicity. It is observed that older age groups and several ethnic groups have poor knowledge of the risks factors and symptoms of stroke.13

With ageing populations and a predicted rise in the incidence of stroke, the immediate recognition and reaction to symptoms is of increasing importance. Currently, the inability of the general public to recognise the symptoms of stroke and failure to contact the EMS results in delays in arrival at hospital. Increasing public awareness about stroke symptoms, the required emergency responses and the available treatment options must be a priority.

AUTHOR BIOS

Caroline Watkins, the only nursing professor of stroke care in the UK, has worked with the Department of Health Vascular Team on developing, and now in implementing, the National Stroke Strategy.

Michael Leathley is a Post-Doctoral Research Fellow at the University of Central Lancashire. His research interests include the long term follow-up of stroke patients, from admission to hospital with an acute stroke, to discharge and beyond, measuring provision of service, support, utilization of resources and charting mortality

Stephanie Jones is a Research Fellow at the University of Central Lancashire. She co-ordinated the National Pre-Hospital guidelines Group and currently manages a National Institute for Health Research Stroke Programme Grant. She has worked collaboratively with the Royal College of Physicians.

References
1. World Health Organisation (2005) The WHO STEPwise approach to stroke surveillance. www.who.int/chp/steps/Manual.pdf.

2. National Audit Office. Reducing brain damage: faster access to better stroke care. Report by the comptroller and auditor general. HC 452 Session 2005-2006. The Stationery Office: London.

3. The Study Group on TIA Criteria and Detection. Transient focal cerebral ischaemia: epidemiological and clinical aspects. Stroke. 1974 5:277-284.

4. Albers GW, Caplan LW, Coull MB. Transient Ischaemic Attack: Proposal for a new definition. New England Journal of Medicine. 2002; 347:1713-1716.

5. Rodriguez RM, Passanante M, Phelps M et al. Delayed Emergency Department presentation in critically ill patients. Critical Care Medicine. 2001;29:2318-2321.

6. Williams LS, Bruno A, Rouch D, Marriott DJ. Stroke patients’ knowledge of stroke influence on time to presentation. Stroke. 1997;28:912-915.

7. Johnston SC. Transient Ischemic Attack. New England Journal of Medicine. 2002;347: 1687-1692.

8. Johnston SC, Nguyen-Huynh MN, Schwarz ME. Stroke Association guidelines for the management of transient ischemic attacks. Annals of Neurology. 2006;60:301-313.

9. Wardlaw JM and Mielke O. Early Signs of Brain Infarction at CT: Observer Reliability and Outcome after Thrombolytic Treatment - Systematic Review Radiology. 2004;235:444-453

10. Stroke Unit Trialists’ Collaboration. Organised Inpatient (stroke unit) Care for Stroke (Cochrane Review). In: The Cochrane Library, Issue 1, 2001. John Wiley and Sons: Chichester, UK

11. Harbison J, Hossain O, Jenkinson D, Davis J, Louw S and Ford G. Diagnostic accuracy of stroke primary care, emergency room physicians and ambulance staff using the face arm speech test. Stroke. 2003;34:71-76

12. Carroll C, Hobart J, Fox C, Teare L, Gibson J. Stroke in Devon: Knowledge was good but action was poor. J Neurol Neurosurg Psychiatry. 2004;75:567-571.

13. Stern EB, Berhman M, Thomas JJ, Klassen AC. Community Education for Stroke Awareness. An efficacy study. Stroke. 1999;30:720-723

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