Clinical results increase calls for new NHS stroke treatment
The results of important clinical trials, published in the last 15 months, have shown mechanical thrombectomy can improve recovery from stroke and have led to increased demands to make it available on the NHS.
Using thrombectomy to remove a blood clot causing an acute ischaemic stroke was found to be safe and effective by the recent PISTE trial at 11 UK hospitals and other studies in the United States and Canada.
The PISTE findings, presented at the International Stroke Conference in Los Angeles last month, showed that at three months after the stroke, 20 per cent more patients in the group who had received thrombectomy made a full neurological recovery compared to the group getting standard treatment alone.
The study, funded by the Stroke Association and the National Institute for Health Research, adds to a growing body of clinical research that the procedure is safe and effective within the NHS.
Physicians can treat smaller blockages causing strokes with thrombolysis, but larger clots, identified by CT scan and angiogram, can benefit more from direct intervention by a thrombectomy which uses a stent procedure to remove the clot from harm’s way. Time is a crucial factor with a target to start operating of four-and-a-half hours or less from onset.
With these advances we can pull out the clot and immediately open the vessel, and not have to wait for a drug to dissolve it
Pioneering consultant neuroradiologist Dr Sanjeev Nayak believes more widespread use of thrombectomy is imperative to save lives and realise substantial savings to the NHS and social care budgets.
His unit at the University Hospitals of North Midlands NHS Trust (UHNM), in Stoke-on-Trent, Staffordshire, was the first to introduce the procedure routinely in 2009 and has performed more thrombectomies than any other hospital in the UK.
“Prior to using mechanical thrombectomy, it was thrombolysis where you give a clot-busting drug,” he says. “But it worked in less than 10 per cent of patients whose main artery to the brain was occluded by a large clot. These patients with large strokes would either die or survive with a severe disability often requiring 24/7 care throughout their lives.
“With these advances we can pull out the clot and immediately open the vessel, and not have to wait for a drug to dissolve it.”
“We have had patients who have come in with no movement at all being able to walk out of the hospital two days later. The benefits clinically and financially are notable.”
A cost analysis based on 200 patients treated between 2010 and 2014 at UHNM demonstrated that the hospital had saved £3.2 million by freeing up bed space and a further £16 million from social care budgets.
“The big problem is that patients are not aware of this service and the time limits,” says Dr Nayak, who has contributed data to the National Institute for Health and Care Excellence (NICE), which is currently conducting a health economic review of thrombectomy procedures. “We are saving lives immediately, but there is no infrastructure to support it. We need a rapid-response ambulance service and 24-hour cover. This needs to be a round-the-clock service.
“The NHS spends £8.9 billion a year treating strokes and we have the potential to save billions from that cost if this service is done properly. It can make a big difference to people’s lives but it needs investment.
“We have calculated that around 8,000 to 30,000 patients a year could benefit from this and, even if you reach less than 50 per cent of them, you are still saving 10,000 lives a year which is incredible.”
Christine Roffe, a stroke physician at the Royal Stoke University Hospital and professor of stroke medicine at Keele University, believes the trials’ evidence points clearly towards thrombectomy becoming a standard feature of future NHS treatment.
“The evidence is now uncontroversial that thrombectomy is more effective than thrombolysis when it can be given,” she says. “It is a better treatment and allows the patients to recover. The ‘number needed to treat’ (NNT) to save one patient from a long-term dependence life is three to seven, which is very low. The NHS normally pays for anything with a NNT of 40 or below.”
Thrombectomies are more expensive than thrombolysis as they require a full neurointerventional team, but at around £10,000 they still offer cost benefits because patients can return to full lives without social care, says Professor Roffe.
“We are still waiting for the formal health-cost analysis and NICE commissioning guidelines, and we will have to look at the infrastructure so we can implement it, but I believe it could be established quickly once we have the political determination,” she adds.
Clinicians want to see a series of ten to fifteen regional centres of excellence where interventionists can stay in practice to maintain high levels of success.
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