Stroke units signal the way forward

The human misery and financial burden of strokes have a devastating impact on the 152,000 people across the UK who suffer the potentially debilitating condition every year. More than 900,000 are living with a legacy of physical and neurological impairment, and half of them depend on others for help in their everyday lives.

Landmark studies by Professor Alistair McGuire at the London School of Economics (LSE) and colleagues from King’s College London estimate that dealing with stroke costs the UK economy £8.9 billion a year, made up of £4 billion in treatment costs, around £2.5 million for informal care and the rest in lost productivity.

Despite great strides forward since the introduction of the National Stroke Strategy (NSS) by the Department of Health in 2007, effective treatment in the crucial therapeutic window, which experts have recently extended from three to four-and-a-half hours after the stroke, can be inconsistent.

“We have seen very good progress in many aspects of stroke care, but there is a lot of unfinished business and an overarching concern is that people think the job is done – when that is not the case,” says Joe Korner, director of external affairs at the Stroke Association, the UK’s stroke charity.

The NSS has seen a dramatic reduction in 30-day mortality rates – from 30 per cent to below 20 per cent over the last seven years – because patients are getting to dedicated stroke units quickly with rapid access to clot-busting drugs and brain scans.

“Some services are very good, but others have too many delays,” says Mr Korner. “Unfortunately there are places around the country where, if you are unlucky enough to have your stroke on a Friday evening, you may not get the level of support you need.”

The need and financial imperative of getting stroke services right has been established with the LSE research indicating that investment in stroke units saves money in the long run by minimising the damage caused by the stroke, and reducing the long-term rehabilitation and care bill that follows for most patients.

Repeated healthy lifestyle messages from successive governments are not achieving the sea change in public habits that could drastically reduce stroke, along with cardiovascular disease, and a misconception that the condition only affects the elderly has also acted as a barrier to improvement.

One in three people who suffer a stroke are under 65 years old. Many of them will have had a TIA – a transient ischaemic attack – also known as a mini stroke that causes a temporary blockage in the blood supply to the brain with the symptoms usually receding after 24 hours with no permanent damage.

We have seen very good progress in many aspects of stroke care, but an overarching concern is that people think the job is done – when that is not the case

The 54-year-old broadcaster Andrew Marr, who is still recovering from his stroke in January last year, revealed that he had two mini strokes without seeking extra medical help leading up to the full stoke. He considers himself lucky to be alive.

Mr Korner commented: “The impression that stroke is something for an elderly age group is a major break on progress. With TIAs, the general assumption among the public and to an extent GPs is that you have had a funny turn so you need to go home, have a cup of tea and an aspirin, and you will be all right.

“You should be treated as an emergency because there are protocols that can reduce the danger which is vital as the risk of a stroke after a TIA is very high within the next two days.”

Tim England, clinical associate professor in stroke medicine at Nottingham University and a consultant at the Royal Derby Hospital, points out that the move towards bespoke stroke centres offering gold-standard care had boosted patient outcomes.

Patients are now taken to regional hospitals that are centres of excellence for immediate assessment and treatment from a multi-disciplinary team to get the best chance of survival and recovery.

Reconfigured services in London, Manchester, Nottingham and the East Midlands, and soon Birmingham, are changing the dynamics of stroke treatment and raising it to the response level of cardiac services.

But research into finding drugs to minimise damage after strokes, including stem cell therapy, is still in its infancy. “If I had a magic wand, I would wish for drugs that would help prevent damage after a stroke,” says Dr England. “People are working on that, but it is some way off.”

Mr Korner concludes: “This is a preventable and treatable condition, but unless concerted action is taken in this country and across the world we are going to see huge numbers of needless deaths and needless suffering of many thousands, if not millions, of people.”