Dr Victoria Haunton is Clinical Research Fellow and Honorary Specialist Registrar at Leicester Royal Infirmary.
Despite the dramatic revolution in stroke medicine, levels of stroke knowledge amongst the general public remain surprisingly poor, and there are still significant difficulties in getting patients to access stroke services promptly. Stephanie Jones et al sought to try and understand these problems in their important integrative review. Worryingly, they found that people struggle to name even one stroke risk factor or stroke symptom, particularly when open ended questions are used. Knowledge is especially poor in older members of the population, ethnic minority groups and those with a lower socio-economic status, but there is also a surprising lack of knowledge amongst those who have already suffered a stroke. Furthermore, there appears to be a real paradox between what people say they would do and what they would actually do in the event of a stroke; whilst at least 47% said they would contact emergency medical services if they suspected they or a relative were experiencing a stroke, only 18% of stroke patients had actually done this. There is therefore an urgent need for further public education. In light of their findings, Stephanie Jones and colleagues suggest that the ideal campaign should minimise barriers to health services and provide cues to action.
Their review of previous initiatives suggests that the most effective such interventions have been stroke screening, community educational programmes and first aid training. However, these need to be repeated regularly as their effects are time limited.
Although the findings by Stephanie Jones et al are sobering, improving public awareness about stroke is a focal element of the UK Government’s National Stroke Strategy. Another key focus of the National Stroke Strategy is stroke prevention. Hypertension, obesity, diabetes and hypercholesterolaemia should all be managed according to clinical guidelines, and appropriate action should be taken to reduce overall vascular risk. Furthermore, all those at risk should be given information about exercise, smoking, diet, weight and alcohol. However, whilst these risk factors for stroke should not be forgotten, in the case of the elderly, specific attention should be paid to atrial fibrillation. Atrial fibrillation (AF), which is all too frequently asymptomatic, accounts for up to 15% of ischaemic strokes in all ages and 30% in persons over the age of 803. When AF is detected, it is therefore vital that the opportunity to protect patients with anticoagulation is not missed. Warfarin offers excellent, cost-effective, stroke prevention with a relative risk reduction of 62% (95% CI, 48% to 72%)4 and surprisingly low rates of significant bleeding, and there are also newer anticoagulants, for those who cannot tolerate warfarin or who struggle to remain in the therapeutic range.
Decisions regarding anticoagulation should be guided by open and informed discussions with patients and individual assessment of risk. Various risk stratification tools have been used for this in recent years. However there has been marked inter-tool variability in terms of absolute stroke rates by risk group and the need for anticoagulation. In 2009 the Birmingham CHA2DS2VASC stroke risk schema was devised to try and bring some simplicity and consistency to anticoagulation decisions. CHA2DS2VASC is based on a refined version of the 2006 ACC/AHA/ESC guidelines and combines the important, but previously neglected, stroke risk factors of female gender, age 65-74 years and coronary artery disease with the established risk factors of previous stroke/TIA, hypertension, heart failure and diabetes mellitus. Burak Pamucku et al provide a very helpful, concise overview of, and background to, the CHA2DS2VASC schema as well as clear instructions on how to use the tool effectively.
Unfortunately, despite our best efforts in stroke prevention, strokes still occur. For those patients, the single biggest intervention which will improve their outcome is admission to a stroke unit and specialist stroke care. There is strong evidence that this significantly reduces death, dependency and the need for institutional care. But what makes up an effective stroke unit? This question is comprehensively answered by Peter Langhorne et al in their excellent paper from 2002. Although published a decade ago, this paper is as relevant today as it was then, and indeed continues to be one of the most cited papers from the journal.
Despite the greatest evidence being for stroke units and specialist stroke care, it is arguably the advent of thrombolysis which has led to the greatest change in perceptions of hyperacute stroke care. Alteplase is currently licensed for use in patients aged less than 80 years with signs and symptoms of acute ischaemic stroke who present to hospital within three hours with haemorrhage excluded on brain imaging. The outcomes from thrombolysis in such patients is good; the literature reports an improvement in a third of patients and a full resolution in a tenth with low rates of clinically significant bleeding. However, there has been much debate about the age and time restrictions currently in place for thrombolysis. Both are felt to be arbitrary and lacking in strong evidence. Geriatricians in particular have long advocated equal access to healthcare resources for all, regardless of patient age. Stefan Engelter et al explored this issue back in 2006 in their systematic review of cohort studies of intravenous thrombolysis in stroke patients of ≥ 80 versus <80 years of age. They concluded that there was scope for benefit from thrombolysis for the older age group and that is would be safe and reasonable to include such patients in randomised placebo-controlled trials. These conclusions are particularly pertinent as we await the publication of the results of the Third International Stroke Trial (IST-3) later this year.
Although thrombolysis and hyperacute care have helped to raise the profile of stroke medicine, we must not neglect the longer term management of stroke patients and the chronic problems caused by their strokes. Indeed, good rehabilitation and long-term management is at the very heart of effective stroke care. Weakness and poor mobility are perhaps the most recognised complications of stroke, followed by speech disturbance and dysphagia. The management of dysphagia has proved to be controversial, an issue explored by Norine Foley et al in their systematic review. This important review presents emerging evidence that nasogastric tube feeding is not associated with a higher risk of death compared to percutaneous feeding tubes and that general dysphagia therapy programmes are associated with a reduced risk of pneumonia in the acute stage of stroke, which may challenge the beliefs of some physicians. However, the review concedes that there is still a paucity of evidence in this field and thus a clear and pressing need for further high-quality research.
Whilst weakness, speech difficulties and dysphagia are well recognised in stroke, other complications may be under-recognised and under-detected. One such complication is visual impairment. In their clear and comprehensive paper Fiona Rowe et al highlight the wide range of post-stroke visual sequelae, including low vision, visual field defects, and eye movement and perceptual deficits. Their study of 323 stroke patients with a suspected visual problem referred to ophthalmology services found that ninety-two per cent did indeed have a visual impairment, hinting that the scale of the problem may be even larger. As visual impairments impact on rehabilitation strategies and outcomes, it is important that patients receive appropriate ophthalmological evaluation.
Another area which may be under reported but with profound impacts on rehabilitation strategies and outcomes is post-stroke urinary incontinence. The data presented by Dan Wilson et al suggests that as many as 39-44% of stroke patients are incontinent of urine in the 1st week after admission, and that 15-20% continue to be so at the time of discharge from hospital. Depressingly, there appears to have been little change in these rates since the commencement of the National Sentinel Audits of Stroke in 1998. The impact of urinary incontinence is considerable, and not just on patients’ quality of life. Discharge destination appears to be heavily influenced by the presence of urinary incontinence; 62% of patients who were incontinent at discharge were discharged to care homes compared to a return to independent living for 91% of continent stroke survivors. Although there is a lack of randomised trials in the management of post-stroke urinary incontinence, there is nothing to suggest that stroke patients do not benefit from standard pharmacological and non-pharmacological continence measures, and these should be tried. The importance of a continence care plan and staff training should also not be forgotten.
Whilst continence can be used as an indicator of likely discharge destination, various other clinical variables can be used to predict other functional outcomes after stroke, and these are explored by John Reid et al. Indeed, they were able to validate a simple model incorporating age, pre-stroke independence, normal verbal component of the Glasgow coma score, arm power and being able to walk without assistance in predicting the likelihood of patients being alive and independent six months. Interestingly, and perhaps a little surprisingly, they found that radiological variables from the initial brain scan did not significantly improve the performance of outcome models derived from clinical variables, reminding us that, as always, we should treat the patient in front of us and not the results of their investigations.
The reminder to treat the patient in front of us is also very much at the heart of the paper by Christopher Burton et al which aimed to better understand the palliative care needs of acute stroke patients. Whilst a third of stroke patients will die during the acute phase of their illness, and access to specialist palliative care expertise for stroke patients is recommended by both the National Stroke Strategy and National Clinical Guidelines for Stroke, the palliative care needs of stroke patients remains poorly understood. In their prospective study of 191 acute stroke patients admitted to hospital in England, Christopher Burton et al found high rates of pain, anxiety, fatigue, low-mood and loneliness, together with frequent concerns about death, dying, dependence and disability. Given this, there appears to be an urgent need to improve palliative services in stroke medicine. As there is already a lack of capacity within specialist palliative care services, embedding palliative principles and models within existing stroke services would seem prudent.
The high rates of palliative needs of stroke patients should, therefore, not be regarded as negative or depressing but instead as a real opportunity to make a positive difference. Furthermore, despite the apparently disheartening and mortality and morbidity rates in stroke, we can afford to be optimistic. The field of stroke medicine continues to grow and evolve and there is a wealth of stroke research occurring locally, nationally and internationally. So, what will this bring? What does the future hold? In the immediate future, we are likely to see changes to the current guidelines on thrombolysis and blood pressure management. Further education of the general public will hopefully yield great rewards in terms of faster access to specialist stroke services and thus better outcomes, and a greater understanding of neuro-plasticity is likely to bring changes in our approaches to stroke rehabilitation. Further down the line, we may see novel treatments such as stem cells being employed in the treatment of stroke, and the review by Soma Banerjee et al provides a fascinating glimpse into this world.
For now, stroke physicians will continue to build on the core foundations of good primary and secondary preventative strategies, urgent specialist stroke care for all those affected and holistic, multidisciplinary patient-centred rehabilitation.
The revolution continues. Watch this space.
- Stroke knowledge and awareness: an integrative review of the evidence Stephanie P. Jones, Amanda J. Jenkinson, Michael J. Leathley, and Caroline L. Watkins
- Intravenous thrombolysis in stroke patients of ≥80 versus <80 years of age—a systematic review across cohort studies Stefan T. Engelter, Leo H. Bonati, and Philippe A. Lyrer
- Simplifying stroke risk stratification in atrial fibrillation patients: implications of the CHA2DS2–VASc risk stratification scores Burak Pamukcu, Gregory Y. H. Lip, and Deirdre A. Lane
- What are the components of effective stroke unit care? Peter Langhorne, Alex Pollock, and in Conjunction with The Stroke Unit Trialists’ Collaboration
- Visual impairment following stroke: do stroke patients require vision assessment? Fiona Rowe et al.
- Urinary incontinence in stroke: results from the UK National Sentinel Audits of Stroke 1998–2004 Dan Wilson, Derek Lowe, ALEX Hoffman, Anthony Rudd, and Adrian Wagg
- Dysphagia treatment post stroke: a systematic review of randomised controlled trials Norine Foley, Robert Teasell, Katherine Salter, Elizabeth Kruger, and Rosemary Martino
- Predicting functional outcome after stroke by modelling baseline clinical and CT variables John M. Reid et al.
- The palliative care needs of acute stroke patients: a prospective study of hospital admissions Christopher R. Burton, Sheila Payne, Julia Addington-Hall, and Amanda Jones
- Human stem cell therapy in ischaemic stroke: a review Soma Banerjee, Deborah Williamson, Nagy Habib, Myrtle Gordon, and Jeremy Chataway
This introduction was written by Dr Victoria Haunton and the collection selected by Dr Victoria Haunton and Prof Tom Robinson.