By Rachel Pugh
Patients with stroke in the UK are being failed by not being offered thrombectomy according to Dr Deb Lowe, National Clinical Lead for Stroke Medicine with the NHS’s Improvement ‘Getting it right first time’ (GIRFT) programme1.
In her talk entitled ‘What’s new in stroke, Dr Lowe, a consultant stroke physician and geriatrician at Wirral University Teaching Hospital, insisted that mechanical thrombectomy should be offered to 10 per cent of patients with stroke rather than the current figure of 1.1 per cent, most of whom are in London. She is pushing for the establishment of 30 thrombectomy centres nationally. At the moment there are 22.
Describing the case of a 45-year-old barrister with children under five, who is in a nursing home being tube fed after the best available care for a stroke 3 years ago, she said: “There was no thrombectomy service available then and there still isn’t now. We are failing people in this country by not delivering thrombectomy. We are among the worst in the EU. We are also getting worse at getting patients into stroke beds, not better.”
She stressed the major quality improvements in stroke care and management, made since the introduction of the National Stroke Strategy in 2007 and the Sentinel Stroke National Audit Programme (SSNAP) since 2013 - mainly in the hyper and acute redesign. Progress on post-discharge rehabilitation and life after stroke has been limited.
The GIRFT programme has also started regional visits 2018 to stroke centres since November and meetings arranged with clinical leads and trust executives, to collect data and make local recommendations supported by GIRFT Implementation teams.
Dr Lowe pressed for the need for a major change in stroke care, given the burden on the NHS and to society:
- Stroke is the leading cause of disability and the fourth largest cause of death in the UK.
- Every year 80,000 people are admitted to hospital with a stroke and 50 per cent of them are left with a disability.
- Costs the economy £26 billion/year (£3.2 billion to the NHS, £5.2 billion to social care and £15.8 billion to informal care.
- The cost of strokes is forecast to rise by 2035 to £91 billion.
The ‘game changer,’ according to Dr Lowe is mechanical thrombectomy. This should be offered to people last known to be well between 5 and 24 hours previously, and who have had an acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomography angiography (CTA) or magnetic resonance angiography (MRA) — especially if there is potential to salvage brain tissue.
Delivery of mechanical thrombectomy, however, requires major changes, including modelling of workforce and population needs, specialist commissioning, neuroscience centres working 24/7 and training of more neuro interventionalists. The UK currently has 82 of whom one-third are based in London. She is working with the Royal Colleges to pilot a new accredited training programme for hospital consultants later this year.
Major improvements on the horizon include automated CT/CTA interpretation and the use of artificial intelligence. There is also work on acute bundles of care for Intracerebral Haemorrhage (ABC-ICH) at Salford Royal with an aim to have a 10 per cent reduction in 30-day fatality2. Research is also progressing to identify a biomarker for haemorrhage stroke3.