Every second matters when a haemorrhage or clot disrupts blood flow to the brain and cells up there begin to die.
Known as a stroke, it will happen to one in four of us.
It is then a race against time, in which both the public and health professionals must play their part to maximise a stroke sufferer’s chances of returning home, relatively unscathed.
Each year, approximately 7,500 people in Ireland experience a stroke and an estimated 90,000 are living with disability and after-effects from the impact on their brain. However, stroke mortality has fallen from 19 per cent in 2008 to 11 per cent last year, thanks to improvements in how it is treated.
RM Block
Ireland now has 22 dedicated stroke units, where specialised care saves lives, reduces disabilities and speeds recovery.
The Irish Times was recently invited on a walk-through at one of these units, in Tallaght University Hospital (TUH), Dublin, to highlight the steps in optimum stroke treatment.
Recognition
The chain of care needs to kick in the moment one side of a face droops; an arm loses power or speech becomes slurred or confused.
Other signs include the sudden onset of dizziness, blurred vision or severe headache. Only when somebody realises what is happening can a stroke sufferer start to receive help.
Public awareness campaigns have used the FAST acronym (Face drooping, Arm weakness, Speech difficulty, and Time to call for emergency help) to flag symptoms.
Ambulance
The second a stroke is suspected, call an ambulance, not your mother, pleads Prof Rónán Collins, consultant in geriatric and stroke medicine, as he stands at the entrance of the TUH emergency department (ED).
“Over half the patients do not get into hospital within three hours of their stroke,” he says. They may not know what is happening, or have some idea but deliberate over what to do and call others for advice, or favour a trip to the GP over the ED.
“The problem is, that all the treatments we have for acute stroke are time dependent,” says Collins, who is the HSE national clinical lead for stroke. If it turns out to be something else, “nobody is happier than us if you’re wrong, to reassure you that it’s not a stroke”.
The National Ambulance Service and Dublin Fire Brigade prioritise calls about a suspected stroke and will blue light the person to the appropriate hospital.
Crews assess the person on the way and phone ahead, so stroke unit staff are briefed and waiting at the ED door as the ambulance arrives. At this stage, it is what Collins describes as a “pit stop” for the ambulance. The crew will stay with the patient until an emergency return trip to north Dublin’s Beaumont Hospital for a specialist procedure has been ruled in or out.
Resuss
In the fast-tracking through ED, one of two bays here is used as the patient is stabilised. Often the ambulance crew have already put a line in, so blood samples can be drawn and dispatched to the lab immediately.
A “quick see” by a doctor will rule out a “mimic stroke” that could be caused by alcohol, drugs, or perhaps very low blood sugar in a diabetic patient. But they don’t hang around – maybe two minutes here – before it is straight to the scanner unit, where a CT will have been ordered when the ambulance was incoming.
Scanner
“This is probably the most important rung in the whole pathway” – once the patient has been stabilised – says Collins, as we step into a room where two radiographers sit at computer screens, overlooking a large, white scanner, absurdly reminiscent of a giant Polo mint.
Radiographers are used to more routine work being interrupted by the arrival of a stroke patient who must take precedent. There are two main types of stroke: the most common is ischemic, caused by blockage of an artery (or occasionally a vein); the other is haemorrhagic, caused by bleeding.
A CT scan is done, to show the structure of the brain, and followed by an angiogram, which displays the blood supply to the brain. If the time a stroke happened is unknown, a CT perfusion is also performed, which will indicate what parts of the brain are salvageable, or not.
Radiographer Kerry-Anne Murtagh says a CT scan takes about two minutes – the longest part is getting the patient settled on the table. A series of angiograms should be completed within five minutes and, if a perfusion scan is needed, that will be another four or five minutes. In a neighbouring room, a radiologist, who is medically trained, is ready to report immediately on these scans.
Trainee radiologist David McAuliffe says it can be quite pressurised work. It is not just the urgency around a fast stroke scan, “it’s the multitude of scans that have come before and are coming after that you know you need to report”.
“I’m fairly experienced,” says Collins, “but I’m in here frequently as well, asking the guys, do you think that is really what it seems to be? Because reading scans under time pressure, the more eyes you have looking at it, the more likely you are to be accurate. There’s a lot at stake here because if we make the wrong decision, give the wrong treatment or don’t intervene, the outcome can be very poor for people.”
If Collins is not physically in the hospital, as the stroke unit operates 24/7, a scan image will be pinged to his mobile phone within seconds. AI-assisted software will highlight areas of concern.
The initial scan will indicate if there is a bleed. “Obviously if someone has a haemorrhage, we’re not going to be giving them clot-busting treatment.”
“Clot-busting” drugs, a treatment known as thrombolysis, are only licensed for use up to four and a half hours after a stroke. If a large blockage in a blood vessel has been identified, the patient will not only get this medication but the waiting ambulance will transfer them at speed to Beaumont for physical removal of the clot, a thrombectomy.
It is a very specialised procedure and the only other centre in Ireland where it can be done is Cork University Hospital. Collins likes to use a plumbing analogy: “If your pipe is blocked, pouring Domestos might work.”
But if there is a large vessel blockage, they don’t know wait around to see if it does work.
“We’ll send them over for a Dyno-Rod as well.”
If the patient does not need a thrombectomy by the time they get to Beaumont, all is good. Either way, provided they are stable, they will be transported back to Tallaght for a bed in the acute stroke ward.
The first audit of stroke care in Ireland carried out by the Irish Heart Foundation in 2008 highlighted the need for a concerted, national programme to improve treatment. At that time, when there was only one stroke unit in the country, just one per cent of patients received clot-busting treatment.
By last year that had risen to 11 per cent and is now on par with the UK. A similar percentage of stroke patients here have a thrombectomy, compared with 3.3 per cent across the water.
Acute stroke unit
A few minutes’ trolley ride from the scanner, the multidisciplinary team continues the care. The eight-bed ward, with a ninth dedicated bed in an isolation room, is housed within TUH’s William Stokes Unit.
It is very important to have specialist nurses who are familiar with managing stroke treatments, says Dr Derek Hayden, a consultant in geriatrics and general internal medicine who is director of stroke services at TUH. Other vital health professionals include physiotherapists and dietitians.
The benefit of stroke-focused care that patients receive in the unit, compared to being on a general hospital ward, has real impacts in terms of survival and improvement and reduction of disability, he explains, before his beep goes off to call him away to an incoming case.
It is a point stressed by Dr Dan Ryan, consultant geriatrician/stroke physician. While clot-busting medication is extremely effective in reversing stroke disability, only one in five of stroke patients is suitable for this treatment.
But 100 per cent of them can, and should, go into a stroke unit, as this also increases rates of survival and independence. However, there are not enough designated beds around the country to deliver this specialised care.
Shay Sargent (70) is here recovering from a haemorrhagic stroke at home five days ago. A fit-looking GAA stalwart, he says he has no memory of his sudden collapse. Difficulties with swallowing are a common after-effect and he has a nasal gastric feeding tube for now.
“We often have to provide nutrition support for those patients,” says dietitian Anna Hourihane. Strokes are associated with increased energy needs and, particularly in the two weeks afterwards, patients are more at risk of weight loss.
Standing at Sargent’s bedside, Collins asks him to wiggle his toes: the left leg moves vigorously; on the right the response is more subdued but it is progress, which intense physiotherapy should accelerate in the weeks to come.
Across the way, Patrick Gilmer is sitting out in a chair beside his bed. He had a milder stroke but it was his second this year.
During the first in early spring, “I started feeling dizzy and I lost the power of my arm on this side,” he says, looking down at his right hand. He thinks he was in here at least three weeks after that but felt he had fully recovered before something similar happened seven months later.
“The standard of care that you get in this unit is absolutely terrific,” he says. “I’m doing fine. My hand is nearly back again. They have me on new blood thinners and they said it will be grand.”
Rehabilitation
A lot of attention is paid to the first critical hours of care for stroke patients but the key piece for survivors, says Ryan, is the rehabilitation that follows. That starts in the unit here.
Some will bounce back and walk out within days, particularly if previous good health and age is on their side.
The care of heavily dependent patients is continued at Peamount Healthcare in Newcastle, Co Dublin, “where you dial down the medic and you dial up the rehab”.
About 80 per cent recover sufficiently to be able to go home from there. Others may go to long-term residential care.
Early supported discharge (ESD)
About 20 per cent of stroke survivors can go straight home from TUH early because staff will continue to provide physiotherapy, nursing and social work support in their houses. They get the same level of intensity of physio, Ryan explains, through four home visits a week.
The ESD scheme not only improves bed capacity in the unit but also results in stroke survivors being more independent, spending less time in hospital and more likely to avoid long-term residential care.
Six-month review clinic
Here stroke survivors are seen by clinical specialists, physiotherapists and speech therapists. This is aimed at trying to reduce hospital readmissions which, staff had observed, was most commonly due to pneumonia from a swallow problem, or a fall or fracture.
“I called it the stroke readmission prevention clinic,” says Ryan. “But in essence, it’s enhancing the quality of care out there. Previously, 10 or 12 years ago, when you went home from hospital, that was it.”
Prevention
One quarter of strokes occur in people under the age of 65 but the majority are age related. With Ireland’s ageing population, a European report predicted a 58 per cent increase in strokes here between 2015 and 2035.
Even with improved prevention strategies, “I think we can reasonably assume we’re probably going to get somewhere between a 40 to 50 per cent increase in the total numbers of strokes over the next 10 years,” says Prof Collins.
Prevention and improved treatments not only reduce life-changing fallout for individuals and their families but can also cut the cost of associated long-term care for the health service.
HSE prevention advice prioritises checks of blood pressure and pulse – especially for those aged over 40, or who have family history of heart disease or stroke.
After that it is eat a healthy diet, be physically active, don’t smoke, don’t exceed low-risk alcohol guidelines and don’t use drugs – cocaine-related strokes are on the increase.
