Issue 23 / 18 June 2012

IN cases of severe apoplexy, patients could not survive “the greatness of the illness combined with the misery of advanced life”, wrote Aretaeus of Cappadocia in the second century.

Happily, these days the prognosis is rather better for people with apoplexy or, as we now call it, stroke. But has that early sense of hopelessness about the condition entirely disappeared?

Twenty years ago, two US neurologists, Professor Jose Biller and Dr Betsy Love, suggested the historical view of stroke as a blow delivered by external, even celestial, forces had led to a kind of “therapeutic nihilism”, a belief that nothing could be done.

We now know that a great deal can be done — and that it’s crucial it be done quickly — but unfortunately that doesn’t mean it always happens.

Professor Geoffrey Donnan established this country’s first dedicated stroke unit at Melbourne’s Austin Hospital in 1978 and was last week honoured with the Order of Australia for his services to neurology.

While great progress had been made in treatment and awareness of stroke, we “still have a long way to go”, he told The Australian. “The fact that only about 50% of Australians get access to stroke units still isn’t good enough.”

Last year’s National Stroke Audit of acute services made a similar case, estimating 30%–40% of the 60 000 Australians who have a stroke each year do not receive treatments that have been proven to be effective.

Only a third of the 184 hospitals surveyed offered thrombolysis, and just over half of patients were being treated in a dedicated stroke unit, the audit found.

“Stroke unit care is the single most important recommendation for acute stroke management”, the report said. “[It] significantly reduces death and disability after stroke compared with conventional care in general wards.”

A 2009 Cochrane review found management in a dedicated stroke unit reduced a patient’s risk of dying or going on to require institutionalised care by 18%.

“Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke”, that review concluded.

Of the hospitals surveyed by the National Stroke Audit, 74 had such a unit. Based on the Stroke Foundation’s recommendation that all hospitals admitting more than 100

stroke patients a year have a dedicated unit, the figure should have been 90.

Perhaps even more concerning was that only 71% of patients in hospitals that did have a stroke unit were actually being treated in it.

It might be an exaggeration to call them apoplectic, but clinicians have been railing against inadequate access to stroke unit care for a decade or so now.

Given the clear evidence of benefit, isn’t it time to jettison the last remnants of historical apathy when it comes to improving outcomes in stroke?

Jane McCredie is a Sydney-based science and medicine writer.

Posted 18 June 2012

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2 thoughts on “Jane McCredie: Stroke of apathy

  1. Dr.Bernard Vaughan says:

    12 years ago I had a stroke. I felt it coming on. At breakfast the fork fell out of my hand. I phoned a neurologist, who informed me that he could not fit me in to his appointments for 2 days , and suggested I go to a private hospital casualty. There I was seen after half an hour and a CT was ordered. This confirmed an infarct but no haemorrhage. I was seen in the evening by the duty physician who confirmed the diagnosis. The next day I was hemiplegic. After my retirement as a radiologist I performed a locum in Logan Hospital Queensland. An acute stroke patient was sent from casualty for a CT which showed a typical infarct. The patient was then transferred to Brisbane. He had an IV line for the CT contrast. I could easily have injected tissue prothrombin activator if I had any. Perhaps it could be kept in radiology departments and given by the radiologist if haemorrhage is excluded by CT, saving valuable time.

  2. Sue Ieraci says:

    Dr Vaughan – that might be a good strategy if tPA in stroke were unequivocally both effective and safe. Unfortunately, neither is supported by evidence. What would you do if the person you gave it to in your radiology practice had a significant bleed caused by your intervention?

    Many of us cannot understand why the results of IST-3 have not received more attention: they showed a HIGHER acute mortality in the first 7 days, which only became equal at 6 months when the controls had died of other causes. The benefits have been difficult to show – the IST team changed their outcome measure between study registration and publication. Even then, the treatment arm showed no benefit in the ability to live independently. tPA is no panacea. Stroke Units, on the other hand, are both beneficial and safe.

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