IMPLEMENTING the “exciting” advances being made in stroke treatment across Australia will be difficult without big changes to health infrastructure, training and resources, experts say.
Professor Stephen Davis, director of the department of neurology at The Royal Melbourne Hospital, told MJA InSight that the evolution of endovascular therapy represented “a huge paradigm shift in the management of acute stroke”.
“But this does mean that the health system must now be re-engineered to ensure patients have access to this treatment”, he said.
Professor Davis was commenting on an editorial published today in the MJA
which discussed the “spectacular” results of recent neurointervention trials for acute stroke care. (1)
The trials all used either advanced imaging to identify patients who would respond well to reperfusion, or angiography to prove major vessel occlusion, or both, then randomly assigned these patients to receive endovascular reperfusion, usually in addition to alteplase thrombolysis, or standard acute stroke care.
The combination therapy resulted in potent reperfusion and a dramatic treatment effect, to the extent that three of the five neurointervention trials were stopped early, the editorial authors, Professor Richard Lindley and Professor Christopher Levi, wrote.
Dr Bruce Campbell, neurologist and chair of the National Stroke Foundation, told MJA InSight that from a physician’s perspective, endovascular therapy could be used in about 10% of all stroke cases.
“This may seem like a small amount, but these patients [with major vessel occlusion] are at the highest risk of death and disability from stroke.”
Dr Campbell led the Australian arm of a trial on endovascular therapy for ischaemic stroke, which found that when the therapy was initiated at a median of 210 minutes after the onset of stroke, it increased neurological improvement at 3 days. After 90 days, 71% of patients who had received endovascular therapy achieved functional independence, compared with 40% of those who had received alteplase-only treatment. (2)
The editorial authors said these trials highlighted that the “endovascular revolution” had arrived, and the health community needed to work quickly to redesign stroke care services and build a specialist workforce.
They suggested that a possible solution to the current shortage of neurointerventionalists was the emerging model to train neurologists in interventional neuroradiological skills, due to the growing consensus that a neurointerventionalist did not need to be a radiologist, provided they had received appropriate training.
In a written statement to MJA InSight, Professor Lindley, from the University of Sydney’s Westmead Clinical School, and Professor Levi, a senior staff specialist at the John Hunter Hospital, Newcastle, said that while the recent advances in neurointervention could make a dramatic difference to patient outcomes, their implementation in Australia will prove challenging.
“Interventional stroke management not only requires a high functioning stroke unit, but also the initial delivery of intravenous thrombolysis, and there remains a considerable gap between evidence and practice in the delivery of intravenous therapy.”
They said Australia also had a critical scarcity of expertise in the domain of endovascular clot retrieval, which represented the single biggest barrier to patients accessing these advances in stroke care.
Professor Graeme Hankey, professor of neurology at the University of WA’s school of medicine and pharmacology, agreed. He said it was important to drive the wider adoption of stroke treatment as a professional specialisation.
“Then we would have stroke specialists who are trained specifically in endovascular therapy”, he told MJA InSight, saying this would hopefully result in a more effective utilisation of hospital resources.
“This morning I saw three stroke patients, and several physicians were needed to treat each patient. But someday I hope that just one specialist will be needed to treat one incident of stroke”, Professor Hankey said.
However, Professor Davis said that while there was a lack of neurointerventionalists, it was important to guarantee physicians undertaking training in endovascular therapy were exposed to a large number of cases.
He said it would be preferable to have “a smaller number of specialised clinics with a very high case load, rather than having many centres being able to perform the therapy, but not very often”.
Dr Campbell said wide implementation of endovascular therapy in Australia posed a unique challenge.
“We are fortunate here in Victoria that we have both stroke and interventional teams working in specialised centres”, he said. “But Victoria has the advantage of a more compact geography — it is going to be hard to provide endovascular therapy in other parts of Australia.”
In Queensland, for example, most interventional expertise is located in Brisbane, but this is too far away for stroke patients living in Far North Queensland to access.
Professor Hankey warned that these issues must be addressed quickly as Australia’s growing and ageing population meant demand for stroke specialisation would only continue to rise.
(Photo: Arno Massee / Science Photo Library)