In this powerpoint presentation, Dr Amer Jafar, Aneurin Bevan Health Board in Wales is summarising the main research articles that were published in September 2010 issue of the ‘Stroke’ Journal.

STROKE September 2010

Fewer than half of hospitals have access to stroke-specific services known as Early Supported Discharge (ESD), despite evidence showing that patients fare significantly better when such services are available.

This audit has addressed for the first time the issue of stroke care in the young or in the working age group with a key message stating that vocational support for stroke patients of working age should be regarded as a core element of all stroke services. Less than half of services in Britain specifically provide a service that involves educational or vocational training.

The key findings of the report include:

• 74% of patients are now getting some access to clot-busting drugs (thrombolysis)
• While 98% of hospitals now have a neurovascular clinic, the median wait from referral to being seen in one is 3 days.
• 36% patients are still being treated on a general assessment ward 24 hours after being admitted to hospital with a new stroke.
• Almost half of sites report the need to admit patients to non-specialist wards because of bed shortages.
• 44% of stroke services have an available specialist ESD team.
• 28% of patients discharged to specialist ESD teams are still waiting over 48 hours for physical therapy, occupational therapy or speech and language therapy.
• 55% of stroke services have access to specialist community rehabilitation team.
• 43% of high risk patients with suspected TIA are seen on the same or the next day.
• 85% of low risk patients with suspected TIA are seen within a week.

Key recommendations include:

• Patients with acute stroke should be admitted directly to a specialist stroke unit and have access to continuous physiological monitoring. General assessment units are not an adequate substitute.
• Standards of care offered in all specialist stroke beds should meet those defined in the National Clinical Guidelines for Stroke 2008.
• Stroke services should be organised to deliver thrombolysis to all appropriate patients regardless of where they live or the time of day or week they present.
• Patients requiring end of life care should be able to receive such care to a high standard on a stroke unit.
• Vocational rehabilitation should be made available to all stroke patients wishing to return to work.
• Care of stroke patients transferred to community hospitals should meet the standards defined for specialist stroke unit care set out in the National Clinical Guidelines for Stroke 2008.
• All services should be able to deliver high quality specialist early supported discharge to appropriate patients.
• High quality longer term rehabilitation should be provided to all patients who require on-going treatment without undue delay.
• Facilities to investigate high risk patients after TIA should be available at all times including weekends.
• Information provision should be improved to provide universal access to all in-patients and out-patients.

Its hypothes is based on the information that high level of homocysteine is a risk factor for stroke, cardiovascular diseases and TIA. The research team was aiming to assess whether the addition of once-daily supplements of B vitamins to usual medical care would lower total homocysteine and reduce the combined incidence of non-fatal stroke, non-fatal myocardial infarction, and death attributable to vascular causes in patients with recent stroke or transient ischaemic attack of the brain or eye.

In this randomised, double-blind, parallel, placebo-controlled VITATOPS  trial, the researchers assigned patients with recent stroke or transient ischaemic attack (within the past 7 months) from 123 medical centres in 20 countries to receive one tablet daily of placebo or B vitamins (2 mg folic acid, 25 mg vitamin B6, and 0·5 mg vitamin B12). The primary endpoint was the composite of stroke, myocardial infarction, or vascular death. All patients randomly allocated to a group were included in the analysis of the primary endpoint.

The trial concluded that daily administration of folic acid, vitamin B6, and vitamin B12 to patients with recent stroke or transient ischaemic attack was safe but did not seem to be more effective than placebo in reducing the incidence of major vascular events. These results do not support the use of B vitamins to prevent recurrent stroke.

In his editorial in the same issue of the Lancet Neurology,  Professor Peter Sandercock from Clinical Neurosciences Department in Edinburgh  mentioned that the jury is still out on homocysteine reductions, at least until the present trials (There are few unfinished trials regarding the homocysteine lowering and its effect on cardiovascular diseases) are complete.

This presentation is part of the activity of Gwent Stroke Team to participate in the videoconference weekly stroke care meetings. These meetings were started 6 months ago and aiming to exchange clinical experience in acute stroke management between stroke physicians from all over Wales. In this presentation Dr Amer Jafar, is reviewing the August 2010 issue of the journal ‘Stroke’, the international stroke Journal published by the American Heart Association.

Stroke August 2010 [Compatibility Mode]

The 7th World Stroke Congress, organized by the World Stroke Organization (WSO), is a landmark event attended biennially by leading medical professionals interested in finding global strategies to combat the second most common cause of death worldwide.

The WSO Seoul 2010 Congress will facilitate the dissemination and discussion of all aspects of stroke and provide a platform for experts to present the latest research.

In the first teaching course of the congress, James Grotta from USA is giving an overview about the recent and the ongoing acute stroke trials. In the same session there are presentations related to the subjects of how to organise acute stroke unit care and thrombolysis in country of low resources in addition to the subject of CT technologies in acute stroke.

There are other teaching sessions and hundreds of papers and research posters which are going to be presented and discussed in the congress. Some of the themes of the meeting are specifically focusing on issues like: clinical stroke syndromes, venous thrombosis syndrome, evidenced- based rehabilitation following stroke, alternative medicine in stroke management, subcortical stroke, intracerebral haemorrhage and advances in Neuroimaging.

The organisers of the session of stroke rehabilitation are planning to discuss the usage of virtual reality as an intervention tool in addition to the subject of computer games and rehabilitation.

For the 9th year running the Welsh stroke Conference has managed to attract the attention of the hundreds of stroke specialists and members of the multidisciplinary teams from Wales and all around the country. The conference which was held on 25th June 2010 in the River Front of Newport has started with a presentation from Professor Steven Cramer about the subject of brain repair after stroke. The speaker is an Associate Professor of Neurology at the University of California, Irvine. His research focuses on brain repair process after central nervous system injury in humans, with an emphasis on recovery of movement after stroke.
The subject of cerebral small vessel disease and its diagnosis and management was the main focus of Dr Mike O’Sullivan lecture. Mike is one of the Neurologist and MRC fellow in Cardiff. His main research interest is in mechanism of cognitive impairment in aged population and its relation to cerebral small vessel disease.

The third lecture in the first session of the stroke conference was about advances in stroke rehabilitation by Professor Robert Teasell from Ontario. The lecturer has edited 4 books and authored over 200 peer-reviewed articles in his field. Professor Teasell is the primary investigator of the acquired brain injury evidence-based review (ERABI) and the spinal cord injury research evidence (SCIRE)) projects.
The main lecture of the conference was given by Professor Jeffrey Saver from California about the subject of future of stroke medicine. He is currently chair of the stroke council of the American heart association. Professor Saver is the principal investigator of a specialized program of translational research in acute stroke.

The 9th Welsh stroke conference has addressed the issue of living with stroke and discussed subjects like: oral health care and visual problems post stroke. Professor Kennedy Lees from Glasgow was speaking about thrombolysing for acute ischaemic stroke and the evidences available so far for the practice in hyperacute stroke care. Professor Keith Muir was lecturing about Neuroimaging for stroke patients and the recent advances in this field. He was a guest speaker few weeks ago in North of Gwent where he was speaking about the latest developments in the field of stem cell in stroke research and management.
The organisers of the conference have chosen few posters about subjects related to stroke service delivery, stroke research and stroke case presentations. The experience of the stroke teams in Wales in using the teleconferencing to facilitate educational meetings across Wales was presented in a poster by Dr. P. Jones and Dr.Tom Hughes from University Hospital of Wales.

Since 1990, the European physicians and scientists are meeting in a conference to discuss their latest research activities in stroke.
The orginsers of the European Stroke conference managed to oragnise a special meeting for the stroke nurses and the allied health professionals working in stroke care. This type of activity was started successfully in 2007.
On 25th May 2010, the 19th European stroke conference is starting with hundreds of papers, drug trials and research posters and presentations from all over Europe and other countries in the world. In fact the representatives to the conference are coming from almost 90 countries giving the feature of an international stroke conference to this 19th European one which is held in Barcelona, Spain for three days.
The main topics for discussion in this European stroke conference are: Acute Stroke, Emergency management, stroke units and complications. Another important topic is the subject of intracerebral/ subarachnoid haemorrhage and venous diseases. Rehabilitation and reorgnisation of service after stroke is a subject which attract good number of presentations and posters in this conference. There is a mini symposium about an update regarding carotid stenosis.
‘www.strokeupdate.co.uk ’ is happy to participate in the European stroke conference on annual basis and share the results of the European stroke trails with the rest of the world.
Read the final programme of the conference here

ESC Final Programme__

Professor K. Lees and his team have published recently (The Lancet 2010;375:1695-1703) the results of their pooled analysis of the data from the stroke thrombolysis trails. Early administration of intravenous recombinant tissue plasminogen activator (rt-PA) after ischaemic stroke improves outcome. Previous analysis of combined data from individual patients suggested potential benefit beyond 3 h from stroke onset. The team re-examined the effect of time to treatment with intravenous rt-PA (alteplase) on therapeutic benefit and clinical risk by adding recent trial data to the analysis. The data was added from ECASS III (821 patients) and EPITHET (100 patients) to a pool of common data elements from six other trials of alteplase for acute stroke (2775 patients).
The findings showed that treatment was started within 360 min of stroke onset in 3670 patients randomly allocated to alteplase (n=1850) or to placebo (n=1820). Large parenchymal haemorrhage was seen in 96 (5•2%) of 1850 patients assigned to alteplase and 18 (1•0%) of 1820 controls, with no clear relation to onset of start to treatment.

In his interpretation to the results Professor Lees stated that patients with ischaemic stroke selected by clinical symptoms and CT benefit from intravenous alteplase when treated up to 4•5 h. To increase benefit to a maximum, every effort should be taken to shorten delay in initiation of treatment. Beyond 4•5 h, risk might outweigh benefit.

WSB March 2010