Focus on stroke: What’s needed for a fitter future?

Provided with permission of the Stroke Association. Copyright: Stroke Association

We asked a number of leading clinicians, researchers and other professionals working in stroke the question:

With unlimited resources, what one change would you make today to transform the stroke field in ten years’ time?

Keith Muir, SINAPSE Professor of Clinical Imaging and Consultant Neurologist at the University of Glasgow: “I would put unlimited resources into research, so that we had a proper network of centres all contributing to clinical trials – because that’s the only way forward. Without that, clinicians are just guessing what the right thing to do is.”

Masud Husain, Professor of Clinical Neurology at the Institute of Neurology, University College London: “Develop a treatment that has a real impact on cognitive function after stroke. It’s unlikely that drugs or behavioural therapies alone are going to be as useful as combinations of these interventions. Whether new technologies such as deep brain stimulation or transcranial direct current stimulation can also be used to improve learning or neural plasticity after stroke remains to be explored. With unlimited resources, we’d be able to accelerate discovery of new forms of treatment for cognitive disorders in stroke.”

David Werring, Clinical Senior Lecturer in Neurology, UCL Institute of Neurology and Consultant Neurologist, National Hospital for Neurology and Neurosurgery: “It would be for the majority of the population to understand the symptoms of a stroke and the importance of the rapid recognition of symptoms and rapid treatment.”

Stephen Payne, Lecturer in Biomedical Engineering at the University of Oxford: “The key question is: Can we find a way to tell what type of stroke it is in the ambulance, without having to spend time getting to a specialist unit? And are there any treatments that you can give for either kind of stroke – haemorrhagic or ischemic – that will at least slow the progress of the stroke down?”

Eileen Gambrell, Service Manager at the stroke patient group Different Strokes: “We need to recognise that people’s needs change over time and that everyone is an individual, so a one-size-fits-all approach doesn’t work. I would give patients individual long-term rehabilitation plans structured according to their individual needs and find a way to allow them to easily refer themselves back into rehabilitation programmes as and when they need to.”

Damian Jenkinson, Interim National Clinical Director for Stroke, Department of Health: “The foundation of good care is organised stroke units. I would ensure 100% access to all patients to stroke units so they spend all of their time in a specialist area. At discharge, I would ensure that as many as possible have early supported discharge. These measures would make the greatest difference in terms of reducing death and disability from stroke.”

Hugh Markus, academic clinical neurologist, Professor of Neurology, Head of Stroke and Dementia Research Centre at St George’s, University of London: “Secondary prevention: medical and surgical interventions to prevent stroke. We’ve come a long way because we can treat blood pressure, use aspirin, and treat cholesterol, but there’s still a lot we don’t understand. The potential of things like genetic studies is they allow you to get completely new mechanisms of stroke, which you can then target.”

Paul Guyler, Lead Consultant for Stroke Medicine at Southend University Hospital, Southend-on-Sea: “The biggest challenge we have now is continuing to educate people that if they have a stroke, especially if it is initially mild or improves quickly, to call for help. Because it doesn¹t hurt, people often wait to see if it gets better, and the brain can be permanently damaged in that time.”

Hugh McCann, Professor of Industrial Tomography, University of Manchester: “Early diagnosis and intervention – even in the ambulance – for people with any kind of traumatic head injury, whether someone’s had a stroke or come off a motorbike, is absolutely critical.”

Adrian Parry-Jones, NIHR Clinical Lecturer in Stroke Medicine, University of Manchester: “I would identify an effective, widely available treatment for haemorrhagic stroke.”

Lalit Kalra, Professor of Stroke Medicine at King’s College London: “The single most important goal would be to raise public and professional awareness that stroke, despite being a devastating disease, is both preventable and treatable. However, this can only be achieved by investment into research to reduce the burden of stroke and developing clinical services that deliver these evidence-based treatments.”

Anthony Rudd, Consultant Stroke Physician at St Thomas’ Hospital, London: “I would put a lot of resources into community and long-term care. The acute stuff is going to happen now, the momentum is there. I don’t think we have that yet for the longer term management.”

Caroline Watkins, Professor of Stroke and Older People’s Care and School Director of Research, School of Health at the University of Central Lancashire: “No matter what we do, people will still have strokes, and one of the hardest things is to adjust to life after stroke. So, for me, something we need to address is the psychological and emotional impacts of stroke. If you measure everybody at any one stage after stroke, at least a third would be clinically depressed and many more very fed up and frustrated.

“People have traditionally thought that motivational interviewing is all about changing people’s behaviour, helping them to stop smoking or drinking too much. In our study we used our modified motivational interviewing-based approach to help people to adjust to life after stroke – to change what they make of it. Changing what they made of it made low mood and depression much less likely. This approach is very simple and it’s easy to train people how to do it, so I’d like to see more effort and funding in this kind of area.”

Fatemeh Geranmayeh, a Wellcome Trust Research Clinical Fellow in the Computational, Cognitive and Clinical Neuroimaging Laboratory at Imperial College London: “Mass population screening to prevent strokes. We don’t have the technology to repair the cells that die following a stroke, so GP surgeries and hospitals, should perform screening for blood pressure, cholesterol, diabetes and other risk factors and treat these early. If the timeline is longer, invest in stem cell therapies and other such measures, but we need a leap in technology for that to become available clinically. On a ten-year timescale, I would say more intensive risk factor screening for stroke prevention.”

Nick Ward, Reader in Clinical Neurology at the Institute of Neurology, University College London: “I would like to see more attention paid to early post-stroke rehabilitation. Whether it is in speaking, walking or reaching and grasping, improvements can be seen with close to 100 hours of practice and yet we probably deliver less than ten hours on average. It’s true that individuals will respond in different ways, and we hope that in the future good-quality structural and functional brain imaging early after stroke will help predict what dose and type of rehabilitation treatment will be best for each person.”

Sophie Scott, Professor of Cognitive Neuroscience, Institute of Cognitive Neuroscience, University College London: “I would put a lot of time and resources into how we deal with patients acutely. I would throw a lot, everything we can do – occupational therapists, speech and language therapists – into working with people immediately after their stroke, and not just send them home. At the moment, we’re very patchy in how we’re providing support for people. We know that recovery is possible and can occur, and there’s a very good chance we could be doing all sorts of things to improve that.”

Alun H Davies, vascular surgeon: “Something we don’t seem to have got right is rehabilitation. I’m possibly slightly biased because my other half had a stroke when she had my third daughter, but we are not geared up for looking after patients particularly well in hospital. Any system where therapy services manage to give people half an hour or an hour a day is not giving them what they need, and it’s only available five days out of seven.

“Also, stroke services aren’t uniform around the country. I think they’re better than they were, since the introduction of hyper-acute stroke units and other things, but there’s still very much a postcode lottery. We looked at this ten years ago – there was a five-fold variation in practice. If you look at the National Vascular Audit Database, there is a substantial difference in the time between presentation and intervention, which is quite marked, and there is still a three- or four-fold difference around the country.”

Reporting by Penny Bailey, Moheb Costandi, Nic Fleming, Chrissie Giles and Michael Regnier.

This article is part of the Wellcome Trust’s Focus on stroke, a series of articles, interviews and videos running throughout May 2012, which is the Stroke Association’s Action on Stroke Month.

For more information on stroke, visit the Stroke Association’s site or call its helpline on 0303 303 3100. If you or someone with you is suspected of having a stroke, call the emergency services immediately.