12 October 2015
Experts aim to roll out new treatment
A pioneering new way to remove blood clots from blocked arteries could soon become part of everyday medical practice.
The treatment, known as thrombectomy, allows a special wire to pull out a clot from a blocked artery to restore blood flow as soon as possible. It works alongside another established treatment called intravenous thrombolysis; a specialist clot-busting drug that can be given to patients to break down blood clots. Together the treatments have the potential to limit the damage caused to stroke victims.
Now local, national and international stroke care experts are working to find new ways of delivering the additional new treatment, which is yet to be introduced into routine clinical practice with the exception of a few specialist centres, in hospitals across the country.
Stroke is the third leading cause of death in England and the leading cause of disability. More than 150,000 people have a stroke every year in the UK but, according to The Stroke Association, up to 10,000 of these could be prevented if more people were aware of the symptoms and sought out emergency treatment.
At a conference on hyper-acute stroke care hosted by the University of Central Lancashire (UCLan), in partnership with the All India Institute of Medical Sciences (AIMS), UCLan Professor of Stroke and Older People’s Care Caroline Watkins commented: “This innovative new treatment has massive implications for the way we treat stroke patients but of course it presents practical challenges such as identifying which patients need the treatment and potentially having to transfer them to a different hospital that has a physician who can deliver the treatment.
“We also need to decide who these experts would be such as a stroke doctor, neuroradiologist or even cardiologist. The treatment itself is ground-breaking but we need to put the foundations in place to deliver this high quality care.”
Professor Martin Dennis from the Centre for Clinical Brain Sciences in the Stroke Research Group at the University of Edinburgh commented: “These are exciting times for stroke care.
“The treatment itself is ground-breaking but we need to put the foundations in place to deliver this high quality care.”
“We know that being looked after by stroke specialists in a stroke unit makes good outcomes after stroke more likely, as does giving the clot busting drug thrombolysis. Now we have another tool in the box, thrombectomy; a special wire is inserted to pull out the clot from the blocked artery, to restore blood flow and so improve outcomes. We have been discussing today how to implement this into routine practice.”
Early discussions suggest the new treatment will need to be delivered at specialist centres following a thrombolysis which can be given at the patient’s local hospital. Practitioners trained in thrombectomy will need to have an understanding of cerebral circulation (the way that blood flows through the brain), and an appreciation that the blood vessels in the brain are much more delicate than elsewhere in the body. It is also important to recognise that because the process may have to be done in two stages; in hospital then at a specialist centre, this has implications both in time delay and also financially.
Professor Watkins said: “The costs of reorganising stroke services to ensure that this new treatment can be offered to those who are suitable is something that needs to be considered and work is already underway to find the best approach. Thombectomy is technically challenging, it requires training, practice and then frequent delivery to maintain staff skills. This is without doubt a team effort, delivering in a timely manner, on a clearly defined and accelerated pathway.”
Professor Dennis added: “We are pushing the boundaries of hyper-acute stroke care. If there is one thing that is fundamental to delivery of good stroke care it is expert clinicians and superb nursing, with a team that works well together.”
Plans to roll out the new treatment method come as a worldwide study into the best nursing methods for different types of stroke gets underway with 20,000 participants from six countries taking part; 5,000 of these will be from the UK.
HeadPost, led in the UK by Professor Caroline Watkins, is examining the best nursing methods for different types of stroke. The work includes vital research on whether stroke patients should be laid down or sat up when admitted to hospital.
“HeadPost will hopefully give us the best nursing methods for different types of stroke and ultimately lead to improved care for stroke patients.”
Professor Watkins said there is ‘no good evidence’ for using either position, (laid down or sat up): “The way nurses position patients following stroke varies between countries,” she said. “Most patients are placed upright in the UK and Australia, but in China and India they are reclined. In the United States and Switzerland, position is based on the type of stroke. None of this is evidence-based. Whenever there is uncertainty, we need a trial.”During the research stroke units will be randomly allocated one of the positions – upright or lying flat first, and will then changeover to the opposite position after a defined period. All patients who are admitted with symptoms of stroke will be monitored by nurses in that position.
Nurses will carry out neurological assessments of the patients on admission, maintaining positions, every hour for the first 24 hours and again after seven days or on discharge, whichever is sooner. Researchers will conduct follow-up interviews with patients after 90 days.
Professor Watkins added: “What nurses have to understand is there is no evidence for what they are doing now. Some things we do because it is custom and practice.
“HeadPost will hopefully give us the best nursing methods for different types of stroke and ultimately lead to improved care for stroke patients. It’s a really exciting project, it’s great to be able to offer patients in the UK the opportunity to take part and ultimately it means we can save more lives.”
The UK contribution to the global research will be centred in the Lancashire Clinical Trials Unit (CTU), a facility directed by Professor Watkins. The unit is the first of its kind in Lancashire and will primarily focus on supporting complex intervention trials in stroke, midwifery, cancer, musculoskeletal health, public/population health and mental health.