The new lottery in stroke care

Posted: 20 September 2010 by Steffen Bayer

In the recent past there was a postcode lottery in stroke care. People who have had a stroke need to receive thrombolysis drugs within a vital ‘three hour window’ for effective treatment. But their chances of such treatment depended on whether the nearest hospital was one of the few to offer it. They often paid the price in disability – and the NHS picked up the costs for long-term rehabilitation and care.

Thankfully that situation is improving. There has been a big push to build stroke care capacity and make thrombolysis more widely available. Unfortunately, however, there is now a new lottery – based on the time at which a person has a stroke. If it is in the evening or at night, then your chances of getting good treatment plummet. The lack of universally available 24-hour capacity means that, in many cases, it is not possible to get the patient to hospital, scan them, interpret the results and administer the necessary drugs within three hours.That’s tough luck for a lot of people.

It doesn’t have to be like this. Stroke services in some locations such as London and Manchester have been restructured and centralized so they have round-the-clock capacity to deliver thrombolysis drugs within the three hour period. The challenge, now, is to roll this capacity out nationally. That’s not going to be easy, particularly in rural areas where travel distances are long.

The problem is not getting the drugs to the patient – but ensuring the correct diagnosis via a scan. Some 80 per cent of strokes are infarctions which require thrombolysis to clear the blockage, producing excellent outcomes. But 20 per cent of strokes are caused by a haemorrhage, which thrombolysis only worsens. That’s why scanning and correct diagnosis is vital.

What’s the answer? In one country, I have heard they give thrombolysis in all stroke cases and accept, as a regrettable downside, that there will be some fatalities among those who have had a haemorrhage. That’s unlikely to be acceptable to the NHS. A more desirable solution would be something similar to the supply of defibrillators - diagnostic equipment in every ambulance, or at least available locally. The development of low cost and mobile scanning equipment allowing medics to distinguish between infarctions and haemorrhages would be a major step forward.

A few years ago, less than 1 per cent of stroke victims received thrombolysis in time. I reckon we could get that figure to 10 per cent. It might not sound ambitious, but it could transform thousands of lives every year and save the NHS millions in long-term care costs.