Can we get better results for our stroke patients?
View(s):
With current technology allowing the economically advanced nations to get good results on patients with strokes, why are we lagging behind?I am informed that the clot buster drug re-combitant Plasminogen Activator, is now readily available at the Emergency care Units of Teaching Hospitals and is being administered to patients who after emergency CT scans show a block in an artery to the brain causing a Stroke (85% of strokes). I am made aware that at least the Teaching Hospitals in Colombo, Kandy, Peradeniya, Galle and Anuradhapura have made available the facility, to the public 24/7. Thanks to the Ministry of Health, Jaffna. Kalutara may also be functional.
The drug is only administered to those arriving in hospital within the “Time Window” of 4.5-6 hours as prescribed. Administration of the clot buster drug after this period has elapsed usually gives poor results and could on occasion aggravate the stroke. This is not always true as blocks to the arteries in the back of the brain the “Time window“ is broader. The problem is that most patients arrive late, This is true at most centres. Even in Australia only about 30% come in time and is an eye opener with the facilities they have.Why is this delay to arrive in the hospital with facilities?
Several factors have been recognised. Not knowing the early symptoms and signs of a stroke, such as facial numbness, weakness of a side of the face, weakness of an arm or leg, slurring of speech for blocks in the front arteries of the brain and dizziness, instability, difficulty in swallowing for the arteries at the back of the brain.
Once these symptoms arise the relations need to be cognisant of them as well. Public awareness programmes in the print and electronic media during prime time are common place in many countries, Our elderly population is expanding and it is high time that the responsibility for orchestration on this score be taken up by the media moghuls.
The other factors for late arrival are, being asleep, living alone, patient waiting to see in the belief that symptoms will go away, can’t get to a telephone as the limbs are weak or can’t speak coherently or becomes unconscious.
These have been somewhat overcome elsewhere by not allowing those at risk such as the elderly to live alone. Those who have had warning symptoms of an impending stroke (same as those I have mentioned but passes away within a day) should not sleep alone while waiting to see a Neurologist. In some countries elderly can wear an alarm (necklace type) which is easily accessible to the patient, that can wake either the family or the neighbours.
In most of our cities, as yet, an on call ambulance facility is not available, at least those that don’t demand prior payment and is available 24/7.We must thank the Indians through the Prime Minister for having mooted such a facility at least in the future in the Western Province. I hope it be afforded to us living outside the Mecca.
What are the results of such intervention clot dissolution drugs? At best if the patient is brought within the “time window” of 4.5 hours, only about 30 % of them can expect to be mobile, at least after intense physiotherapy be reasonably normal. These results are for Australia.Our Sri Lankan figures for the same are lower, around 15%. They are acceptable considering the gross morbidity that can follow on a stroke, the worst being a cerebral,an invalid, in a vegetable state or dead.What is horrendous (is?) when it strikes the young and the fit.
However, this rather gloomy eventuality has been dramatically changed in the current day and time, “a quantum jump” in Stroke care, has occurred, I must emphasise. Since about 2014, the pioneers of interventional radiology promoted the concept of delivering the clot busting drug which is currently being given intravenously from an arm vein, instead to be delivered directly to the site in the artery in the brain that is blocked. This was done by passing a special sophisticated catheter, introduced into the arterial side of the circulatory tree, through a puncture in the upper thigh.The results improved dramatically.
They went further, as the larger clots in the main arteries were resistant to satisfactory dissolution, by sending a catheter capable of sucking out or better yet of extracting the clot. The patency rate from this type of extraction is proven by subsequent contrast enhance CT scans to be almost 95-100% patent.If the patient arrives within the time window of 4.5 hours, he or she is dramatically cured and maybe able to literally walk out from the hospital in a few days! This reality is commonplace in the US, Australia, England, Europe and a whole host of other countries. Their only bugbear is that even there the number of patients coming in time is poor.
Coming back to Sri Lanka, we are yet in the stage of mostly giving the clot ‘buster” drug intravenously into a forearm vein. The facility however exists in the catheter extraction of the clot here in Sri Lanka, in Colombo, in the Central Hospital on Norris Canal Road. I am not advertising, because when I got a stroke it was done on me, there, even after 20 hours, about, a year ago and from being completely paralysed with being only able to blink to communicate, I am here, the transformation to what I am now, to be able to address you all, not even looking at my script!
For this I have to thank the procedure and the dedicated trio of doctors who did it. My family, are all in the medical profession including myself and we did not know of this new procedure, being available in Sri Lanka. I feel it’s my duty and am morally bound to make you aware, hence my presence here.
I have to make a plea, I need your help to initiate a pragmatic programme to get better results with strokes. Now that the roads into the interior are being developed,that mobile phone access is almost universal in this country, what we need is a 24/7 ambulance service and to train paramedics to travel in them and help in the immediate care of the airway and the like. This, ie the training, our anaesthetists will readily do. This will facilitate at least those living within the city of Kandy or thereabouts to come to Kandy or Peradeniya hospital within the period of time. This should be our initial step. Concurrently public awareness programmes on stroke symptoms, what to do, whom to ring etc need to be promoted.The ultimate goal is to make available dedicated scanners, interventional Radiologists 24/7. So that we can extract the clot.Though we will have to make do with what is available, at the moment, we must move with alacrity towards a radiological expertise 24/7 on call, and retriever catheters.
While on clot buster drug, introduced into a forearm vein by/at the local GP or the closest hospital, the stroke patient can be brought to the hospital, made sure with a CT Scan that it is a clot blocking causing the stroke (85% of the time) and then go ahead with it’s extraction. There is no problem in bridging with the clot dissolution drug, it does not handicap the procedure.
The retriever catheter is quite expensive. We heard recently that a BMW 7 series car that the privileged lot travel in, costs Rs. 50 million. With this we could save 50 lives!
To make sure that all citizens, be they economically sound or not, irrespective where they live, must benefit from the procedure,at least that should be our target. So that catheters are provided to those unable to fund them. An organization, like the “Heart to Heart Foundation” has to be inaugurated with honest altruistic people . They could receive donations and I am sure it will succeed in this country as it is a form of Abeyadhana.
The Non communicable Diseases (NCD’S) are now within the national radar. Let’s be pragmatic, develop our ambulance facility. Our rehabilitation services with enhanced cadres of Physiotherapists, Occupational therapists, Speech therapists, would be needed. We will need to develop graduate schools for them, to improve the quality, as we realise that we need them, because “the time window“ will remain prohibitive for some time.
The population is ageing. Conjugal living is becoming a reality. Homes for the aged are mushrooming everywhere. NCD’s like strokes heart ailments, cancers, fractures, visual acoustic deterioration dementia, prostatic problems are going to loom on the horizon. As we gradually out live our so called ”designed period” we will have to take each problem in turn. It is a truism that a society is assessed by how they care for their infirm and elderly.
(Abridged from an address to the Association of Professionals of Kandy by Prof. Channa Ratnatunga)