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Stroke: the dramatic revolution

By Victoria Haunton and Thompson Robinson

Stroke is a devastating condition with high rates of mortality and morbidity and profound implications for health economics and resources worldwide.  At present, in England alone, stroke is the third largest cause of death and the single largest cause of adult disability.  Each year, approximately 110,000 people in England will have a first or recurrent stroke and more than 900,000 people are currently living with the effects of stroke, with half of these being dependent on other people for help with everyday activities.  The financial repercussions of stroke are substantial, with an estimated cost to the English economy of £7 billion per year.  However, this condition, which was for so long regarded as a low priority and simply a natural consequence of ageing, has undergone something of a revolution in recent times.  The field of stroke medicine has seen significant advances and there is an ever increasing awareness that there are real opportunities to make a dramatic difference to stroke patients.

Despite the dramatic revolution in stroke medicine, levels of stroke knowledge amongst the general public remain surprisingly poor, and there are still significant difficulties in getting patients to access stroke services promptly.  In an article from a themed collection of papers from the journal Age and Ageing which focuses on stroke, research by Stephanie Jones and her team sought to try and understand these problems.  Worryingly, they found that people struggle to name even one stroke risk factor or stroke symptom, particularly when open-ended questions are used.  Knowledge is especially poor in older members of the population, ethnic minority groups and those with a lower socio-economic status, but there is also a surprising lack of knowledge amongst those who have already suffered a stroke.  Furthermore, there appears to be a real paradox between what people say they would do and what they would actually do in the event of  a stroke; whilst at least 47% said they would contact emergency medical services if they suspected they or a relative were experiencing a stroke, only 18% of stroke patients had actually done this.  There is therefore an urgent need for further public education.  In light of their findings, Stephanie Jones and colleagues suggest that the ideal campaign should minimise barriers to health services and provide cues to action.  Their review of previous initiatives suggests that the most effective such interventions have been stroke screening, community educational programmes and first aid training. However, these need to be repeated regularly as their effects are time limited.

Although the findings by Jones et al. are sobering, improving public awareness about stroke is a focal element of the UK Government’s National Stroke Strategy.  Another key focus of the National Stroke Strategy is stroke prevention.  Hypertension, obesity, diabetes and hypercholesterolaemia should all be managed according to clinical guidelines, and appropriate action should be taken to reduce overall vascular risk.  Moreover, all those at risk should be given information about exercise, smoking, diet, weight and alcohol.

However, despite our best efforts in stroke prevention, strokes still occur.  For those patients, the single biggest intervention which will improve their outcome is admission to a stroke unit and specialist stroke care.  There is strong evidence that this significantly reduces death, dependency and the need for institutional care.

The high rates of palliative needs of stroke patients should not be regarded as negative or depressing but instead as a real opportunity to make a positive difference.  Furthermore, despite the apparently disheartening and mortality and morbidity rates in stroke, we can afford to be optimistic.  The field of stroke medicine continues to grow and evolve and there is a wealth of stroke research occurring locally, nationally and internationally.  So, what will this bring?  What does the future hold?  In the immediate future, we are likely to see changes to the current guidelines on thrombolysis and blood pressure management.  Further education of the general public will hopefully yield great rewards in terms of faster access to specialist stroke services and thus better outcomes, and a greater understanding of neuro-plasticity is likely to bring changes in our approaches to stroke rehabilitation.  Further down the line, we may see novel treatments such as stem cells being employed in the treatment of stroke, and the review by Soma Banerjee et al. provides a fascinating glimpse into this world.

For now, stroke physicians will continue to build on the core foundations of good primary and secondary preventative strategies, urgent specialist stroke care for all those affected and holistic, multidisciplinary patient-centred rehabilitation.

The revolution continues.  Watch this space.

Dr. Victoria Haunton is Clinical Research Fellow and Honorary Specialist Registrar at Leicester University. Prof. Thompson Robinson is Professor of Stroke Medicine at Leicester University. They recently edited an online collection of papers on stroke medicine for the Age and Ageing journal,  and this has been made freely available for a limited time.

Age and Ageing is an international journal publishing refereed original articles and commissioned reviews on geriatric medicine and gerontology. Its range includes research on ageing and clinical, epidemiological, and psychological aspects of later life.

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