Issues and answers in stroke care

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Issues and answers in stroke care

J van Gijn, M S Dennis

In this section we address three aspects of stroke care that are important yet could not be reviewed in depth. The first is the organisation of stroke care (stroke units), in the acute phase as well as in the rehabilitation phase. The type of stroke services that hospitals provide varies considerably from place to place. To some extent this reflects differences in local conditions and needs, but at least there is now good evidence that hospital-based stroke services need to be organised. Which proportion of stroke patients needs formal rehabilitation depends on case-mix, with age and severity of stroke being the main factors. A rough estimate is that 20% of patients die within 30 days, and that 40-60% of survivors remain functionally dependent at the end of that period. The second issue is that of vascular cognitive impairment and its prevention. The increasing sensitivity of neuro-imaging techniques has revived the notion of chronic ischaemia as a cause of mental decline. The intellectual changes are mostly mild but the high prevalence makes this disorder a major health problem. Lastly, cost-effectiveness of hospital care for stroke patients is a controversial issue, given the great variation across Europe in the proportion of stroke admissions. Do stroke units and rehabilitation difference? Stroke units

make a

Stroke units definitely make a difference. The latest systematic review of all randomised trials that compared organised inpatient stroke care with contemporary conventional care showed a long-term (median 1-year follow-up) reduction in deaths (odds ratio 0.83, 95% CI 0.69-0.98) and in the combined poor outcomes of death or dependency (0.69, 0.59-0.82; figure 1) and death or institutionalisation (0.75, 0.65-0.87)2 Specialist stroke units were defined as either a ward or team exclusively managing stroke (dedicated stroke unit) or a ward or team specialising in the management of disabling illnesses, which include stroke (mixed assessment/rehabilitation unit). Conventional care was usually provided in a general medical ward. The review was based on 19 trials (of which three had two arms for conventional care); 12 trials assigned a total of 2060 patients to a dedicated stroke unit or a general medical ward, six trials (647 patients) compared a mixed assessment/rehabilitation unit with a general medical ward, and four trials (542 patients) compared a dedicated stroke unit with a mixed-assessment rehabilitation unit. Organised inpatient (stroke-unit) care, when compared with conventional care, was best characterised by

Lancet 1998; 3 5 2 : (suppl II) 2 3 - 2 7 University Department of Neurology, Utrecht, Netherlands (J van GUn FRCPE);Department of Clinical Neurosclences, Western General Hospital, Edinburgh, UK (M $ Dennis FRCP) Correspondence to: Prof J van Gijn, University Department of Neurology, PO Box 85500, 3508 GA Utrecht, Netherlands

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coordinated multidisciplinary rehabilitation programmes of education and training in stroke, and specialisation of medical and nursing staff. The stroke-unit care was usually given in a geographically discrete ward. Beneficial effects were independent of patients' age, sex, or stroke severity and of variations in stroke-unit organisation. Length of stay in a hospital or institution was 8% (95% CI 3% to 13%) shorter than with conventional care, but there was considerable heterogeneity of results. The benefits of the stroke-unit approach were subsequently confirmed, in terms of case-fatality, by one more trial. ~ Also, for one of the trials included in the meta-analysis, the reduction in the rate of death or dependency was sustained for 5 years2 To date, no single factor or even small group of factors has been identified as being responsible for the favourable effect. 4 The integrated care from several disciplines probably benefits a wide range of stroke patients in different ways, by reducing death from secondary complications of stroke (including stroke recurrences) as well as by reducing the need for institutional care through a reduction in disability. Rehabilitation If spontaneous restoration of function occurs, the rate of recovery is most rapid in the first weeks and months; the curve gradually flattens as the 1-year mark is approached. Therefore the efficacy of early interventions can be easily overestimated. Formal assessment of separate elements of the rehabilitation process has produced somewhat less robust results. Physiotherapy for limb weakness and general mobility favourably influenced function in three randomised trials, the size of the effect being proportional to the intensity of treatment2 Visuospatial dysfunction poses major problems to those involved in rehabilitation. In the few small randomised trials of attempts to restore visuospatial function, therapy seemed to benefit patients' performance on specific tasks but not to improve functioning in activities of daily living2 In some units patients with unilateral neglect are positioned so that their intact side faces a wall, to encourage them to respond to stimuli on the affected side, but there is no evidence that this strategy influences outcome. Studies assessing the effectiveness of speech and language therapy in dysphasia have been marred by methodological weaknesses. 6 Several small randomised trials have suggested that similar outcomes can be achieved with the help of volunteers given appropriate guidance and by regular treatment from trained therapists2 Systematic review of the existing evidence is urgently needed, and probably new trials as well. Swallowing problems have been highlighted by several studies, but there is no evidence that swallowing exercises speed restoration of an effective swallow/ There are similar uncertainties about how best to feed patients in the initial period after a stroke. If dysphagia persists for weeks, percutaneous endoscopic gastrostomy should be considered; a small

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Figure 1: Odds of death or dependency at the end of scheduled follow up with stroke unit compared with conventional care Odds ratios and 95% CI are presented as a black box and horizontal line. Open diamond=pooled odds ratio and 95% Cl for a group of trials; black diamond=pooled result for all trials. Data were not available for two trials, From reference 1, with permission. References for trials listed can be traced through ref 1

trial has suggested an amazing gain in survival, which needs confirmation.* It is important that the targets of rehabilitation are realistic. Fairly accurate predictions can be made within a few weeks; patients and their relatives should be told repeatedly what can and cannot be achieved, although some uncertainties will remain. Since many stroke patients will also require community-based resources at some stage in their illness, it is crucial to integrate outpatient rehabilitation and home care with hospitalbased facilities, and to ensure that transfers between each part of the service are as seamless as possible. Is vascular cognitive impairment preventable? A brief answer to this question is: we do not know, but it probably is. The subject here is not so much the prevention of acute stroke (which is dealt with on pages 15-17), though strokes may clearly affect cognition2 The central issue is that of multifocal or diffuse demyelination of the brain, commonly but not invariably ischaemic in nature and associated with arteriosclerosis. 1° These lesions can be recognised on computed tomography or magnetic resonance imaging scan (figure 2), provided disorders of white matter other than ischaemia have been excluded (panel). Their presence is usually associated with the classic vascular risk factors. 11 A variety of studies have shown a correlation between the presence and extent of these lesions and the severity of cognitive impairmentY With the concept that mental impairment or even dementia results from chronic ischaemia, neurological semeiology has come almost full circle. In the first half of this century gradual deterioration of cognitive function in the elderly was often attributed to "arteriosclerosis" (Netter's well-known atlas on disorders of the nervous system contains a drawing of a shriveled sin24

brain with fattened arteries). T h e n the pendulum swung towards primary degenerative disease of the Alzheimer type being assumed in all instances of gradual slowing of intellect and loss of memory; according to this line of thinking, vascular causes could be inferred only through summation of consecutive strokes, large or small ("multiinfarct dementia"). With the advent of increasingly sensitive imaging techniques, it became clear that ischaemia could, after all affect mentation insidiously, without overt episodes of stroke. The only difference with the older theories is that the underlying vascular disorder affects not the most proximal but the most distal parts of the cerebral arterial tree--ie, the arterioles. Back to prevention. This is a major challenge in health care, since lesions of the white matter occur in about a quarter of peoPle aged 65 or over in the general population, with cognitive impairment being proportional to the severity of the lesions. 13 Even though full-blown dementia is rare and some of the less severe lesions may have to be attributed to Alzheimer's disease, the elderly undergo a continuous and silent epidemic of insidious mental slowing and intellectual decline from ischaemia-not so severe that an independent existence is endangered, but commonly severe enough to drain much of the colour from life. Longitudinal studies are still scarce in this disorder. The few there are addressed the natural history, not intervention.' .... Although highly likely, the ability of modification of hypertension and other vascular risk factors to alleviate this invisible burden of disease in the elderly remains to be proved. Appropriate care: between the ideal and the affordable For patients admitted

to hospital,

stroke units lead, on

average, to a better outcome than does general medical Stroke • Vol 352 • October • 1998

THE LANCET because they live alone or have a severe stroke tend to be admitted anyway. 16 For most other patients with stroke, management in hospital offers several advantages. The benefits of integrated stroke teams and the issues around rehabilitation have been dealt with above. The costs of management in hospital are due mainly to nursing care, with a relatively small proportion being due to investigations and medical care (figure 3).

Stroke may be misdiagnosed A referral diagnosis of stroke has been proved incorrect in 13-27%, ~sa9 and this range may well be the same for patients not referred. Disorders mimicking stroke include not only migraine and hyperventilation, but also multiple sclerosis, epilepsy, and confusional states, some of which definitely need specialist care. Even if the clinical diagnosis is initially confirmed in the emergency department, computed tomographic scanning shows nonstroke lesions such as a tumour or subdural haematoma in 1-2%2 °

Neurosurgical facilities

Figure 2: Magnetic resonance imaging scans (T2-weighted) of a 46-year-old salesman with untreated hypertension and 3-year history of progressive dementia He never had a stroke. The family history was negative. There are severe abnormalities (hyperintensities) of the cerebral white matter.

care, but this comparison does not in itself imply that best hospital care is better than home care. Randomised trials of cost-effectiveness have not yet been done to support this opinion, which means that proponents of either strategy have to rely on deductive reasoning, with all its inherent pitfalls. Inevitably the result is divergent patterns of care in Europe, with the proportion of stroke patients admitted to hospital ranging from only 55% in the U K to 95% in Sweden. 16'17We think there are more arguments for than against hospital care, although we might be biased by the environment in which we work. Also, there are obvious exceptions, such as the case of those patients who are infirm because of severe coexisting disease but who are surrounded by a strong social network. Conversely, patients who cannot be cared for at home

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Although cerebellar strokes and strokes affecting the brain stem are commonly difficult to distinguish from each other clinically, they differ in the management required--rapid neurosurgical intervention should be available for ventricular drainage or resection of a haematoma or swollen infarct in the cerebellum21 With prompt intervention the outcome can be surprisingly good. Subarachnoid haemorrhage is another disorder that should definitely be managed by a specialist team that includes neurosurgeons and neuroradiologists. The overall case-fatality rate is still about 40%, with another 10-20% of patients with subarachnoid haemorrhage remaining functionally dependent, but over the years there has been a slow trend towards improvement in outcome. ~ Hemicraniotomy for progressive swelling and impending herniation secondary to large infarcts in the middle-cerebral-artery territory has been advocated in some centres, but the effects of such operations on survival and quality of life have not been assessed in a randomised trial.

Thrombolysis According to a systematic review of randomised trials of thrombolytic drugs given intravenously (streptokinase or tissue plasminogen activator), these agents result in an overall increase in deaths early after the stroke and during follow-up (an increase of about 37 per 1000 patients treated, mostly from intracerebral haemorrhage). However, these drugs also reduce the number of patients in the combined outcome category of death or dependency (by about 65 per 1000 patients treated). 23 This "kill or cure" dilemma may be less of a problem with tissue plasminogen activator than with streptokinase and if patients are treated within 3 h of the stroke (see article on page 10), but most of the evidence for this time window is derived from indirect comparisons revolving around a single trial. 24 It is too early to extrapolate the results of thrombolysis in specialist centres to routine clinical practice. More information is needed on the influence of stroke severity and type, age of patient, time window, concomitant exposure to antithrombotic drugs, type and dose of thrombolytic drug, and computed tomographic scan appearances before thrombolytic drugs should be used routinely outside randomised controlled sIII25

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Figure 3: Proportion of direct hospital costs attributable to different aspects of care provided in Edinburgh, Scotland These data relate to a period before stroke services were organised. The development of a stroke team and unit may have altered the proportions, although probably not by very much. From reference 5, with permission.

trials?3 But at least the era of nihilism in the management of ischaemic stroke has ended. T o speed up completion of further trials and to offer patients at least a chance of profiting from immediate intervention, stroke patients must be admitted to hospital as soon as possible. Primary-care physicians are unlikely to change their practice overnight and to drop everything they are doing to deal with a suspected stroke in the same way as is now customary for myocardial infarction. Nevertheless, there is no justification for indifference ("Just let me know when you've got some more positive results") from community carers.

indirect comparisons have shown differences in efficacy in the range between 30 and 1300 rag/day. 27 Patients with non-disabling stroke and atrial fibrillation benefit greatly from anticoagulant treatment. 2s If the annual risk of intracranial haemorrhage is kept below 1.5%, there is also a net gain in costs29 Patients with severe carotid stenosis ipsilateral to the affected hemisphere as detected by duplex scanning are candidates for angiography and endarterectomy. That strategy is costly, however, at US$145 000 (in 1991) per stroke avoided29 For those in sinus rhythm and without an operable lesion, clopidogrel is slightly more effective than aspirin,3° but barely enough to justify the increase in cost. The level of risk at which cholesterol-lowering drugs are cost effective is not only a political but also a scientific question, because of uncertainty about whether findings in patients with coronary disease can be extrapolated to those with stroke. There is, likewise, a lack of specific evidence of whether modification of other risk factors (blood pressure, diabetes, smoking, obesity) is beneficial to stroke patients, but here the costs are lower and the plausibility greater. Politicians need to keep in mind the point that the more the "high-risk" strategy is refined to make prevention cost-effective, the smaller becomes the proportion of all strokes in the community that is prevented. References 1

2

Information for patients and carers One of the greatest sources of dissatisfaction among patients and their carers is communication about the disorder. Very little information tends to be given about the nature of stroke, its cause, management, and likely prognosis. Even when provided it may be in a form that is difficult to understand or retain. A possible solution is for one of the team members to sit down with the patient and his family on one or more occasions to explain the situation and answer any specific questions. It is in the early period at home, after return from hospital and rehabilitation, that feelings of desolation and isolation are usually strongest. Home visits by a "stroke nurse" have therefore been assessed in two randomised trials. If patients' social activities were the measure of outcome, these made little difference. 25 In the larger of the two studies, patients' and carers' satisfaction was one of the main yardsticks, and it was definitely increased by the home visits26

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Secondary prevention The risk of further strokes should be minimised (see article on page 15), although the decision to investigate and treat needs to take account of the patient's functional state. The higher an individual's risk of further stroke or other serious vascular complications, the more the individual has to gain from prevention, and the more cost-effective the intervention becomes. Secondary prevention is by no means synonymous with prescribing aspirin. Incidentally, the protective effect of aspirin is 20-25% for all arterial disease together and a rather modest 13% for patients with transient ischaemic attacks or non-disabling ischaemic stroke? 7 The best dose of aspirin is to some extent unsettled, but neither direct nor sin26

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Stroke Unit Trialists' Collaboration. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. BMff 1997; 3 1 4 : 1 1 5 1 - 5 9 . Ronning O M , Guldvog B. Stroke units versus general medical wards, II: neurological deficits and activities of daily living--a quasirandomized controlled trial. Stroke 1998; 29: 586-90. Indredavik B, Slordahl SA, Bakke F, Rokseth R, H~heim LL. Stroke unit treatment: long-term effects. Stroke 1997; 28: 1861-66. Stroke Unit Trialists' Collaboration. H o w do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke 1997; 28: 2139-44. Warlow CP, Dennis MS, van Gijn J, et al. Stroke--a practical guide to management. Oxford: Blackwell Science, 1996. W h u r r R, Lorch MP, Nye C. A meta-analysis of studies carried out between 1946 and 1988 concerned with the efficacy of speech a n d language therapy treatment for aphasic patients. Eurff Discord Gommun 1992; 27: 1-17. De Pippo KL, Holas/VIA, Reding MJ, Mandel FS, Lesser ML. Dysphagia therapy following stroke: a controlled trial. Neurology 1994; 44: 9-60. Norton B, H o m e r - W a r d M, DouneUy M T , L o n g RG, Holmes G K T . A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. BMff 1996; 312: 13-16. Pasquler F, Leys D. W h y are stroke patients prone to develop dementia? ff Neurol 1997; 2 4 4 : 1 3 5 - 4 2 . van Swieten JC, van den H o u t JH, van Ketel BA, Hijdra A, Wokke JHJ~ van Gijn J. Periventricular lesions in the white matter on magnetic resonance imaging in the elderly: a morphometric correlation with arteriosclerosis and dilated perivascular spaces. Brain 1991; 114, 761-74. Prohovnik I, W a d e J, Knezevic S, Tatemichi T, Erkinjuntti T, eds. Vascular dementia---current concepts. N e w York: John Wiley, 1996. Leys D, Scheltens Ph, eds. Vascular dementia. Dordrecht: I C G Publicatons, 1994. Breteler M M B , van Swieten JC, Bets ML~ et al. Cerebral white matter lesions, vascular risk factors, and cognitive ftmction in a populationbased study: the Rotterdam Study. Neurology 1994; 44; 1246-52. Bowler JV, Eliasziw M, Steenhuis R~ et al. Comparative evolution of Alzheimer disease, vascular dementia, and mixed dementia. Arch Neuro11997; 54. 697-703. de G r e e t JC, de Leeuw FE, van Achten E, et al. Cerebral white matter lesions and cognitive function. Cerebrovase Dis 1997; 7 (suppl 4): 66 (abstr). Bamford J, Sandercock P, Warlow C, Gray M. Why are patients with acute stroke admitted to hospital? BMff 1986; 292: 1369-72. Asplund K, Rajakangas AM, Kuulasmaa K, et al. Multinational

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comparison of diagnostic procedures and management of acute stroke: T h e W H O M O N I C A study. Cerebrovasc Dis 1996; 6: 66-74. Norris JW, Hachinski VC. Misdiagnosis of stroke. Lancet 1982; i: 328-31. Martin PJ, Young G~ Enevoldson TP, H u m p h r e y PR. Overdiagnosis of T I A and minor stroke: experience at a regional neurovascular clinic. QJMed 1997; 90: 759-63. Sandercock P, Molyneux A, Warlow C. Value of computed tomography in patients with stroke: Oxfordshire C o m m u n i t y Stroke Project. BMJ 1985; 290: 193-97. Mathew P, Teasdale G, Bannan A, Oluoch-Olunya D. Neurosurgical m a n a g e m e n t of cerebeUar haematoma and infarct. J Neurol Neurosurg Psychiatry 1995; 59: 287-92. H o p JW, Rinkel GJE, Algra A, van Gijn J. Case-fatality rates and functional outcome after subaraclmoid hemorrhage: a systematic review. Stroke 1997; 28: 660-64. Wardlaw JM, Yamaguehi T, del Zoppo G. Thrombolytic therapy versus control in acute ischaemic stroke. In: Warlow C, van Gijn J, Sandercock P, Candelise L, L a n g h o m e P, eds. Stroke module of the Cochrane database of systematic reviews. Oxford: Update Software, 1998.

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24 Mailer JR, Brott T, Broderick J, et al. Tissue plasminogen activator for acute ischemic stroke. NEnglJMed 1995; 333: 1581-87. 25 Forster A, Young J. Specialist nurse support for patients with stroke in the community: a randomised controlled trial. BMJ 1996; 312: 1642-46. 26 Dennis M, O'Rourke S, Slattery J, Staniforth T, Warlow C. Evaluation of a stroke family care worker: results of a randomised controlled trial. BMJ 1997; 314: 1071-76. 27 Algra A, van Gijn J. Aspirin at any dose above 30 mg offers only modest protection after cerebral ischaemia. J Neurol Neurosurg Psychiatry 1996; 6 0 : 1 9 7 - 9 9 . 28 E A F T (European Atrial Fibrillation Trial) Study Group. Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. Lancet 1993; 342: 1255-62. 29 Asplund K, Marke L-A, Terent A, Gustafsson C, Wester P-O. Costs and gains in stroke prevention: European perspective. Cerebrovasc Dis 1993; 3 (suppl 1): 34-42. 30 G e n t M, Beaumont D, Blanchard J, et al. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996; 348: 1329-39.

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