Randomised placebo-controlled studies have shown that thrombolysis with a clot-busting drug (rtPA - alteplase), administered within three hours of the onset of symptoms of ischaemic stroke, significantly improves clinical outcome at three months. However, only 30 percent of patients with acute ischaemic stroke get to a hospital within the first three hours.
"Rapid delivery to hospital by ambulance and referral to a stroke unit is essential for victims of acute stroke", stated Professor Danilo Toni, Department of Neurological Sciences, Università "La Sapienza", Rome. "However, assessment and treatment by an expert stroke specialist is not always possible and tools such as telemedicine and Stroke Lysis Box can facilitate rapid assessment and treatment of the acute stroke victim."
Telemedicine can allow a greater proportion of acute stroke victims to be assessed for and treated with thrombolysis. An expert stroke physician in a specialist stroke centre, linked in a telemedicine network to non-specialist centres, can support the caring physician in the non-specialist centre in diagnosing a stroke and assessing acute stroke victims for acute treatment. Remote patient interviewing, data transmission and videoconferencing are available 24 hours a day to all hospitals linked in the telemedicine network.
The "Stroke Lysis Box" helps in another way. It enables hospital emergency departments to provide rapid clot-busting treatment to appropriate acute stroke victims and is extending the availability of thrombolytic treatment to trained, but less experienced physicians in a wider range of hospitals than stroke centres.
The Stroke Lysis Box is a portable, comprehensive source of information and equipment to make it possible to carry out a rapid assessment of an acute stroke victim and initiate thrombolysis therapy, where appropriate, without any loss of time in the emergency department. In an emergency, when the window to treat an acute ischaemic stroke patient is less than three hours, treatment is often delayed as doctors have to first gather all the information and treatment equipment and medication required before treating a patient. The thrombolysis procedure must be made as simple as possible so that it does not fail due to lack of organisation and staff must be well-trained in its use.
To ensure that patients benefit from thrombolysis within a three hour window requires co-operation and co-ordination of all emergency medical services involved. The meeting heard how the ACT NOW initiative is being spread across Europe. It aims to promote best practice in early patient assessment and treatment of acute stroke by communicating how pre-hospital and hospital procedures can be interlinked and modified to speed the transfer of the patient to specialist care. Stroke treatment aims to limit the damage that can occur as a result of the stroke. If recognised in time, acute stroke can be treated effectively. However stroke patients need to be given priority treatment and preferably need to be treated by a dedicated stroke unit, which can effectively reduce stroke mortality. Effective stroke management requires a multi-disciplinary approach from highly trained and prepared staff.
"The ACT NOW initiative including the Expert Report and tools such as the Stroke Lysis Box will help us drive change in our procedures", stated Professor Gary Ford, Consultant Stroke Physician, University of Newcastle, United Kingdom. "With appropriate training, more ambulance staff can make an emergency stroke assessment. We need to agree and implement referral pathways and guidelines between emergency medical services and specialist stroke units to help ensure all staff are aware of their role in contributing to effective early care of people with stroke."
The ACT NOW Expert Report has been developed by a multi-disciplinary panel of experts with a keen interest in the management of stroke. The report aims to communicate and cascade best practice internationally and nationally within the constraints of national health care systems. The report shares best practice in acute stroke management within emergency medical services and relevant hospital departments and gives examples of pathways to optimise co-ordination between disciplines. National versions of the ACT NOW Expert Report are planned for distribution in all European countries to promote best practice, building on guidelines issued by the European Stroke Initiative (EUSI).
Stroke is a neurological emergency that can affect one particular area or sometimes all of the brain. It can be caused by a burst blood vessel (haemorrhagic stroke) or when a vessel is obstructed by a blood clot (ischaemic stroke). Ischaemic stroke can be treated with clot-busting drugs, such as alteplase, which is injected directly into a vein. To achieve best outcome, patients need to receive the medication within three hours after onset of stroke symptoms. Alteplase is an enzyme that occurs naturally in man and causes blood clots to dissolve.
Telemedicine can extend the use of thrombolysis in areas without a nearby specialised stroke facility. As an example, the TEMPIS project in Bavaria consists of two stroke centres with an established stroke network of 12 regional hospitals in a telemedicine network offering a 24 hour service with a weekly rotation between the two stroke centres.