Stroke treatment has changed dramatically in 20 years. It all started when a couple of neurologists made a phone call.
Step into Lorraine Gallant’s living room and you can’t miss the “stroke wall.” It’s a collection of newspaper clippings and photographs that Lorraine, 80, has amassed since her stroke last summer. Smack in the middle is a poster highlighting the word FAST — the four-letter acronym that saved her life.
Lorraine’s wall probably wouldn’t exist if she had had the stroke 20 years ago. Back then, stories on stroke care were bleaker, says Dr. Frank Silver, medical director of the stroke program at Toronto’s University Health Network.
A pioneer of stroke care in Canada, Dr. Silver used to carry around his own newspaper article about a man who had a stroke in an Ottawa movie theatre. He was taken to hospital within the first hour of his stroke — but nothing was done. The patient just sat there.
Before 1997, stroke — the leading cause of disability for adults — had earned an unfortunate nickname in the medical community: Humpty-Dumpty syndrome. With no treatment available and very little else that could help patients, stroke could only be diagnosed. To put someone back together again was a long shot.
Luckily, that gloomy outlook wasn’t shared by everyone. Mixed in with the skeptics was a small group of doctors armed with some revolutionary ideas around stroke care. In just two decades their ambitious work, supported by the Heart & Stroke Foundation, has changed what happens when someone has a stroke — before, during and after. For Lorraine, they changed everything.
In a normal day, your heart pumps about 7,500 litres of oxygen-rich blood through your body. About 20 per cent of that blood needs to funnel directly to the brain to keep it working properly. That’s equivalent to filling up a Honda Civic gas tank around 30 times.
As long as the blood is flowing, it’s business as usual. But disruptions can lead to stroke. Most strokes (roughly 80 per cent) are caused by a blood clot that blocks blood flow; that’s called an ischemic stroke. Less common is hemorrhagic stroke, where a weakened blood vessel breaks open and causes uncontrollable bleeding.
When a stroke goes untreated, research shows that 1.9 million brain cells are lost every minute.
The Lazarus effect
In Canada a stroke occurs every 9 minutes. In the 1990s the general attitude, even amongst medical professionals, was, “Sorry for your bad luck.” Sometimes, Dr. Silver had to defend his decision to specialize in stroke neurology. “People would say to me, ‘There’s nothing you can do for stroke, so what’s the point?’ ”
Then came tPA. Tissue plasminogen activator is a drug that can dissolve blood clots. It was originally used to treat heart attacks. By 1995 clinical trials were underway to test tPA as a treatment for ischemic strokes. That’s when doctors started to see what they called the “Lazarus effect.”
Like Lazarus rising from the dead, some patients treated with tPA were literally walking away from strokes. The drug broke up the blood clot and stopped damage to their brains as it was happening. But this effect was only possible if the medication was received within hours of a stroke’s onset.
That posed a problem in the late 1990s, when stroke wasn’t even considered a medical emergency, and few Canadians recognized when someone was having a stroke.
Dr. Silver, along with a small group of neurologists in Ontario, approached the Heart & Stroke Foundation to help increase public awareness in the hopes of getting more people with stroke treated fast.
The team’s plan was to teach people how to recognize the signs of stroke. But they soon realized that would not be enough. Increased awareness might just fill emergency rooms that couldn’t cope. In order to reduce stroke deaths and disability, the whole healthcare system would need an overhaul.
To treat a stroke fast enough to get the benefits of tPA, a hospital needs a CT scan. More importantly, it needs a specialist available 24 hours a day, to interpret the brain scan and diagnose a stroke. tPA is a remarkable treatment but it’s not for everyone. Giving it to someone with hemorrhagic stroke (bleeding in the brain) could be a fatal mistake.
Coordinating the equipment and expertise to diagnose and treat stroke fast was a major hurdle.
The team turned to the concept of a dedicated stroke unit, which was pioneered at the Sunnybrook Health Sciences Centre in Toronto in the 1980s. Stroke units ensure that patients receive care from a specialized interprofessional team of physicians, nurses and allied health workers. Research was already showing that stroke units could dramatically improve patient outcomes.
Acute stroke treatments require that a neurologist on call is available to treat patients at any hour. That was a sticking point for some specialists — it was too much of a culture shock. Unable to persuade every hospital across the province to launch its own stroke programs, the team developed a plan to establish three pilot stroke centres, in Kingston, London and Hamilton with a fourth site added in Toronto soon after.
Build it and they will come. Maybe. Standing between the pilot centres and stroke patients was a rule that forced ambulances to transport patients to the nearest hospital, regardless of what services were available there.
To overcome this barrier, the Foundation worked with ambulance and paramedic services to write new protocols around patient transportation. Now, when stroke was suspected, first responders could bypass a local hospital and take a patient straight to a stroke centre.
Selling Ontario on stroke care
Soon enough, the four pilot centres were seeing positive results. “The evidence was overwhelming,” says Dr. Silver. “Interventions improved outcomes, reduced mortality, and increased their chances of returning home — all without increasing the length of (hospital) stay.”
The next challenge was to move beyond the pilot sites. Stroke care would need more funding. The team just needed to get the idea in front of the right people.
In early 2000, Mary Lewis, then director of government relations at the Heart & Stroke Foundation, had the idea to approach Toronto’s Empire Club, which has a history of attracting top-shelf speakers including Winston Churchill, Bill Gates, our past prime ministers and even the Dalai Lama. Dr. Frank Silver didn’t have the household name that the club usually courted. But that was a small wrinkle, which Lewis promised wouldn’t matter once he delivered his speech.
When he arrived at Toronto’s Royal York Hotel to speak to the club in March 2000, Mary Lewis had arranged for two well-known stroke survivors to accompany Dr. Silver to the podium.
Phil Lind, a senior executive from Rogers Communications, and Ontario’s former attorney general, Ian Scott, both made impassioned appeals for stroke care funding. For Scott, the event was a rare public appearance, since his own stroke six years earlier had impaired his ability to speak.
Someone in that room was listening. Six weeks later, the Ontario budget was unveiled with a special addition: $30 million to develop and staff more stroke centres in Ontario.
Improving stroke care across Canada
With funding from the Ontario government secured, another Heart & Stroke researcher, Dr. Antoine Hakim, applied for another grant to create the Canadian Stroke Network (CSN), a forward-thinking organization that would, in partnership with the Heart & Stroke Foundation, roll out stroke care to the rest of the country.
Launched in 2000, CSN developed Canada’s first Stroke Best Practice Recommendations. The guidelines pulled together the latest, evidence-based recommendations on stroke prevention, diagnosis, treatment and rehabilitation. Since the first edition in 2006, they have come to be relied on by healthcare professionals around the world.
CSN also provided seed money for Telestroke, an innovative program led by Dr. Silver that uses video conferencing to connect hospitals in smaller or remote communities with stroke neurologists. When stroke is suspected, the neurologist can view the patient’s brain scan and advise the local medical team on treatment. That immediate access, studies have shown, saves lives as well as healthcare dollars.
When the federal funding agreement for CSN expired in 2014, the Heart & Stroke Foundation stepped in to maintain the Canadian Stroke Best Practice Recommendations.
The timing couldn’t have been more perfect. Shortly after Heart & Stroke took over the recommendations came the biggest breakthrough in stroke care since tPA. The ESCAPE trial was co-funded by Heart & Stroke and led by researchers Dr. Michael Hill and Dr. Andrew Demchuk, at the University of Calgary. They used high-tech imaging and specialized endovascular devices (delivered directly through the patient’s blood vessels) to physically remove a blood clot and restore blood flow to the brain. The result was a 50% reduction in the death rate from major ischemic stroke, and dramatically reduced rates of disability.
The results of the ESCAPE study have been duplicated in four other clinical trials and changed the way stroke is treated in Canada and beyond. This treatment was incorporated into the Best Practice Recommendations within weeks of the release of ESCAPE.
Heart & Stroke’s vast network means that emerging evidence like ESCAPE can be quickly delivered into the hands of healthcare professionals who care for stroke patients, says Dr. Patrice Lindsay, the Foundation’s director of stroke. This ensures stroke patients in Canada receive the right treatments in the right setting and at the right time, which can lead to a better recovery.
Dr. Lindsay adds that the Foundation monitors the quality of stroke care delivered in Canada, another way to promote continual improvements so that Canada’s stroke systems are world-class.
Quick action saves Lorraine
Lorraine Gallant turned down her grandson’s first invitation to the family cottage that weekend in June 2015. PEI was under a hot, sticky bubble of summer heat. She planned to spend her afternoon at home, preferably with the air conditioning on. But with a bit of coaxing, he convinced her to make the 10-minute drive and join the rest of the family at the cottage.
By the time she hung up the phone, Lorraine’s hand had fallen asleep. It was still numb when she arrived at the cottage and when her vision tunneled minutes later, Lorraine staggered across the lawn, her eyes fixed on a lawn chair that appeared to be reversing away from her. Then everything went dark.
Lorraine’s granddaughter, Amy yelled frantically to her mother, “Call 9-1-1.” Just weeks before, Amy had watched a Heart & Stroke commercial highlighting the word FAST as a way to recognize the signs of stroke. The acronym stands for: Face — is it drooping? Arms — can you raise both? Speech — is it slurred or jumbled? Time — to call 9-1-1 right away.
“It’s just like the man in the ad,” Amy screamed.
Learning how to tell time again
Lorraine’s doctors say her granddaughter’s quick action played a big part in the treatment of her stroke and her unusually speedy recovery.
Like many stroke survivors, Lorraine required rehabilitation to strengthen her left side. While in rehabilitation, she had to relearn some of the basics. For example, she asked her daughter, Betty, if the black blob hanging on the wall was a grotesque bug.
“It’s a clock, Mom,” Betty tried to explain. But that didn’t mean much to Lorraine. “What does a clock do?”
Lorraine’s stroke knocked out her ability to tell time, but left other important memories intact — like the hours she had spent teaching second graders how to tell time.
Neuroplasticity is a promising area of stroke rehabilitation research. Studies have shown that when one area of the brain is damaged, it can reorganize itself so another healthy part takes over. When her daughter returned for another visit, Lorraine pointed out that she was early.
While she was in rehabilitation, Lorraine set three goals. She’d make a new quilt, play Scrabble again, and if everything went well, she’d get her driver’s license back. Thanks to a revolution that began in Canada and didn’t stop, Lorraine reached all three of her goals before the first anniversary of her stroke.
That type of turnaround, says Dr. Silver, is what’s most rewarding about this pioneering work that started 20 years ago. “We started with nothing. We had no organization. Stroke wasn’t interesting. It was a nihilistic approach to care.”
But today, he says, stroke research holds so much promise for even more progress to come.
“Our stroke team rushes in, and you do see these patients who are very incapacitated because of their stroke and at the end of their treatment they’ve made an excellent recovery.”