Doctor's Review: Medicine on the Move

December 15, 2017

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Conference proceedings: 3rd Canadian Stroke Congress

The country's best brains are on the case

The Canadian Stroke Congress has become such a recognized fixture of Canada's medical meetings calendar that it's easy to forget that this year's congress was only the third such event. It continues to grow apace, with over 1100 conference-goers gathering at Calgary's Telus Convention Centre from September 30 to October 2, 2012, the largest attendance yet.

"This event has generated new heights of scientific and clinical interest this year and has become the stroke event of the year,” says Dr Pierre Boyle, chair of the board of the Canadian Stroke Network. Canada has quietly become a leader in the field of stroke medicine, both in basic research and in clinical practice. As McGill neurologist Dr Robert Côté put it: "The Congress reflects very well what a vital and expert stroke community we have in Canada — with just a bit of international seasoning."

There are still plenty of gaps in our understanding of both ischemic and hemhorragic stroke. Basic research proceeds apace and was well represented at Calgary. But nobody expects any sort of magic bullet to turn up soon. Stroke, at least in Canada, is a problem that's likely to get worse before it gets better. The most likely path to improved outcomes is through better coordination and delivery of care.

To this end, says congress co-chair Dr Michael Hill: "The great advantage of the Canadian Stroke Congress compared to others around the world is that it's so multidisciplinary. There are physicians here, and trainees, nurses, physiotherapists, policymakers, occupational therapists, all aspects of stroke care."

Stroke of genius

Both the city of Calgary and the province of Alberta are themselves showcases for what can be achieved with modern integrated stroke care. The Alberta Provincial Stroke Strategy was implemented in 2006, based on recommendations in the Canadian Best Practice Recommendations for Stroke Care. Primary Stroke Centres have been established throughout the province, while further training and practice standards are overseen by an Alberta Stroke Council.

"It’s paying off throughout the province," Dr Thomas Jeerakathil of the University of Alberta told the conference. In the six years since the stroke strategy was implemented, the proportion of stroke patients receiving a brain scan has increased from 88 to 97 percent, the proportion undergoing dysphagia screening is up from 38 to 57 percent and the proportion receiving care in a designated stroke unit rose from 27 to 53 percent.

The jewel in Alberta's crown is the award-winning Calgary Stroke Program, which the Canadian Stroke Network featured in a magazine handed out to all delegates, entitled This is What Quality Stroke Care Looks Like. Calgary's Early Supported Discharge program allows patients to receive rehabilitation services in their own homes, reducing rehab inpatient stays and waiting lists, saving money and achieving cognitive and physical results as good as or better than hospital care. Calgary also provides a mentoring service in which former patients help new ones adjust to life after stroke.

Different Strokes

But Alberta was not the only province in a position to toot its own horn. Nova Scotia has been rolling out a stroke strategy since 2005. Data from the three rural districts where it has been running longest show improvement that is both dramatic and sustained. Sixty-seven percent of all stroke patients are receiving treatment in stroke units compared to none in 2004. Dysphagia screening is up from 28 to 61 percent. Only 7 percent are discharged to long-term care facilities, compared to 12 percent in 2004.

In Canada, there will always be strokes that occur far from the best teaching hospitals and even the nearest stroke unit. Telestroke, two-way audiovisual links connecting stroke centre neurologists to rural emergency rooms, are proven to improve care in distant communities. Dr Mark Bisby of Ottawa University, who has studied telestroke services, found that they actually save money; Alberta's has saved over $1 million in four years.

"The case for telestroke is compelling and the need is urgent," he said, adding that Canadians should be "scandalized" that most of the country still lacks it. Rural Alberta patients using the service get tPA at the same rate as those in a Calgary teaching hospital. The $150,000-odd annual cost is trivial compared to the savings in long-term care. The other province with a widespread program, Ontario, reports equal success. "This is no longer an experimental approach to stroke-care delivery," said Dr Frank Silver from the University of Toronto who leads Ontario’s program. "We’re achieving the same outcomes as the best stroke centres in the province."

The need is especially great because emergency rooms may be failing stroke patients. The ER is first point of contact for almost all stroke patients who make up 5 percent of ER patients yet under 2 percent of emergency residency programs' lecture time is devoted to stroke care. A survey led by emergency physician Dr Devin Harris of St. Paul's Hospital in Vancouver found that only 2 out of 20 emergency residency programs had compulsory on-the-job training in stroke neurology, compared to mandatory cardiology training in 19 out of 20 programs. "The treatment of stroke and TIA has changed dramatically over the last 15 years," he said. "We need to meet these challenges."

New stroke guidelines

The congress saw the release of updated Canadian Best Practice Recommendations for Stroke Care. Perhaps the biggest novelty is the addition of a new risk factor: sleep apnea. Impaired nighttime breathing not only increases the chance of a first stroke, it also appears to predict higher post-stroke About 10 percent of the population suffers from clinically significant sleep apnea, with men predominating. But apnea is doubly troublesome because it’s so common after stroke, affecting at least 60 percent of patients. The new guidelines recommend screening stroke patients for sleep apnea and treating it to reduce the risk of a second stroke.

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