The Young Stroke Physicians and Researchers (YSPR) Committee, composed of young members of the European Stroke Organisation, is dedicated to promoting the involvement of young stroke physicians and researchers in the ESO and the broader field of stroke care
On behalf of the YSPR, Dr Sarah Gorey highlights some key challenges in stroke-related care, as well as recent innovations in treatment.
What are the key challenges facing the diagnosis of stroke?
First off, stroke can sometimes be difficult to diagnose, even for an experienced doctor. Up to a quarter of stroke presentations do not present with the typical ‘FAST- face, arm, speech’ symptoms that we are all aware of. There are two types of stroke: haemorrhages (or brain bleeds) and ischaemic strokes (clots blocking blood vessels in the brain). The best way to confirm the diagnosis of a stroke and to find out which type of stroke is happening is to get a rapid brain scan. This is another challenge as not all healthcare settings have equal access to rapid brain scanning for patients with suspected stroke. Obviously, the type of treatment given depends on the kind of stroke diagnosed on a brain scan. Stroke is a time-sensitive condition, which means that patients will do best if they get treatment as quickly as possible after their symptoms start, so stroke teams are under pressure to make therapeutic decisions quickly, which is another challenge.
How can digital solutions help with the detection and prevention of stroke?
Prevention is better than cure! Technology and AI can be harnessed to better prevent stroke. Many people already own smart watches which can screen their pulse to detect atrial fibrillation, a common irregular heartbeat that increases the risk of stroke. I would like the same technology to be developed to detect high blood pressure. Hypertension is the leading risk factor for both types of stroke. Because high blood pressure usually has no symptoms, we all need to get our blood pressure checked regularly. Technology and applications could empower patients to be more proactive about checking their own blood pressure at home.
Technology is already used for the diagnosis and treatment of stroke; some countries and cities have mobile stroke units, which include scanners and highly specialised teams who travel to a stroke patient in a specially fitted ambulance. Some hospitals use AI technology to assist radiologists in detecting strokes on scans—this can help rapidly select patients for stroke treatments.
How does stroke affect women differently from men?
There are a number of ways that women are affected differently by stroke compared to men. Women are at risk of stroke at lower levels of high blood pressure compared to men. For example, a woman with a mildly elevated blood pressure of 120-129 has the same risk of stroke as a man with a blood pressure of 140-149.
Secondly, women who experience pregnancy-related conditions like pre-eclampsia or gestational diabetes can be at an increased risk of stroke later in life. Women who have had pre-eclampsia or gestational diabetes need to keep a careful eye on their blood pressure and average blood sugar reading, even after pregnancy.
Migraine is more common in women, but women who experience migraine with aura also have an increased risk of stroke. Sometimes, these women have a delayed diagnosis of stroke, as they either delay presenting to their doctor because they think their symptoms are due to migraine, or they are mistakenly diagnosed with migraine after they present. This also underscores how important quick access to brain scans is. The only fail-safe way to differentiate a migraine from a stroke is by doing a brain scan.
Women have a longer life expectancy than men, but as women age, they are also more likely to get atrial fibrillation, which is another risk factor for stroke. Strokes caused by atrial fibrillation are often more severe and cause worse disability. Anticoagulation tablets can reduce the risk of atrial fibrillation-related strokes. Still, some studies have reported that women are also less likely to be treated with anticoagulation than men due to concerns about bleeding side effects of these medications.
How can public policy be updated to alleviate the burden of stroke and reduce the number of stroke-related deaths?
Stroke numbers are rising globally, especially among younger people in lower and middle-income countries. I don’t think people realise how serious the consequences of a stroke can be. Some people are left with permanent disabilities and may be unable to return to work, unable to drive, unable to swallow or speak, and unable to look after themselves independently. Stroke is also a major risk factor for developing dementia later on. That risk is increased even for people who have very mild strokes or ‘mini-strokes’ or transient ischaemic attacks (TIAs), where all the physical symptoms recover.
As such, we need to try to prevent strokes from happening. We need to empower people of all ages, but especially younger people, to be aware of the commonest risk factors for stroke, which are called ‘Life’s Essential 8’ by the American Heart Association. These factors are diet, physical activity, nicotine exposure, sleep, body mass index, blood lipids, blood glucose, and blood pressure. A healthy lifestyle is really important and is a habit that we should be teaching children in schools. All adults should have their cholesterol levels, glucose levels and blood pressure checked by their family doctor every year.
We also need to focus our energies on providing high-quality care to stroke patients. The best way to do this is to make sure that every hospital that treats patients with stroke has a stroke unit. A stroke unit is a specialist ward where all the patients with stroke are treated and all the staff are experienced in treating strokes. Patients treated in stroke units do better than patients treated in a normal hospital ward; they get fewer complications, recover with less disability and have a lower risk of dying from their stroke. Stroke unit teams can include doctors, specialist nurses, physiotherapists, occupational therapists, speech and language therapists, dieticians, and psychologists. This really emphasises how stroke care is a multidisciplinary specialty.
Are there any notable developments or current issues in stroke research or treatment that you would like to highlight?
The biggest advance in stroke treatment, and probably in medicine as a whole, in the last ten years was mechanical thrombectomy. This minimally invasive procedure can remove the clot causing a major stroke and restore blood flow to the brain. Patients usually respond very well to this treatment and often make an excellent recovery. Thrombectomy has been a game changer in stroke care. For every three patients treated with this technique, one person will have an improvement in their disability.
Another exciting frontier in stroke recovery is the use of vagal nerve stimulation (VNS) in combination with therapy-based rehabilitation to improve function in patients with weak arms caused by a stroke. Early studies of this approach have been promising, and larger trials are underway to evaluate the efficacy of this device. There is optimism that in the future, more technologies will show evidence of benefit in stroke rehabilitation and recovery.
