On 18th March 2016, over 200 people involved in Stroke Care from all over the UK attended the British Association of Stroke Physicians Training Weekend in Birmingham. The British Association of Stroke Physicians (BASP) was set up in April 1999 to promote better care for people with stroke in the UK. Among one of its key five objectives was to improve and assure the training of doctors in Stroke Medicine and this training weekend certainly justified this statement. Over two days the programme covered many areas of stroke medicine including hyper acute presentations, radiology, stroke mimics, rehabilitation and service development. The talks were delivered by local, national and internationally renowned experts with a wealth of knowledge on display.
After an introduction by Dr Phil Ferdinand, British Association of Stroke Physicians (BASP) Trainees Committee, the day was opened by Professor Peter Sandercock, Chair of Medical Neurology at Edinburgh University and one of the Co-Chief Investigators of IST-3, the largest-ever trial of ‘clot-busting’ thrombolytic therapy for acute ischaemic stroke. He discussed thrombolysis and ‘Where are we now’ revisiting the evidence, risk and benefits of stroke thrombolysis.
As well as considering the ageing population (by 2050 >1/3 will be over 85, patients which the pre-IST-3 trials have excluded) , the question in A&E ‘’will it give a good recovery or will it kill me’’ for the elderly was not so straightforward. Post-IST-3 we have a situation where one needs to be realistic without automatically excluding patients based on age, which is rather difficult. He concluded moderate-severe stroke within 4.5h thrombolysis reduces disability and increases long term survival. The risk of symptomatic intracerebral haemorrhage from thrombolysis is greatest in patients with more severe strokes (NIHSS>22), rather than treatment delay (4.5h). He highlighted the need to improve standards of documentation which has medico-legal consequences in the event that an eligible patient with significant deficit is not identified promptly or not offered treatment.
A smiling and relieved Professor Iris Grunwald (Interventional Neuroradiologist at Southend University Hospital) talked about Endovascular Treatment for Stroke and stated it was the first time she did not have to defend thrombectomy! There is now clear level 1a evidence for thrombectomy treatment in acute stroke. The challenge now is to organise and setup the necessary services.
Mr Nikolaos Tzerakis, a neurosurgeon at Royal Stoke University Hospital, discussed the risks and ethical issues neurosurgeons face given the high post-op complication rates (up to 55% in some series) in hemicraniectomy cases.
Better engagement with vascular MDT was strongly advised by Dr Jattinder Khaira, Stroke Physician, University Hospital of Birmingham regarding patients with cervical arterial disease. This would help stroke physicians better understand individual cases and the decision process made by our surgical colleagues. One must also consider Doppler studies in posterior circulation strokes. This is relating to the fact 20-30% of patients have fetal PCA where the PCA is therefore, part of the anterior circulation.
‘Who is scared of posterior circulation stroke?’ was the opening line to the audience posed by Professor Keith Muir, University of Glasgow, on his talk on posterior circulation stroke. He acknowledged that he was one of those acutely aware of the potentially life threatening consequences of missing such a diagnosis. Since these patients present with a variety of non-specific symptoms, but one must keep an open mind and if there is any hint of posterior circulation stroke one must request an MRI as the consequences can be life threatening. The ongoing BASICS trial will help determine the optimal treatment modality.
The pre-lunch session was filled by an interesting couple of clinical cases by Dr Neil Jenkins, Infectious Diseases Consultant, Heart of England NHS Trust, talking on Infectious diseases and Stroke mimics. Post lunch sessions were filled by subspecialist interest talks on Paediatric Stroke, an often poorly recognised area of Stroke, by Dr Vijeya Ganesan from Great Ormond Street Hospital, followed by an even rarer condition, CNS Vasculitis – which had the audience questioning whether it really existed as it is so infrequently encountered as well as discussions on RCVS and PRES by Dr Claire Rice from University of Bristol.
The remaining sessions of the first day focused on Rehabilitation. Dr Paul Conroy, University of Manchester, discussed Post stroke Aphasia and the pending Cochrane Review as well as the ongoing CACTUS study in Sheffield using visual computer stimulation. Dr Fiona Rowe, University of Liverpool in her talk on Visual Disorders Post Stroke argued for the importance of implementing orthoptic sessions as a core requirement on every HASU given the high prevalence (60%) of visual disorders in stroke patients. However, there are two major hurdles to its implementation one being funding and the other is not being a recorded measure on SSNAP. Professor Anand Pandyan from Keele University discussed neuromuscular changes post stroke and argued for earlier use of neurophysiology to detect spasticity and thus prevent contractures. Dr William Lester, Haematologist at University Hospital of Birmingham, discussed cerebral venous thrombosis and the current guidelines (Coutinho 2015) via a couple of clinical cases. As well as highlighting current trials including TO-ACT, EXCOA and DECOM-PRESS 2.
Day 2 started with Dr Adrian Large, Cardiologist from University Hospital North Midlands, outlining the case to close or not to close a patent foramen ovale. Selection of the right patient was essential and he highlighted the RoPE score calculator. Likely patients would be the young and those with a diagnosis of cryptogenic stroke. Meta analyses have suggested PFO closure is as good as best medical management. Commissioning of the service in the NHS is not making it widely available with only 20 centres in the UK limited to 30 cases per year.
Dr Peter Enevoldson, Neurologist at the Walton Centre gave an entertaining talk on Illicit Drugs and Stroke. Deciding whether the drug is relevant or a red herring to the clinical presentation is the important first step. It is also important to consider infective endocarditis, HIV/syphyllis as well as the significant management problems these patients pose with poor compliance, non-attendance, and absconding from the ward.
A session discussing hemispatial neglect and associated syndromes by Dr Paresh Malhotra, a Neurologist at Imperial College, focused on the neuroanatomy and assessment of neglect, and it being a very strong predictor of outcome and stroke dependence.
The pre-lunch session debate ‘This house believes that centralisation of hyperacute services is essential for high quality stoke care’ proved a lively affair. Dr Don Sims (University Hospital Birmingham) arguing ‘For’ highlighting patients want local care but are willing to travel for the best care. And current evidence favours centralisation with reduction in length of stay and mortality. Dr Indira Natajaran (University Hospital North Midlands) arguing ‘Against’ identified problems to centralisation including difficulties dealing with stroke mimics, repatriation, pressure on A&E, ambulance journeys, flow of patients and finances. He argued that the political agenda and clinical benefit have to be in agreement, otherwise centralisation should not be imposed.
Sessions on CT and MRI for the stroke physician preceded Professor David Werring, Neurologist at National Hospital for Neurology and Neurosurgery. He updated us on intracerebral haemorrhage including the importance of pathophysiology, neuroimaging in diagnosis and te need to lower blood pressure acutely. The latest therapeutic targets and latest trials highlighting the MISTIE III trials where UK centres are now recruiting. The age old dilemma regarding antithrombotic decisions in ICH survivors are challenging and are being investigated in randomised controlled trials. The disease modification in Cerebral Amyloid with Ponezumab has shown promising results in animal studies, Phase 2 data for which will be out this year.
The final session was on stroke management in the elderly by Professor Christine Roffe, Stroke Consultant at Keele University, who argued that elderly patients should be chosen over younger patients to enter ASU as the odds ratio is greater for elderly patients in ASU. Patients who are dependent before stroke have a higher mortality, but complications are similar. Thrombectomy meta-analyses have not shown higher rates of haemorrhage in the elderly and patients are more independent following treatment.
The training weekend provided a great educational value and helped equip attendees with new knowledge to enrich their clinical practice and future careers. The evening meal allowed trainees to socialise in a relaxed environment in the heart of Birmingham. We look forward to next year’s event in London with great anticipation.