6.6 Acute stroke
See Background Chapter 6.5
Acute stroke is caused by either a sudden reduction in the blood supply to the brain or by a haemorrhage. It is the third leading cause of disability and death (as DALYs) in Europe after depression and ischaemic heart disease (IHD) (see Table 6.6.1). Worldwide, stroke is the fifth leading cause of disability and death. Ten per cent of the 55 million deaths that occur every year worldwide are due to stroke.[1] Despite improvements in stroke care, treatment of the long-term effects remains one of the major problems. Fifty to seventy per cent of those who survive an ischaemic stroke will recover functional independence three months after onset, but 20% will require institutional care. The United Kingdom spends 6% of its national health budget on stroke care, twice as much as is spent on ischaemic heart disease.
Table 6.6.1: Leading cause of deaths worldwide and in Europe
(2002, percentage of total deaths)
IHD (12.57%) / IHD (18.11%) / IHD (16.79%) / IHD (24.45%)
Stroke (9.63%) / Stroke (10.90%) / Other CVD (10.78%) / Stroke (13.19%)
LRI (6.60%) / Other CVD (10.78%) / Stroke (10.42%) / Other CVD (10.77%)
HIV/AIDS (4.95%) / Trachea, bronchus, lung cancers (5.38%) / Trachea, bronchus, lung cancers (5.31%) / Trachea, bronchus, lung cancers (5.73%)
COPD (4.81%) / LRI (4.01%) / LRI (4.46%) / Other cancer (3.96%)
Source: WHO, Evidence, Information and Policy, 2003
Note: LRI = lower respiratory tract infections, COPD = chronic obstructive pulmonary disease, CVD = cardiovcascular disease, IHD = ischaemic heart disease
The current treatment of acute stroke is unsatisfactory. Aspirin and intravenous recombinant t-PA have been shown to be effective and their use approved by regulatory agencies. However, the effectiveness of these agents is limited and they are associated with an increased risk of intracranial haemorrhage.
Over the past 30 years, surprisingly low levels of resources have been devoted to R&D of medicines for acute stroke. There is an urgent need to develop new medicines for the treatment of stroke, particularly in the field of neuroprotection. In the late 1980s and 1990s a number of companies invested heavily in stroke research but the resultant failure of costly, large-scale clinical trials of neuroprotectants has made companies wary of research in this area.
Major improvements are also needed in the chain of care; in the ability of relatives to identify an attack (public education); the prompt referral to an accident and emergency facility (mobile units); accurate diagnosis (imaging and stroke physicians); access to efficacious early therapeutic options such as thrombolytic treatment (protocols and specialized units); and referral to dedicated rehabilitation services (‘intermediate care’ stroke rehabilitation units).[2],[3] It is also important to expand stroke prevention programmes focusing on education and vigorous risk factor management.
[1] WHO burden of diseases and injury (Dataset-2002). Geneva: World Health Organization; 2003.
[2] Adams HP Jr, Adams RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB et al. Guidelines for the early management of patients with ischemic stroke: A scientific statement from the Stroke Council of the American Stroke Association. Stroke 2003;34(4):1056-83.
[3] Fisher M. The ischemic penumbra: identification, evolution and treatment concepts. Cerebrovasc Dis 2004;17:Suppl 1-6.