On the Road to Smarter Stroke Care

Helen Hughes Uncategorised

The world’s first pre-hospital trial of a new generation of clot-busting medication may lead to a change in standard medical practice in stroke treatment centres and emergency departments around Australia.

It is hoped the two-year trial of the potentially more effective drug Tenecteplase, which is being conducted onboard a specialist stroke ambulance in Melbourne, will lead to life-changing outcomes for the 85 per cent of stroke patients who suffer ischaemic stroke.

The study is led by the University of Melbourne and involves Melbourne Academic Centre for Health partners Austin Health, The Florey Institute of Neuroscience and Mental Health, Melbourne Health, St Vincent’s Hospital Melbourne, and Western Health.

L-R Andrew Bivard & Mark Parsons inside the mobile stroke unit at the Royal Melbourne Hospital

In the trial, stroke patients are CT-scanned in the ambulance and, if diagnosed as requiring blood clot-removing thrombolysis, treated with Tenecteplase rather than the standard clot-busting drug Alteplase.

One advantage of Tenecteplase is that is given as a standard dose in an injection. In contrast, Alteplase requires a time-consuming one-hour infusion and has been found to work for only 30 to 45 per cent of patients.

“As well as being easier to administer, safe, and effective, Tenecteplase is less expensive,” says project lead, Associate Professor Andrew Bivard, who is a MACH grant recipient, the chief technology officer with the Australian Stroke Alliance and is based at the Melbourne Brain Centre of Royal Melbourne Hospital and at the University of Melbourne.

To prevent a lack of blood flow causing brain damage, thrombolysis treatment should commence within 90 minutes of stroke onset. The Melbourne stroke ambulance is now treating up to 20% of patients within an hour and Associate Professor Bivard says the study aims to show that treatment at the scene of the stroke, combined with the easier to administer drug, improves patient outcomes.

“In stroke cases the old adage is that ‘time is brain’ because earlier treatment saves the patient from more brain damage,” he said. “This makes the stroke ambulance an invaluable resource because first responders are offered the best chance to dissolve the clot within the strict treatment window, well before transporting the patient to hospital.”

The specialist ambulance has been described as an emergency stroke unit on wheels, consisting of two paramedics, a neurologist, radiographer and a stroke nurse. The highly skilled team is equipped with a mobile laboratory, including a portable CT scanner, a unique telehealth platform, and the capacity to make decisions about the best hospital to take the patient for urgent intervention.

In order to make this stroke expertise more widely available to ambulance paramedics and their patients across Australia, the Australian Stroke Alliance has designed a dedicated telehealth IT application which connects first responders to stroke experts.

The app allows essential clinical data to be shared with specialists at the receiving hospital, influencing treatment decisions, and increasing the safe and timely delivery of medications. In some cases the data might indicate that the ambulance should by-pass the nearest hospital in favour of a specialist stroke centre, where an endovascular team is waiting, ready to remove a clot.

“Getting the right patient to the right hospital as quickly as possible is critical,” says Associate Professor Bivard.  “The new technology makes conventional ambulances ‘stroke capable’ and will provide much greater access to more of our population – including people in rural and regional Australia – than is otherwise possible.”

The Australian Stroke Alliance is preparing to trial stroke-capable ambulances in rural Victoria, southwestern Sydney, and in the Hunter region of NSW.

Neurologist and executive director of the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Professor Mark Parsons, says the stroke capable ambulance trial will enable more accurate diagnosis in the field.

“The communication system developed by Andrew, with the support of the Australian Stroke Alliance, will allow the scrambling of the in-hospital emergency department.

“Stroke and radiology teams will fast-track brain imaging and brain-saving treatment. Based on the Melbourne Mobile Stroke Unit model, we know this may hasten treatment by up to two hours. Even one hour earlier provides a stroke survivor with more than one extra year of disability-free life.”

Prof Parsons says the research has brought together an extraordinary alliance of clinical, academic, scientific, paramedical and consumer partners who are committed to addressing the unmet clinical need to deliver urgent stroke care to Australians.

“We’re cognisant that Australia is facing of a forecasted million strokes each year by 2050, and we need to improve pre-hospital care now to minimise the impact of one of the nation’s biggest killers.

“Using improved medications like Tenecteplase, with telehealth and stroke-ready ambulances will mean more Australians will receive urgent pre-hospital care within the precious treatment window where we can really make a difference.”

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