Twenty Years of Stroke Care

By Jenson Quon

Time flows differently for everyone and in the world of medicine, twenty years is a lifetime in advancement for stroke care. 

On April 2, 1996, at the Rockyview General Hospital, Mrs. A was admitted for chest pain when suddenly she became weak down her right side and couldn’t speak to the attending staff in the cardiology unit. She was having an acute ischemic stroke.  She was then transferred over to the stroke unit and was administered an intravenous infusion of a drug called alteplase or tPA for an hour. This ‘clot busting’ drug dissolves the blood clot blocking the artery in the brain that deprives the brain of critical nutrients, such as glucose and oxygen; 20 minutes later, Mrs. A speech and strength returned marking the first real hyperacute treatment for stroke in Calgary. She was discharged home with her husband in good health and lived for more than a decade free of disability from stroke. 

“I had no idea at the time of treating the first patient with tPA the huge impact that acute stroke treatment would have on the quality of patient lives,” recalls Nancy Newcommon, lead nurse who helped treat Mrs. A all those years ago. “Acute care has evolved dramatically over time (since that first case), it now requires a coordinated, timely system of people, equipment and services in order to have a successful outcome.” 

Mrs. A was one of a series of 30 patients that were being treated at the Foothills Medical Centre in order to demonstrate safety in a community setting, which Dr. Alastair Buchan, former Professor of Stroke Research at the University of Calgary, now Head of the Medical Sciences Division at the University of Oxford led with his team.

The protocol being developed was for the Canadian Activase Study for Effectiveness in Stroke (CASES), which led to the licensing of alteplase (tPA) in Canada. Having successfully treated patients within the community, the trial led to the evolution of the stroke pathways culminating with endovascular treatment with thrombectomy.

1996 was also the year that the stroke clinic launched with Drs. Buchan, Thomas E. Feasby, Keith Hoyte and Gary Klein as founding physicians.

There were many obstacles that faced stroke care 20 years ago, and the search for viable treatments was just the tip of the iceberg.

“The first obstacle was persuading people that stroke could be treated, the second that we could reorganize the ambulance services and get the stroke patients acutely to the Foothills Emergency Department and see them on arrival and access immediate imaging,” said Buchan. “The biggest obstacle was actually getting patients from the Emergency Department into the CT scanner and it was often our job to actually move people physically, acting as porters.”

Stroke care advancement was slow and knowledge of stroke in the general public was minimal, whereas cardiology benefitted from the silver screen and media awareness of symptoms of a heart attack. Public messaging about stroke was in its infancy.

“Stroke care had very little in the way of intervention compared with cardiology where acute cardiac trials demonstrated the utility of beta-blockers, nitrates, and thrombolysis,” said Dr. Buchan on the early days of stroke. “In stroke we were very focused on making a diagnosis in terms of the neurological picture and therefore, where the lesion was located and what was new in the late 1970s and early 1980s was understanding the cause in terms of whether it was a thrombotic process.” 

“CT head scanning was revolutionary. The clinical trials in those days were about preventing stroke with antiplatelet agents and offering carotid endarterectomy for those with the right disease causing the right symptoms. There was nothing that we could do once an acute stroke got started despite many trials of anticoagulants.” 

The Heart and Stroke Foundation in Alberta recognized that change was necessary in stroke and that it could be done in Alberta. An Alberta Stroke Program was set up and the Heart and Stroke Foundation of Alberta created a Professorship in Stroke Research which was awarded to the University of Calgary. In December of 1995 the Heart and Stroke Foundation Professorship in Stroke Research would be awarded to Dr. Buchan and in that same week the NINDS (National Institutes of Neurological Disorders and Stroke) Stroke Trial would demonstrate that stroke thrombolysis could be effective, kick-starting the foundation of the Calgary Stroke Program. 

In order to create a hub of stroke researchers and neurologists in Calgary, the Calgary Regional Health Authority and the community worked closely with the University of Calgary and the hospitals to create three revolutions. The first one being the idea of reperfusion, the second being the use of thrombolysis and the third being the ability to image with CT in an acute setting such as the Emergency Room.

“The most significant impact of the Calgary Stroke Program is that a new generation of stroke physicians such as Dr. Michael Hill, Dr. Andrew Demchuk and their whole team [was created],” said Buchan. “It has generated a whole new field in terms of new academic and practicing clinicians and has made it possible to understand imaging in the acute care setting of stroke within an hour or two allowing us to stratify patients and the ASPECTS (Alberta Stroke Program Early CT Score) scoring system has really helped us with what you might call precision stroke care.”

The Calgary Stroke Program is the largest training program for acute stroke in the country and has the highest number of academic stroke neurologists under one roof. This program is the only one to be fully accredited for comprehensive stroke care in Canada. Other programs are accredited for parts of stroke care only. This thrusts the Calgary Stroke Program onto a national and international level.

Another significant boost to the Calgary Stroke Program came in a $1M donation from The Calgary Health Trust, which came from the Foothills Hospital Home Lottery, towards the renovation and opening of the Stroke Unit on Unit 100.  The funds were used for design and renovation of the stroke unit, which has been a major contributor to improved stroke care in Calgary.

In 2015, the ESCAPE (Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times) trial showed that patients that received endovascular treatment for acute ischemic stroke had a marked reduction in both disability and death. This was a revolutionary finding for stroke treatment.

“The Calgary Stroke Programs greatest achievement to date was the ESCAPE trial that was led by Michael Hill, Mayank Goyal and myself,” said Demchuk. “It is a ground breaking trial published in the New England Journal of Medicine and is one of five trials published in 2015 that has transformed acute stroke treatment with the new technology of mechanical thrombectomy. ESCAPE was unique to the other trials as it showed benefits to the elderly with reduced mortality from the treatment.”

Endovascular treatment uses X-ray images to identify the location of a blood clot and to remove it mechanically by inserting a thin tube in to the artery in the groin and passing through the body into the brain vessel with the clot and removing it with a retrievable stent. This method restores blood flow to the brain and has allowed for many stroke patients to return to their day-to-day lives.

“Stroke care is now night and day. We went from no therapies to two therapies that can reverse stroke,” said Dr. Andrew Demchuk, professor in the Department of Clinical Neurosciences at the University of Calgary, neurologist and director of the Calgary Stroke Program, Alberta Health Services.

Dr. Michael Hill, director of the Stroke Unit for the Calgary Stroke Program, Alberta Health Services and a member of the Hotchkiss Brain Institute, could not agree more with Demchuk’s assessment of how far stroke care has come in the past two decades and the benefits of endovascular therapy.

“You can see people getting better, that endovascular therapy is working” said Hill, “Now we are seeing them get better two or three days’ sooner. On a personal level, it’s really rewarding to see that and get people back on their feet.” 

There are many success stories and a couple that stand out in Hill’s mind is an 87-year-old Stampeder’s fan and a 16-year-old from the East Kootenay region in B.C.

“There was this one lady that suffered a stroke on the day of a Stampeder’s home game, and she had been a regular Stampeder’s fan attendee for the past 50 years. She had attended every single game, so she kind of became part of the Stampeder’s family. After giving her tPA and seeing her recover in a few hours, she still asked if she could go and watch the game.” Hill laughs at the memory, “So I was the bad doctor who broke her streak in telling her she had to stay in hospital, but at the same time it was really good to see her doing better. It was a terrific success.”

The 16 year old from B.C. was a unique case not only for the age of the patient, but because of its significance with endovascular therapy.

“One of the first times we saw such a real success with endovascular therapy was with the 16-year-old kid from B.C. in 2001,” said Hill. “There were many delays in getting to hospital and after we opened his blocked artery, he was ultimately able to get home and he walked out of hospital. It was an amazing, amazing, recovery. Now we’re starting to see that kind of thing more routinely and we’re seeing it every week, twice a week. Pretty incredible evolution of a treatment.”

This highlights that stroke is indiscriminate and affects people of all ages. Although stroke is more common at older ages with individuals over age 55 having the highest risk of stroke, a quarter of Canadians living with stroke are under age 65.  Every moment counts in a stroke emergency as the chance of survival and full recovery decrease with every minute that passes. In the world of stroke care, time is brain.

“U of C is quite unique to be at the front and centre of this given that we have the most stroke clinicians under one roof anywhere in the world. The international community is leaning on us to give leadership and coordinate stroke care,” said Demchuk.

Today, there are 15 active clinical trials that are exploring the breadth of stroke care from new medicines and treatments to preventative care and rehabilitation. The Calgary Stroke Program is the only accredited stroke program in Canada, receiving a distinction from Accreditation Canada in 2010. Both are major draws for international visitors and students.

“Our reputation as a time efficient system has led to a high demand for visitors worldwide from observers, fellowships and research sabbaticals. Training over the past 15 years has resulted in 75 trained fellows, 10 or 15 in India – where we have had a large impact – 25 practicing across Canada,” added Demchuk.

Trainees, such as recent stroke fellow Dr. Amy Yu and University of Calgary Biological Science undergraduate student Gabby Wagner both find the unique opportunities and learning environment offered through the Calgary Stroke Program very enticing.  

Dr. Yu, a neurologist from McGill University who recently graduated from the Calgary Stroke Fellowship Program found that the stroke team are “driven on making stroke better on multiple fronts.” There are opportunities to collaborate and run ideas by colleagues to really understand what works in stroke.

“The mentorship in the Calgary Stroke Program is excellent. If you have an idea, but don’t have the necessary resources, the neurologists will help you obtain them,” said Yu. “There is a lot of opportunity to collaborate with different subspecialists in the field of stroke.”

Yu finds that the team is always looking to inspire each other and are willing to put the work in to getting their vision accomplished. Alberta Health Services also strives to provide the best possible care for patients and when it comes to stroke, it runs very smoothly and ensures that there are strong ties across departments, such as Radiology, that depend on each other.

“We offer good service for the patients,” Yu said with pride. “It’s rewarding to see how a multidisciplinary team can run smoothly and witness patients experiencing good outcomes.”

Wagner is equally enthralled by the energy and support she receives and plans to pursue medicine after her undergrad. Her interest in the brain, its complexity and integrity to life fascinates her.

“I find it mind boggling to think that everything I learn is kept inside my brain and what makes me different from everyone else is what I keep inside my brain.”

She also agrees with Yu that Calgary is one of the lead stroke sites in Calgary and the care that the stroke team provides is exceptional. With the latest major advances in technology in imaging, endovascular treatment, surgical treatment and more efficient drugs will only continue to help diagnosis patients and treat them better.

“Time is brain, as we advance that is going to always be kept in mind. How can we save as much brain the in shortest amount of time possible?”

As stroke care looks towards the next 20 years, this question will continue to drive innovation and research at the University of Calgary and the stroke team in Calgary. What will the next 20 years of stroke be like?