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Stroke Victims: Treatment

My Lords, I, too, congratulate the noble Lord, Lord Rodgers of Quarry Bank, on initiating this very timely debate. Noble Lords have already dealt with most aspects of stroke in a comprehensive and often moving way, so I shall focus on the mini-stroke, known as the transient ischaemic attack—TIA, having been put into Latin and Greek. ““Ischaemic”” means ““holding back the blood””, and this impairs the part of the brain supplied by the artery in question. The main arteries to the brain can become blocked by fatty deposits known as atheroma. ““Atheroma”” is Greek for porridge. It may be Greek porridge but it is certainly not like Scottish porridge. The surface of these bits of atheroma may become roughened and covered by platelets, which are responsible for clotting in the blood. These clumps of platelets may become detached and end up in a part of the brain which stops working for about 15 to 30 minutes. In any patient, the mini-stroke always tends to present in the same way: one patient may have transient weakness of the right arm; another may have transient weakness of the left arm; and another may lose his sight for 15 to 30 minutes. In order to shed light on the mechanisms of these transient attacks, the late Dr Knight of Guy’s Hospital carried out an interesting experiment. He was an outstanding physician and an enthusiastic and inspiring teacher. He took his team of students and nurses to ““Pooh Bridge”” in Ashdown Forest, where Winnie the Pooh had carried out an important experiment about 100 years before. Standing on one side of the bridge, they dropped brightly painted cones into the water and established where they went. Of the 100 cones that were dropped, 31 per cent arrived at one destination and 23 per cent at another. That is a very good example of what happens in the brain. These clumps of platelets tend to arrive in the same part of the brain, causing the same set of symptoms in any particular patient. The treatment is simple: the patient is given a small dose of aspirin—an eighth of the normal dose—and that tends to reduce the amount of platelets adhering to the fatty deposits and so reduce the number of mini-strokes. As has been said already, there is a tendency to regard a stroke as an incurable problem of old age, and these people do not receive the attention that they require. It is possible to limit the damage done by strokes provided that an accurate diagnosis is made within the first few hours. There are enough scanners throughout the country to make this emergency scanning possible, but the problem is that in many hospitals the scanners are used for only eight hours a day. If you tell captains of industry about that, they are horrified. The idea that huge pieces of machinery should lie idle for most of the time is an anathema to them. Some hospitals use their scanners for 24 hours a day, instead of the usual eight hours. Noble Lords will be comforted to know that St Thomas’s Hospital across the river has in the emergency department a scanner which is in use 24 hours a day. That is the way to do it. If, as has been mentioned, there is a simple blockage of an artery, that can be dissolved with the appropriate treatment. If, on the other hand, the stroke is due to a haemorrhage into the brain in substance, not a great deal can be done at that stage. But when the haemorrhage is outside the brain, just underneath its delicate covering—a so-called sub-arachnoid haemorrhage—emergency surgery is required if there has been a demonstrable rupture in the wall of the artery, which is called an aneurism. Although it is perfectly possible to arrange for everyone to have an emergency scan within three hours, as has been mentioned, there is a problem if we do not have sufficient staff to interpret the results, as the noble Baroness, Lady Barker, said. What could be the solution to that? The radiographers could easily be trained to interpret scans. Again, however, more resources are required to train them. Then, there is telemedicine, whereby scans can be transmitted to any part of the world and interpreted by experts. I spend my holidays working on a hospital ship in west Africa. We can spread a piece of tissue on a slide and put it into a machine called a Coolscope, which is a computerised microscope. The image can be beamed anywhere in the world. We beam ours to Bristol and get the answer back in five minutes. More of that needs to be done. My noble friend Lord Swinfen and his wife run a charity promoting telemedicine in many parts of the world. Our present mortality rate is too high, as has been mentioned; it is about 30 per cent. There is no reason why we cannot get it down to 15 per cent, as it is in many European countries and in north America, as the noble Baroness, Lady Murphy, emphasised. Then, there is the problem of rehabilitation. There is no doubt that rehabilitation services are not nearly as good as they should be and that many patients have felt isolated and neglected. They know only too well that if they had expert help they could return much more rapidly to as normal a life as possible. As the noble Lord, Lord Rodgers of Quarry Bank, pointed out, his stroke was not due to any fault in his lifestyle. However, many strokes are due to preventable conditions such as high blood pressure. I was interested to hear the noble Baroness, Lady Rendell, say that you can buy your own blood pressure machine and monitor your own blood pressure. It is easy to do, and it is very revealing. In between cases in my operating list at Guy’s I went into an empty theatre, lay down on the table and wired myself up to the various monitors, including blood pressure and pulse. I then told myself to relax. You can talk to your blood pressure and bring the thing down. It is amazing. You have a measurement of your blood pressure, so you can see it. You can talk to it and teach yourself how to relax and reduce your blood pressure. I was amazed to see it come down to below 100 and the pulse below 50. I suddenly thought that if somebody came in and read those things, they would think that I needed resuscitation and probably do cardiac massage and break all my ribs. So I left the theatre rather rapidly. Those sorts of simple things are so important. Then, there is the question of obesity. We are what we eat. It is amazing how many extraordinary diets people try, including the Atkins diet and so on. At the end of the day, however, you are what you eat and if you eat less, you will lose weight. I had a patient—a man—who was very overweight. He tried everything but it had not worked. I noticed that his wife was nice and thin, so I suggested that he should try eating the same quantity of food as his wife ate. He did not like that idea very much. Three months later I asked his wife how things were going and she said, ““He’s the same weight but I’m putting on a lot of weight””. He was obviously getting at her to eat more. Checking cholesterol levels and getting people to live a healthy lifestyle with plenty of exercise, avoiding smoking and excessive drinking of alcohol are other things that should be encouraged. Of course, we cannot force our views on patients. After all, we are simply advisers and in the end it is their choice. A patient said to his doctor, ““Will I live longer if I stop smoking and drinking?””. ““No””, said the doctor ““but it will seem longer””. That is not true but it is true that the number of strokes can be reduced if healthier lifestyles are encouraged.