Hamad Medical Corporation Women’s Service
HMC presents a unique opportunity in global healthcare. One where there is a complete focus on the quality of patient care underpinned by the development of the world's newest Academic Health System (AHS), which will lead the transformation of health services through an integrated approach to clinical practice, education and research.
One of HMC’s priority areas for development is in the field of Endovascular Stroke Neurology. This is an emerging speciality in Qatar, but one where we have clear plans and strong ambitions. As HMC continues to grow and develop, we are seeking to appoint world class clinicians in this field to help make this a leading centre for stroke development in the Middle East.
We are developing a Comprehensive Stroke Program in Doha, the details of which are as follows:
The continuum of care for stroke requires immediate identification, assessment and investigation of patients presenting with transient ischemic attacks (TIAs) and acute stroke symptoms. If managed appropriately, the devastating long-term effects of stroke can be substantially reduced. Randomized trials (level of evidence 1A) shows that reperfusion therapy within 90 minutes from onset of symptoms with rt-PA can lead to full recovery in “one in three” patients. This number unfortunately declines to “one in fifteen” if treatment is initiated 4.5 hours from onset of symptoms. These very encouraging results with early treatment, while exciting, require a paradigm shift in the way stroke is managed. Key components of a comprehensive program require media awareness campaigns for stroke symptoms recognition, dedicated ambulance and emergency department assessment and initiation of thrombolysis immediately after confirmation of diagnosis. In patients in whom the underlying mechanism is a proximal artery occlusion and/or large clot burden, intravenous thrombolysis may not be sufficient; endovascular treatment is very often required to re-establish flow to allow for reversal of neuronal injury.
The results of the Berlin Stroke Mobile Ambulance project (PHANTOM-S) were recently published (JAMA June 2014). 3213 patients with acute stroke were evaluated, scanned and treated on-route to hospital. The mean time from onset to treatment was less than one hour. This is the future of stroke treatment. The Stroke Program at Hamad will have a mobile CT ambulance under the supervision of the EMS be a key component of stroke care for the citizens of Doha. Dr Loua Shaikh (EMS Doha) fully supports the concept. Working together with the stroke team via tele-technology, reperfusion therapy will be initiated in the field for the appropriate patient.
This will lead to a clinically significant reduction in the onset to thrombolysis time leading full reversal of symptoms in a larger proportion of patients.
After arrival in the Emergency Department at Hamad Hospital the stroke team will evaluate success of reperfusion therapy. All patients will have immediate multi-modal CT (or MRI) imaging to determine the arterial circulation and tissue perfusion status. If imaging reveals an arterial occlusion in the distal carotid or proximal middle cerebral artery (MCA), in whom the likelihood of establishing flow is low (less than 8%) and there is a healthy penumbral tissue, the patient will be transferred to the endovascular suite for stent clot retrieval. There have been rapid advances in in endovascular therapies during the past 18 months that allow for re-establishment of flow within minutes in upwards of 90% of stroke patients with distal carotid and MCA occlusions. These endovascular treatment advances are a welcome ‘game-changer’ in acute stroke care and are becoming the standard of care in hospitals that admit a large volume of stroke patients. Introduction of such therapies to Hamad Hospital will require recruitment of new stroke faculty and establishment of an endovascular/imaging suite in close proximity to the Emergency Department. The space for the new imaging facility has been identified and we are in the final stages of acquiring the equipment (Philips Allura Clarity). We are also currently in the process of recruiting 3 endovascular stroke neurologists as an integral part of the stroke program.
The initial 24-48 hours following an acute stroke are critical for recovery and prognosis.
The risk of aspiration pneumonia (the single most common cause of delayed discharge), DVT, infections and cardiac arrhythmias is very high during this time. Evidence (evidence level 1A) supports that patients admitted to a dedicated stroke unit have a significantly better prognosis and significantly lower mortality. A dedicated stroke unit is now established at the Hamad Hospital and a comprehensive registry has gone live in March of 2014.
The risk of stroke in patients presenting with a TIA is 10% in the initial 30 days following the event. Most strokes occur in the initial 24-48 hours following the TIA. Recent studies have shown that immediate assessment and appropriate treatment can reduce this risk to less than 2%, an 80% risk reduction. This substantial and significant reduction is possible only if all patients complete immediate MRI imaging of the brain and neck vessels and cardiac monitoring for identification of the underlying etiology and initiation of appropriate therapy. The care of the patients will continue in the Stroke Prevention Clinic. We are in the advance stages of establishing a stroke service with 24/7 on-call that will evaluate and treat these high-risk patients following advance neuro-imaging.
The stroke ‘center of excellence” has initiated five clinical trials at Hamad Hospital. Two of the trials are multicenter with Hamad Hospital as the coordinating center. These include the evaluation of dual antiplatelet therapies in hyper-acute TIA, fluoxetine in recovery of function, streptokinase as treatment of acute stroke in low to middle income countries and anti-hypertensive treatment following acute stroke. Additional investigator-investigated studies are being initiated.