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Markus leaps from a discussion about outcomes to a plea to reorganise acute stroke care to improve access to thrombolysis.1 Not one patient received thrombolytic treatment in the studies he quotes, but such subtleties will be lost in the political hubbub about the NHS letting us all down yet again. It is frustrating that after 25 years' research, we have only one drug treatment, alteplase, which seems to work, and we only manage to give it to 2% of our patients, but we should not put all our eggs in this basket.
About 1 in 8 patients would expect to obtain major benefit from thrombolytic treatment, so even if we could increase the proportion treated to 20%, about 1 in 40 patients would benefit overall. To achieve this, Markus suggests that patients receive “rapid ambulance assessment” and perhaps half would be transferred to “specialised stroke centres,” some distance away.1 What of the patients not transferred and condemned to “second class care” in their local hospital? This would presumably include anyone over 80 (over 30% of patients with acute stroke) as there is insufficient evidence of benefit for alteplase to be licensed in this age group. What of the many patients rushed to the specialist hospital in the hope of getting clot busting treatment but found to be unsuitable? The logistics are nightmarish, and the sense of frustration among those whose hopes are dashed would be fertile soil for media mischief. Inevitably, the risks and limitations of alteplase would be ignored, and it would become yet another wonder drug being denied to thousands of NHS patients.
The only proved effective treatment for most patients with stroke is specialist, multidisciplinary team based, stroke unit care.2 Good coordination, communication, and continuity of care are essential ingredients, and these would be put at risk if large numbers of patients received acute care and rehabilitation in different trusts, looked after by different teams. There is no reason why patients with acute stroke, admitted to any reasonably sized hospital, should not have access to immediate brain scanning and expert assessment, if necessary via telemedicine links, but we need to develop these services quickly and quietly, without hyperbole and fuss.
Competing interests: None declared.