Strokeplay
Strokeplay
In 2023, I attended the Australasian Stroke Society’s annual conference in Melbourne. I could start by telling you Melbourne is the capital of Victoria, has a population the same as the whole of New Zealand, is a busy working port, a shopping and dining mecca, Australia’s most culturally diverse city, and a city obsessed with sport. But you know all that already. The event was held in a lovely part of the city, at the Centrepiece Conference Venue, situated between the Melbourne Cricket Ground and the Rod Laver Arena, the home of the Australian Tennis Open.
The park surrounding the two venues has numerous statues of famous Victorian sports people. The directions to Centrepiece could be described as “make your way past the statue of Shane Warne (though someone told me there are actually two statues of Shane Warne) and head towards the statue of Rod Laver.” It was exciting to see the familiar blue tennis courts. My wife is a great tennis fan. She was once the New Zealand Masters over something ladies singles champion, and her team—Net Worth—regularly wins the twilight competition in Wanaka. She considered coming with me. But we decided, having been to Melbourne together before, it would be too much like the rest of our life, Joan waiting for me to come home from work. Perhaps we will go again when the tennis is on.
By the time I booked my accommodation, the venues linked to the conference were sold out. I picked an older cheaper place a few blocks away called the Georgian Court B&B. Georgian, in Britain or America, refers to the reign of the three King Georges, from 1714 to 1847. It may be that old. Or perhaps it has that name because it is in George Street, or looks like the old buildings in Georgia in the other New World. There is no court. The royal court is on the other side of the world. The courts at the Rod Laver Arena are too far away. Probably they just liked the name. There was a bed. There was breakfast, but the breakfast started too late for me to enjoy it before going to the conference, and when I did go to breakfast, the day I left, I found it was almost inedible.
When I turned up at the hotel in the evening there was no-one at reception, though they had left a phone number to call if needed. My phone, I believed, was not connected to the Australian mobile network. I flagged down a passing cyclist and asked him to phone the hotel, which he kindly did. A staff member eventually came in on his own bike and let me in. He advised me they had cancelled the booking, because they saw my credit card was invalid. Last time I was in Australia, my credit card had been compromised. Someone—I suspect it was the lovely young woman in Sydney who took my payment for a meal at Circular Quay—had tried to use it to buy on-line clothing. I had requested and received a new card, which had not been added to the site that made the booking. Now I potentially had nowhere to stay.
The newly-discovered receptionist went onto the hotel computer, which was slow to start and which he agreed was possibly even older than the building, and eventually found me another room. It was decrepit and hadn’t been properly maintained. The doors didn’t shut properly. The paint was peeling. The toilet roll holder was missing. The taps and shower didn’t work properly. The towels didn’t seem to be the original colour, and had multiple bleached patches. But it was cheap and well-located, and adequate for my needs.
I saw many tidier homes in the neighbourhood built in a similar style, and possibly at a similar time, which appear to be private residences, and are better maintained, with clean paths and immaculate gardens. Most of them have expensive late-model European cars parked outside. A steak with vegetables and fries at the nearby Italian restaurant costs 74 Australian dollars. A glass of wine and dessert would add another 34 dollars to the bill. This is not the poorest part of Melbourne.
The official opening was not the first day of the conference, which was held over four days, but instead the first morning consisted of optional extra workshops. The organisers graciously allowed me to attend the morning workshop, which I hadn’t booked for. It was on clinical topics, and for me was the most useful part of the conference. The main speaker was Tony Wong, a stroke specialist from Brisbane, who impressed us all by using the available evidence to guide advice on clinical care in an area of medicine where little evidence is available—what I like to call “an evidence-free zone”, hopefully inspiring younger researchers in the room to fill some of the gaps in knowledge.
The first session was on atrial fibrillation (AF); a topic I welcomed. It is a condition I have had myself, and try to keep myself away from with the help of Flecainide; it is commonly associated with stroke; it kept coming up in other sessions, and has come up in other cardiology and stroke conferences I have attended; and there are overlaps with other areas of medicine that are not well known to neurologists, including cardiology and thromboembolic disease.
Recent evidence suggests AF is not a “cause” of stroke. Researchers are labelling AF as an “epiphenomenon” demonstrating an underlying condition they call “atrial cardiopathy”. Review of pacemakers and reveal devices confirms an increased incidence of stroke in patients with paroxysmal AF, but the AF can occur up to 12 months before or 12 months after the stroke. Continuous monitoring of rhythm, in patients with pacemakers or reveal devices, as I learned at an earlier conference, can also help to quantify the risk. Episodes of AF are usually asymptomatic, what researchers call subclinical AF (SCAF). For people having episodes of AF less than five hours per month, or fewer than five episodes per month, the risk of stroke is the same as for patients without AF; for patients having AF more than twenty-four hours per month, or more than twenty-four times per month, the risk is the same as for people in permanent AF; the rest are somewhere in between.
There currently is no way of testing for atrial cardiopathy, whatever it is. A common focus of study is embolic stroke of unknown source (ESUS) where patients have an apparently embolic stroke with no sign of the source of the embolus, such as AF or carotid stenosis. There is no evidence to suggest Warfarin or new oral anticoagulants (NOACs) is in any way useful, except for patients who can be shown to have documented AF. Researchers have been unable to identify any other subgroup from clinical presentation or investigations—ECG, carotid dopplers, ECHO, etc.—who might benefit from NOACs.
Neurologists love their abbreviations and acronyms, creating a secret language of their own to confuse generalists like me. There are at least two trials, on different aspects of stroke, called RESPECT. Neither acknowledges the existence of the other. More importantly, to me, neither acknowledges Otis Reading or Aretha Franklin, who wrote and popularised the well-known song of the same name.
Lack of evidence has always been a problem knowing when to start Warfarin or NOACs for patients in AF after a stroke. The most prescriptive guidelines, and possibly the most followed in practice, are from the European Heart Association formulated in 2016: three days after a small stroke; six days after a moderate stroke; and twelve days after a major stroke. The descriptive terms are unclear, and many stroke specialists—I know they do in Wellington— employ repeat CT or MRI scans to determine the size of the infarct. Others use clinical scores. Some will start Aspirin in the meantime if the patient has evidence of other vascular disease, such as carotid plaque.
In the trade, I discovered, the guidelines are known as the “Diener guidelines”, after Hans-Christoph Diener, the only neurologist on the guidelines group at the time, who when asked for his opinion, came up with the numbers we still use. In the general practice literature, these are called GOBSAT (good old boys sat around a table) guidelines, a term coined by Trish Greenhalgh. Diener himself was the leading author of review article published at about the same time stating there was “no good evidence” as to the best time to start NOACs. He is believed to have consulted with a few other neurologists he knew; on the golf course. There have been small studies since suggesting starting NOACs slightly earlier rather than slightly later may lead to overall better outcomes, but no-one is confident to practise differently or undertake the required large studies in the presence of established guidelines, and with the possibility for doing harm by precipitating an intracranial haemorrhage.
The group talked about patent foramen ovale (PFO). This defect is present to some extent in a quarter of the general population, but is more common in patients with stroke, and is believed to be a cause of stroke, especially in young people, where a clot can embolise from the systemic circulation, or from the foramen ovale itself, to the brain. It may be the ones from the heart are related to the nature of the defect itself, but the reports the clinicians receive from the bubble ECHOs required to make the diagnosis, they say, are not sufficiently detailed to know what the defect looks like. Most people in the room would request closure of a PFO if they found one in a patient with a stroke. Some would not request closure for a patient who also had AF, and would need to be prescribed life-long anticoagulation anyway, so a procedure would be deemed unnecessary. Some would look for clots in the legs, either by doing a clinical score or by ultrasound. Most would not. Neurologists in the later opening session, I was to find, in a scaringly practical way, demonstrated a lack of awareness of the risks of other complications of deep vein clots, such as pulmonary embolism.
There was some discussion, while we were talking about hearts, about tying off the left atrial appendage, a procedure that has been shown to be non-inferior to Warfarin, and more recently to NOACs, in preventing strokes in people with AF. It is much more expensive than anticoagulation, and though popular in America, it is generally restricted in Australasia as an alternative to anticoagulation for patients with an unacceptably high bleeding risk, which for neurologists is mainly patients with amyloid angiopathy, though most generalists or other specialists could think of other examples. A disadvantage in many cases is that patients who have had the procedure need to be on life-long Aspirin, which increases the bleeding risk anyway; though amyloid angiopathy is not on its own considered a contra-indication to Aspirin, unless an intracranial bleed occurs after starting the Aspirin.
Another neurologist gave a presentation on intracerebral haemorrhage (ICH), which world-wide accounts for 15% of strokes, but is a more common cause in developing countries and in Asian populations. Medical treatment has been disappointing. There is limited evidence for the usual practice of controlling blood pressure (BP), especially in the acute phase, and especially for strict control aiming for a systolic BP of under 120. There is evidence of a modest benefit for reversing Warfarin or NOACs. There is no evidence overall for Tranexamic Acid (TXA) in non-traumatic ICH, though in the available trials many patients were given TXA late and there may be a benefit for some patients from giving it very early. There was no evidence overall in earlier trials for surgical clot removal within 72 hours, but more targeted surgery for lobar bleeds that can be drained early to less than 15ml, using minimally invasive surgery, look more promising, and have shown significant benefit in more recent trials. There were no neurosurgeons in the room; the presenter looked relieved.
Teddy Wu, from Christchurch, talked about intravascular clot retrieval (ICR) for large-core strokes caused by large vessel occlusion (LVO). Early trials of ICR were performed on highly selected patients with small infarcts and large surrounding under-perfused areas. They produced some of the most impressively positive outcomes of clinical trials ever performed, with a number needed to treat (NNT) of 2. Anecdotally, centres around the world ever since have been treating patients with larger cores, especially if they are otherwise well. Teddy showed an email received by John Fink, also a neurologist in Christchurch, and the head of their stroke unit, from a colleague in Michigan. In that American hospital, for patients under age 60 there are no rules about core size, between age 60 and 70 they will treat anyone with a core volume of under 70ml, over age 70 a core volume under 50ml.
Christchurch have been involved in an international randomised controlled trial (RCT) of treating all patients with LVO regardless of core volume. Teddy presented the case of an 82-year-old with a dense left hemiplegia and a core volume of 80 ml, whom he would not have considered treating with ICR, except she was enrolled in the trial and randomised for treatment. She made an excellent recovery, with a modified Rankin score (MRS) of 2. The trial of ICR for LVO has come back showing overall evidence of benefit, with a NNT of 6 to 8, depending on patient selection.
As a result Christchurch will start treating with ICR some patients residing in Christchurch who have strokes from LVO with large cores. They will probably be more selective about flying patients up from Central Otago, or elsewhere in the Southern Region. They are aware of the inequities for rural patients, but also the disruption to patients and families of transfer for an uncertain benefit from a delayed procedure, and the resources required to arrange treatment for seventy patients when only ten are likely to get a good outcome, and we don’t know until the trials are completed which ones are likely to be helped.
Some patients with LVO also have intracerebral atherosclerotic disease (ICAD). These ones are technically more difficult when it comes to ICR and may require other interventions. They may have a different clinical presentation, such as stereotyped strokes associated with reduced perfusion, and there are sometimes clues from the appearance of CT angiography. Secondary prevention assumes a greater importance, for example these patients need aggressive targeting of lipids, and if on NOACs for AF may require antiplatelets as well, at least short-term after a further stroke, with a further increase in bleeding risk. One neurologist in the room pointed out cardiologists do this all the time for patients in AF having coronary stents placed. ICAD is topical at the moment, partly because neurosurgeons have started offering interventions.
In the afternoon, I needed to go into town. I had a dress-code problem. Soon after arrival, I realised I had packed the wrong trousers—the ones I had were old and worn, were too tight, and had a button missing. Don’t tell my wife. As soon as possible, I headed for the shops—I was relieved to find they had some of the same ones as in New Zealand— to get a new pair more suitable for the conference, and while I was there buy a matching blazer, as my false-outdoorsy Columbia jacket didn’t look tidy enough among the group of stroke specialist, and would be especially unsuitable for the dinner.
I started my journey into the city by walking across to the botanic gardens. The gardens had been chosen by the organisers as the site for an early morning fun run. The distance was listed in the programme as 3.827 kilometres. I calculated if I ran at a comfortable eight kilometres per hour it would take me 28 minutes and 42 seconds. I decided at an early stage not to take part, figuring it would take me more time and more effort to walk from my hotel to the start than to do the run, then I would need to walk back for a shower. But, I decided I wanted to see the gardens anyway. Once I had a look around, I walked from there along the south bank of the Yarra into town.
The middle of Melbourne city comprises three or four department stores joined together, covering several city blocks, joined at the first floor level by overbridges crossing the busy roads. It is difficult to navigate. Myers and David Jones and Zara, from the inside, to my untrained eye, all look the same. At one point I found myself trapped in the ladies’ underwear section of one of the shops, I don’t know which one, struggling desperately to find my way out. There were more people in the shops than in the gardens. No; that is misleading; a massive understatement. There were more people in the manicure shop getting their nails done than there were in the gardens. I bought my trousers and jacket and got out of there.
On the way back, I looked into the immense interior of Saint Patrick’s Catholic Cathedral. Marble mosaic floor, tall basalt columns, translucent alabaster, stained glass windows, a gold iconic painting of Our Lady of the Help, carved wooden stations of the cross. All worth a careful look, so I put some money in the donation box and had a walk round. It was empty. I crossed Fitzroy Gardens; tall structural trees, ponds, a great network of paths, runners, walkers, children playing, a bridal party having photos taking, camelias in full bloom, daffodils starting to come out. It was lovely. There had been a murder there the night before I arrived.
The first official sessions of the conference got off to a shaky start. The aboriginal man who was supposed to give the Welcome to Country, after the organisers introduced the committee and thanked the sponsors, was unable to come. A stroke survivor, who said she was relieved to have made it safely up onto the platform without stumbling, did her part to welcome delegates. The assistant Minister for Health and Aged Care was also unable to come and sent in a pre-recorded video presentation. A man from the north of England who had spent time in Australasia and now worked in America, gave a straightforward presentation, from a quantitative point-of-view, about adherence to guidelines, but in a weird and largely unintelligible accent. Then things got really difficult.
The second plenary speaker, who had flown three days earlier from the other side of the world to give her presentation, always a risky option because of the possibility of clots, as she stood on the platform, appeared to be confused, had trouble using the technology, and was unable to work out how to advance her slides. No-one suspected what was coming next. She apologised for her difficulties, looked muddled, lost consciousness, and fell to the floor. The organising committee rallied round her. Everybody else was asked to leave the room. I had been sitting with two other New Zealanders: Anna from Wellington and Teddy from Christchurch. I suggested, having seen in another hospital a patient with heart failure admitted to a stroke unit and (mis-)managed on the stroke pathway because of a stroke three years previously, the woman might need to be seen by a doctor who didn’t specialise in stroke care. They agreed. I went back and explained myself to one of the co-chairs, who graciously accepted my offer.
The presenter, who was now a patient, was conscious, lying on the floor on her back. They had called an ambulance. I did not suggest they lie her on her left side, but it would have been a good idea. One of the stroke specialists was checking she could move her arms and legs. They couldn’t tell me if she was feeling breathless. The patient said her breathing was fine, her legs had not been swollen after the flight, and she had no chest pain or tightness. She looked to be beyond the pregnancy age group, and I didn’t ask about her age or reproductive history. Her main concern was that she would not be able to give her presentation. She was not pale or cyanosed. I didn’t take her pulse. At her request, they sat her up, and put her in a wheel chair. The ambulance came with a stretcher and took her away to the hospital to be checked out.
Anna asked me at morning tea how things had gone. I said I thought it was probably a simple faint, but was not clear what had precipitated it, was worried about the chances of a pulmonary embolus being managed by a group of stroke specialists, and was pleased when the ambulance had come to make their assessment. It was announced later in the afternoon that the lady had been cleared by the hospital and was all right. She came back on the last day, walking briskly onto the stage to the tune of Elton John’s “I’m Still Standing”, and gave her presentation, appropriately titled “Courage, Confidence and Collaboration”.
In the evening, I walked into the city, to Chinatown, for some food. It should be called Everywhere-in-the-World Town. There are restaurants from seemingly every country in Asia, also Mexico and Italy. The most numerous are the Thai restaurants, though these are outnumbered by Thai massage parlours. McDonalds, KFC, Hungry Jacks (what we call Burger King), and Starbucks are all represented. There are at least two Irish pubs. I queued for ten minutes to get into a Vietnamese restaurant that had a good selection of food and seemed very popular. They directed me to a table on which was a QR code I was supposed to use to order the food. I sat for maybe another ten minutes, feeling increasingly hungry, unable to make my order, trying to figure it out, then I got up and left. There was another Vietnamese restaurant three doors away, where a human sat me down, and gave me a menu. I ordered my meal – a bowl of spicy vermicelli soup – which they brought to me at my table, I ate it, and went away satisfied.
Surprisingly, there are two good bookshops in Chinatown. One, The Paperback Bookshop, was open till ten o’clock, when perhaps people are around, eating in the restaurants. I bought a book by Geoff Dyer called The Last Days of Roger Federer, and Other Endings. There is very little in the book about Roger Federer, and a lot about other impending endings—songs, paintings, books, films, and sporting and literary careers, including Dyer’s own. It is more about late career and retirement, which for obvious reasons is becoming an area of personal interest. I knew this, from reading reviews, but I still enjoyed reading the book a few hundred metres from the Rod Laver Arena, where Federer, or “Roger”, as Dyer insists on calling him, won his last Australian opening in 2018.
Back at the conference. There are some new things going on. The Australians are trialling Colchicine as a secondary prevention for people with persistent mildly raised CRP after stroke. Mobile units are speeding up the process of hyperacute stroke care in Australian cities. Helmets using ultrasound instead of CT to rule out intracerebral haemorrhage are proving light enough to be flown with a team to some patients in rural and remote areas. New agents are becoming available to reverse Rivaroxaban and Apixaban. People keep trying different neuro-protective measures to preserve brain after stroke, mainly based on mouse models, so far without much success.
But most of it is the same old stuff that comes up at every conference on any clinical topic, with stroke: issues for Māori, with stroke; simulation training to improve team performance in caring for patients, with stroke; interventions to improve the delivery of evidence-based practice, with stroke; enhancing rehabilitation for Aboriginal Australians, with stroke.
This is the second conference I attended in Australia within a few weeks. I am becoming interested in the health care provided for Aboriginal Australians. No, that doesn’t really explain it; I am interested in the failure of white Australians to provide that care, to allow the indigenous population a voice in how that care might best be provided, and to include aboriginal health workers and others in its provision. There were some positive signs, notably some of the epidemiological research being conducted by researchers out of Melbourne with the team at Alice Springs, determinedly putting the available shocking figures in front of people, and developing qualitative research co-designed with Aboriginal people exploring some of the barriers to care. Their presentation included a man who appeared to be the only Aboriginal person at the conference, who read out some of the quotations from participants—an “indigenous voice”—and made his own perceptive comments.
The conference dinner was held at the MCG. A group of us waited outside for the doors to open. Then they let us in and directed us up the stairs. Tables were set out in a large room overlooking the hallowed venue. There was a band, playing an instrumental introduction to the Beatles’ “Norwegian Wood” as we walked in. Pleasant enough to listen to, but without the sitar George Harrison had available to him on the 1965 recording. The singer added his voice to the mix—in tune, but loud and intrusive. I listened to the familiar lyrics:
She asked me to stay and she told me to sit anywhere
So I looked around and I noticed there wasn’t a chair.
I found what I thought was a spare seat at a largely empty table, but it turned out to be needed by a hospital group, then at my next choice a solitary woman was holding six places for friends. With some other New Zealanders, I found an empty table in the south-east corner of the room, away from the music.
I sat with an interesting group at our table, people I wanted to get to know, but there was no way I could hear what they were saying. After a few years of attending bigger louder events, probably listening to exactly the same music, and decades of largely unprotected exposure to tractors, firearms, lawnmowers and chainsaws, my hearing has gone. At the time, I had been too stubborn to get myself some hearing aids, and with the loud background music, I probably wouldn’t have worn them if I had them.
During a welcome break in the music, John, one of the other New Zealanders, asked me about my interests apart from medicine. I told him about my writing. I also mentioned we live on a small farm. John, as it turns out, is also surrounded by farm animals where he lives, and goes for regular walks across the paddocks. He asked me what I had told them at the airport in response to the question: “had I been on a farm recently? In a rural area?” I told him I would be safe from a bio-security point of view taking my own precautions: I can’t even come off the farm into our own house without decontaminating myself first. I also mentioned last time I had been in Melbourne, along with many others, was for a WONCA rural conference (last acronym—World Organisation of National Colleges and Academies, though nobody calls it that). And, yes, rural. “Ever been in a rural area?”—“Nah.” The band started playing again. The audible and accessible part of my world disappeared.
The food was good. I ate it. Some of the others got up to dance. Of all the activities I can think of, this is my least favourite. Some people have a fear of public speaking. They would rather die than get up and speak in public. I feel the same way about dancing. I watched from the distance of my corner table. I tried to smile at people for as long as possible while they tried to tell me something. It was like trying to derive meaning from the presenter at the earlier session with the trans-Atlantic or trans-Pacific accent: too hard. While the others carried on dancing, I walked back across the park to my hotel.
There was one more morning. The conference was winding down, and this was reflected in the programme. The hyperacute stuff, the new exciting treatments that make a minimal improvement in most people’s lives, and to be honest makes some of them worse, was gone from the list of presentations. Like the stroke survivors, those of us still at the conference were left with the less exciting topics: fatigue, aphasia, stroke knowledge assessment tools, and imperfect discharge planning. There were some award presentations on at the end of the morning, which I didn’t attend. As far as I know, no-one was required to accept an award on my behalf. It was time to go home.