Taking on one of New Zealand’s biggest killers

But, if you do have a stroke, it may be reassuring to know that you are probably in one of the best places in the world and at the best point in history to suffer from a stroke. “New Zealand is well advanced in providing stroke treatment and rehabilitation, and a huge reason for that is the support we have received from the Neurological Foundation,” says Professor Barber.

Since he was appointed as the Chair of Clinical Neurology in 2008, Professor Barber has been instrumental in significantly improving the management and care of stroke patients in New Zealand.
A recent milestone was his involvement in establishing New Zealand’s first dedicated hyperacute stroke and rehabilitation unit at Auckland City Hospital, Taiao Ora.

Opened only 18 months ago, Taiao Ora, on Ward 51, enables stroke patients to have all their care delivered in one specially designed facility, with some of the most well-trained clinicians (doctors, nurses, and allied health staff) and advanced treatments in the world.
“Before we had this facility, stroke patients would be admitted to one ward for hyperacute care, then shifted to another for initial investigations, and then to another for rehabilitation – sometimes in a different hospital,” Professor Barber says.

“Now it’s like a one-stop-shop. Stroke patients come into the specialist hyperacute unit at one end, and then rehabilitation further along the ward, and we do everything we can to ensure they come out the other end ready to go home.”

While Professor Barber focuses on immediate treatment to reduce the brain damage that stroke can cause, rehabilitation after stroke is the other critical factor in the patient journey and is integrated into the unit. [Read about Professor Cathy Stinear’s world-leading stroke rehabilitation research on page 8.]

“The research teams are embedded in the ward, and the different streams of research can come together. It’s fantastic, it facilitates the sharing of ideas, and it must be almost unique in the world.” As soon as a stroke patient arrives in hospital, they are assessed for suitability to receive one or both brain-saving treatments – either the clot-busting drug alteplase or stroke clot retrieval, where the clot causing the stroke is pulled out of the artery.

The drug alteplase was the first-ever stroke treatmentthat could reduce the damage caused by stroke and was introduced in the 2000’s when Professor Barber returned from his Neurological Foundation-funded PhD studies at the University of Melbourne and Royal Melbourne Hospital.

The drug has been incredibly successful. However, it does have limitations. To begin with, only patients who arrived within the ‘golden window’ of 4.5 hours from the onset of symptoms were initially able to receive the therapy.
This obstacle inspired a second pivotal study, the EXTEND trial, which aimed to broaden this window. Professor Barber was part of the international team that showed advanced brain scanning techniques can identify patients who can still benefit from alteplase after 4.5 hours had elapsed or if the time of the onset of symptoms was unknown.

“That was an absolute game-changer. It has opened up alteplase therapy to many more people worldwide that would have previously been denied treatment.”

But the most significant new stroke treatment is clot retrieval. Professor Barber was part of the team on one of the five pivotal international studies published in 2015, showing what a game-changer this therapy is. His research since this time has been focused on streamlining and perfecting this therapy.

During a stroke clot retrieval, a microcatheter is inserted into one of the large arteries in the groin and gently advanced (“pushed”) along the aorta and into the arteries supplying the brain. The clot is located using artery scanning techniques, and a mesh-type stent device is used to capture the clot and pull it out.

So far, 1200 patients across New Zealand have been treated with this procedure.

When we spoke to Professor Barber, 20 had been performed at Auckland Hospital the previous week, their busiest week ever. Busy clot retrieval centres also operate in Wellington and Christchurch, where patients from central and southern New Zealand are treated.

For every three people who receive the clot retrieval treatment, one is saved from a life of ongoing disability.
“That means there are now 400 kiwis who have been given a second chance at life. If their stroke happened five or seven years ago, the outcome would have been very different.”
“New Zealand was one of the first cabs off the rank to introduce clot retrieval,” Professor Barber adds. 

"Because we were part of the team testing whether this therapy would work, and already had the advanced brain scanning techniques in place, we could safely adopt this life-changing therapy very quickly. Many other countries are still playing catch-up.”

Add to that, the stroke clinicians in New Zealand are very well-trained.

“Most neurologists have been ‘fellowship trained’, many through Neurological Foundation fellowships, which is huge. It means that when we’re training, we can go to any centre of excellence in the world and say, ‘Hey, can I come and work and do research with you – I’ve got my own funding’, and no one says no to that. It’s unique and absolutely fantastic.”

There are new stroke treatments on the horizon. In Christchurch, Drs John Fink and Teddy Wu (both former Neurological Foundation Chapman Fellows) are investigating the potential of tenecteplase, another clot-busting drug, which has potential advantages over alteplase.
Tenecteplase looks like it is better at dissolving large clots, and it can be given over a couple of minutes, whereas alteplase has to be given over an hour.

“That would free up nurses in the emergency department to do other things and means that patients can be transferred via ambulance or helicopter without needing a nurse to manage a one-hour infusion.”

“International companies are coming to us to use and test new clot retrieval devices. This is because of our high case volumes and our careful attention to detail. Another research focus is minimising harm and looking after patients better while they receive the treatment.”

“But, the most important area where we can improve is with stroke prevention. We are the ambulance at the bottom of the cliff, and we don’t want you falling off. If you are in your 40s or older, go to your GP regularly to get your blood pressure checked to make sure you don’t have atrial fibrillation, diabetes or high cholesterol. Stop smoking, cut down the alcohol, and exercise for at least 30 minutes three times per week. This will reduce your risk of stroke and heart attack, and our chance of meeting professionally!”

About Professor Alan Barber

Professor Alan Barber became the inaugural Neurological Foundation Chair of Clinical Neurology (CCN) 13 years ago. His task was to facilitate the ‘bench to bedside’ process, directly linking the neuroscience researchers at the University of Auckland with the clinical neurology unit at Auckland City Hospital, helping the hard work of scientists safely reach patients and developing clinician-researchers.

He has more than delivered on this challenge, particularly in his specialty area of stroke, bringing enhanced treatment options to patients and seeing stroke outcomes and survival rates improve. Notably, since becoming the Chair, he has pioneered the development of a ground-breaking clot retrieval technique in New Zealand that has saved hundreds of lives.

We are proud to announce his tenure as the Chair of Clinical Neurology has been extended a further five years, allowing Professor Barber to continue ‘bench to bedside – and beyond’.

Professor Barber is also Clinical Lead of the Auckland Hospital Stroke Service, and Deputy Director of the Centre for Brain Research at the University of Auckland. More recently, he was elected President of the Australia and New Zealand Association of Neurologists (ANZAN).

We are hosting an online talk with Professor Alan Barber and Professor Cathy Stinear on Tuesday 5 July. Click here to register.