Conference Coverage

European cardiologists seek involvement in acute stroke

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Multispecialty approach is key to U.S. rollout

The convergence of technological advancements for intracranial mechanical thrombectomy (stent retrievers) and the use of noninvasive imaging (CTA/MRA) to improve patient selection for revascularization have revolutionized the treatment of acute stroke as demonstrated by the recent publication of five randomized clinical trials supporting revascularization for acute ischemic stroke. Similar to our national goal for minimizing door to balloon time (DTB) for acute heart attacks, there will now be a similar effort directed at expediting stroke treatment.

Dr. Christopher J. White

However, we have not solved the manpower issue of offering this specialized therapy in the local hospitals where the stroke patients are. Unfortunately, the demand for endovascular stroke treatment has outstripped the ability of traditional radiology specialists to provide this care, in many hospitals. The good news is that many other specialists, including interventional neurologists, vascular surgeons, neurosurgeons, and interventional cardiologists have endovascular skills readily adaptable to treating patients with acute stroke.

At Ochsner Medical Center in New Orleans, we have demonstrated the feasibility of interventional cardiologists working 24-7–365 with neurologists as a team, to perform endovascular revascularization for acute stroke patients. Reassuringly, we found no difference in outcomes among those acute stroke patients treated by radiology specialists and those treated by the interventional cardiology team (Catheter. Cardiovasc. Interven. 2015;85:1043-50). Because there is an uneven distribution of radiology specialists in our communities where patients with strokes need time-sensitive treatment, we need to develop teams composed of a variety of physician specialties, including interventional cardiologists, who can deliver rapid and safe intracranial mechanical thrombectomy to selected patients with acute stroke in their local communities.

Dr. Christopher J. White is medical director of the John Ochsner Heart & Vascular Institute in New Orleans. He is an adviser to and consultant for Neovasc, and consults for Surmodics.


 

EXPERT ANALYSIS FROM EUROPCR 2015

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PARIS – The leaders of European interventional cardiology have thrown down the gauntlet to their colleagues, declaring during a special call-to-action session at EuroPCR that a revolution is underway in the treatment of acute stroke, and interventional cardiologists need to train up and become part of it.

“Something big is going on today. If we want to be transformative and impactful, I think stroke intervention is one of the main points where we can do so as interventional cardiologists,” said Dr. Alberto Cremonesi of Villa Maria Cecilia Hospital in Cotignola, Italy, a past president of the Italian Society of Interventional Cardiology.

Dr. Petr Widimsky Bruce Jancin/Frontline Medical News

Dr. Petr Widimsky

Dr. Petr Widimsky highlighted the five prospective, randomized, controlled trials that have come out in the past few months and triggered the revolution in acute stroke therapy. All five studies – MR CLEAN, ESCAPE, EXTENT IA, SWIFT PRIME, and REVASCAT – were halted early because of the significant advantage mechanical endovascular therapy with stents or thrombus retrieval devices demonstrated over standard therapy featuring clot thrombolysis with tissue plasminogen activator.

Collectively, the five trials showed a 60% greater chance for good functional recovery from stroke with endovascular interventions. The rate of a favorable neurologic outcome as reflected in a modified Rankin score of 0-2 was 48% with the use of stent/retriever devices, compared with 30% with thrombolysis alone, noted Dr. Widimsky, professor and chair of the cardiology department at Charles University in Prague.

The Food and Drug Administration began approving these endovascular therapy devices in 2012. The major challenge is how to make this therapy available to the vast numbers of patients in need. After all, the successful clinical trials were carried out by highly skilled interventional neuroradiologists operating in centers of excellence – yet such centers are few and far between.

“There should be no fight between the specialties. In hospitals with high patient volume and good work flow and experienced neuroradiologists available 24/7, there is no need for cardiologists to jump in. But in hospitals where that’s not the case then cardiologists can be of help,” he asserted at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

There aren’t nearly enough interventional neuroradiologists or endovascularly trained neurosurgeons to fill the enormous need, and neurologists simply don’t have the mindset for this sort of work, Dr. Widimsky added.

“Neurologists, with few exceptions, don’t do interventions. In general, they are people who think conservatively. These procedures should be done by someone who is working with procedures every day, and that’s not what neurologists do,” he continued.

Because interventional neuroradiology services weren’t available at Dr. Widimsky’s hospital, he and his fellow interventional cardiologists took on the task several years ago, gaining specialized training and then forming a multidisciplinary acute stroke team. The results, he said, have been gratifying.

The new endovascular therapy for acute stroke has much in common with contemporary management of ST-elevation MI, Dr. Widimsky observed. Just as in an acute MI, where time is heart muscle, in acute stroke time is brain. In most patients, the endovascular procedures are most effective when done within 3 hours after acute stroke onset. By 6 hours, the rate of good functional recovery falls to about 20%. But some patients can derive benefit even with much later intervention provided they have sufficient collateral circulation, which can be determined by sophisticated perfusion imaging techniques.

Dr. Widimsky pointed out a couple of ways to streamline today’s standard acute stroke management flow in order to save substantial time. The typical pathway today is for EMS personnel to take a patient to the emergency department for evaluation for suspected stroke, which can take up to 30 minutes. That patient then goes to CT imaging to determine whether the stroke is ischemic or hemorrhagic, then to the neurology unit for thrombolytic therapy, which can take another 30-60 minutes. Only afterwards, if indicated, does the patient go to the catheterization laboratory for endovascular intervention.

A faster, better approach, he said, is to train EMS personnel to recognize suspected cases of acute stroke, have them bypass the ED and instead take those patients straight to a hospital with high-quality CT imaging available 24/7, and if imaging indicates the patient is a candidate for mechanical revascularization, to then bypass the thrombolysis suite and go directly to the catheterization laboratory. That can save an hour to an hour-and-a-half in total.

Dr. Alain Bonafe

Dr. Alain Bonafe

Who should be performing these endovascular interventions? Dr. Alain Bonafe presented highlights of a recent joint consensus statement by the European Stroke Organization, the European Society of Minimally Invasive Neurological Therapy, and the European Society of Neuroradiology that declared the decision to undertake these procedures should be made jointly by a multidisciplinary team in experienced centers providing comprehensive stroke care, and that the procedures should be carried out by accredited interventionalists with certified expertise, regardless of their specialty.

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