Didier Leys, Prof.

Didier Leys, Prof.

 

Professor Didier Leys, former President of the European Stroke Conference (ESC), talks about the highlights we can expect at the ESC this year and specifically on the most important factors in the management of acute ischaemic stroke.

 

I think some of the topics we can expect to see coming up are firstly the organisation of stroke care, as time is the most important problem in stroke. In particular, there will be discussions on regional organisation of stroke care, telemedicine, and we shall hopefully hear about the experiences of the specialised stroke ambulances that are in use in Berlin. These include a CT scanner on board, and are one method of reducing the delays between patient presentation, diagnosis and initiation of stroke treatment.

Secondly, there has been work conducted on the topic of selecting patients for their eligibility for thrombolysis beyond the currently recommended time window through the use of neuroimaging techniques, and this may be presented at the ESC this year.

There will definitely be talks on bridging therapy and the combination of intravenous rt-PA with mechanical thrombectomy. Although three negative trials were published in the past, work has continued in this area looking into the identification of eligible subgroups of patients, so it will be interesting to hear about these results.

Two weeks ago, the results of DESTINY-21 were published, investigating hemicraniectomy for the treatment of patients over the age of 60 years with an ischaemic stroke. {Note: Before going into details it should be mentioned that DESTINY-12 did not meet the primary endpoint and the description of outcome hereafter should be understood against this background.} DESTINY-1, in patients aged younger than 60 years showed a positive outcome for this treatment, but in older patients it is not so clear. Comparing treated patients with non-treated patients, treatment has a benefit, but there are ethical aspects up for discussion, as the majority of survivors required assistance for most bodily needs one year after treatment.

With regard to haemorrhagic stroke, there are likely to be lively discussions on the management of blood pressure in the acute phase of a stroke, following the publication last year of INTERACT-23.

The recently published ARUBA4 study, which showed that in patients with an AVM found on imaging (but without any signs of a stroke), the best form of stroke prevention was no surgical treatment, will also trigger discussion at the ESC.

All the new results from clinical studies are discussed in the late breaking sessions on the last day, and we never know what is going to be presented until just before the conference.

The breaking news and the clinical trials sessions are the most important sessions for an experienced stroke physician. Here they will learn about the latest data and can discuss the topics together.

For a young stroke physician, the teaching courses are really helpful. We recommend that our trainees attend these sessions. The poster sessions are also useful, as they can discuss the data directly with the authors.

TIME is the most important factor in thrombolysis as efficacy is related to time of administration: treatment given 30 minutes after onset of symptoms is better than treatment at 2 hours, and treatment at 2 hours is better than treatment at 4.5 hours. The main barrier to thrombolysis is the delay in arrival of patients at a unit where thrombolysis can be administered and the delay in administering treatment for those who arrive within the 4.5-hour time window.

The barriers causing the delays are different in different regions, but in general patients who are alone at the time of stroke, and who cannot notify someone are at a high risk of delay. Then there is the problem of stroke symptoms not being recognised by the family or carers, or the lack of realisation that a stroke is an emergency. This is especially the case for patients who have a rapid recovery. Another high risk factor is when a call is placed to the GP. In this case, it is almost certain that the patient will arrive too late.

The problem of transport is varied, and patients in remote areas, such as the mountains, or regions such as Finland, etc, may not be able to reach an equipped hospital within the time window for thrombolysis.

Once the patient arrives at the hospital, everything has to be done to avoid in-hospital delays, such as access to imaging, or alert of the stroke team.

There are three main steps to help overcome the barriers I have mentioned:

  1. The population has to be educated to identify the signs of a stroke and to call the emergency number. This has to be done in a simple, selective and effective way, so that the main signs of stroke – hemiplegia, sensory loss, and visual or speech disturbances of sudden onset are suspected of being a stroke. Of course other symptoms can also be due to a stroke, but we can’t educate the general population on everything – only the main signs that cover the majority of cases. Campaigns on the radio, television, at bus or metro stations can be very effective and the role of the GP in educating patients should also be emphasised here.
  2. A centralised emergency number should be in place, so that once the symptoms of a stroke are suspected, this number is immediately called. In the European Union this number is 112, and the caller is put through to someone who speaks their own language. There are specific regional numbers as well, such as 15 in France, which is answered directly by an emergency physician who decides not only on the need for transfer to hospital, but also on which hospital the patient should go to – in this case, the next stroke unit, which may not necessarily be the next hospital. The emergency call centre than pre-notifies the hospital stroke team that a patient is on the way.
  3. Finally, in-hospital co-ordination plays another important role in reducing the time barrier. The stroke team should be pre-notified of any impending arrival of a suspected stroke patient, so that they can be ready to receive them on arrival and the patient can directly go to neuroimaging rather than via the emergency room, which requires further assessment delays by the emergency physician. Ideally the admitting hospital should be a stroke unit, and within most countries in the EU, there are enough stroke units in place. MRI is the most accurate form of diagnostic imaging and can even be used in patients with wake-up stroke, to estimate the time of onset. If MRI is not available or contra-indicated, then CT, which is faster (approximately 2 minutes compared with 20 minutes for an MRI), is used.

Time is brain! This is the most important message over everything else and we should do everything possible to earn time and treat more patients. The earlier thrombolysis is given, the greater the benefit for the patient.

This message is probably more important than some of the other details, such as telemedicine, specialist stroke ambulances, etc., which may only apply to certain specific situations. The one message I would like to communicate is that Time is Brain.

There is nothing specifically connecting Nice and the ESC. But France is a very central European country. Flights come into Paris from all over the world and in fact Nice is the second largest airport in France, with many direct European connections. In 1995, the ESC was held in Bordeaux, but this was difficult to reach. The ESC in 2008 in Nice was very successful and it just makes sense to hold the ESC in France every 5-6 years.

Well, I am not from Nice, I live in the North of France, but I have been here a few times for meetings and congresses. Nice is situated on the French Riviera and it is a very attractive part of France. The best area to visit is the beach and especially the Promenade des Anglais – the English promenade. Of course, if you have more time, then you can take boat trips out to look at the coast and islands nearby, too.

  1. Jüttler E, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 2014;370(12):1091-1100.
  2. Jüttler E, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 2007;38(9):2518-2525.
  3. Hill MD, Muir KW. INTERACT-2: should blood pressure be aggressively lowered acutely after intracerebral hemorrhage? Stroke 2013;44(10):2951-2952.
  4. Mohr JP, et al for the ARUBA investigators. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet 2014;383(9917):614-621.