Innovation in stroke aftercare across Europe: an interview with Professor Urs Fischer

What is the global impact of stroke?
Stroke is the epidemic disease of the twenty-first century and the second most frequent cause of death in 2011, accounting for 11% of all deaths worldwide. Stroke is also the second most important cause of permanent disability and one in five women and one in six men suffer a stroke.

Similar to myocardial infarction in acute ischaemic strokes clots are blocking arteries in the brain, resulting in tissue damage with consecutive neurological deficits or even death, if the artery is not reopened immediately. Therefore, the main aim of acute stroke treatment is the reopening of the blocked arteries.

The impact of stroke is tremendous, in terms of the personal fate of these patients and their families, but also the whole society. For example, if a young person suffers from a stroke they are no longer able to go back to work when the outcome of the stroke is poor. This impacts society as a whole as well as healthcare and has incredible socio-economic consequences. It’s very important to appreciate the impact of stroke all over the world.

How has stroke treatment changed over the last couple of decades?
The success in acute stroke treatment started 20 years ago, when there was no effective and evidence based treatment against stroke. In 1995, the first trial showed that intravenous thrombolysis with IV rt-PA is significantly better compared to placebo in patients with an acute ischaemic stroke.

It was called the NINDS trial and this was the first major breakthrough in acute stroke treatment. This therapy significantly improved the outcome of many stroke patients all over the world.

Even though this drug is better than placebo, many patients couldn't be treated because of the narrow time window as this therapy is effective only when provided within the first 4.5 hours after symptom onset.

This is because intravenous thrombolysis is very effective in the very early hours and its effect then begins to decrease rapidly. This presents a major challenge, treating patients within this short time frame, especially for patients living in rural areas or in patients, waking up with a stroke.

A second problem is that patients with occlusions of large vessels and with large clots did not undergo recanalization sufficiently following IV-tPA. Therefore, new treatment approaches had to be investigated to reopen these blocked arteries. One possibility were endovascular procedures, which means going into the brain with a catheter and trying to remove the clot (similar procedure as in patients with myocardial infarction).

There are several devices which have been specifically designed for this type of procedure. First generation devices were able to reopen the occluded arteries, but large studies did not show any benefit of these devices compared to the treatment with IV-tPA. however.

After 2006, new devices – so called stent retrievers - were introduced. These devices open the blocked arteries by squeezing the clot into the meshes of the stent. These stents with the clots are then retrieved out of the arteries in order to restore blood flow of the vessel again.

The use of stent retrievers has recently been studied in many different trials, to date there are six published, large, randomized, controlled trials and one more that is to be published soon. All seven trials showed that the combination of the drug (intravenous thrombolysis) and the device is significantly better than intravenous thrombolysis alone, increasing the number of patients which survived without major handicap after endovascular therapy.

However, endovascular therapy with and without intravenous thrombolysis is only possible for patients with an acute occlusion of major vessels, whereas intravenous thrombolysis alone remains the preferred treatment for patients with occlusions of smaller vessels, inaccessible for catheters.

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