RC 111 - Management of acute stroke
1. To understand the strengths and shortcomings of the relevant multicentre trials assessing the role of endovascular treatment in patients with acute ischaemic stroke.
2. To understand the outcomes of these trials, the context in which they were achieved and how they can be ensured in a different environment.
3. To appreciate potential differences in management of patients with anterior vs posterior circulation strokes.
In 2015 and 2016, eight randomised controlled trials were published, reporting a clear benefit of endovascular treatment over standard care for patients with an acute ischaemic stroke caused by a large vessel occlusion of the anterior intracranial circulation. Individual patient data from five of these trials were pooled in the HERMES collaboration project and first results were published in 2016. After publication of the first positive trial, MRCLEAN, stroke treatment underwent a revolutionary change since the introduction of intravenous therapy with thrombolytics more than twenty years before. The different trials used different inclusion criteria and showed differences in outcome. In this lecture, a short history of acute stroke treatment trials, an overview of the differences between the 2015 and 2016 trials, new studies with subgroup analyses, and the pooled data from the HERMES collaboration will be presented and discussed.
1. To understand the principles underlying endovascular clot aspiration.
2. To become familiar with the different materials available for mechanical clot retrieval.
3. To understand the circumstances in which stenting of an intracranial blood vessel is needed.
Since the 90s, the mainstay of primary stroke treatment is the use of clot-dissolving medication. Nowadays, mechanical thrombectomy has established itself as a very powerful tool in the management of acute ischaemic stroke in the (hyper)acute setting. The number of mechanical thrombectomy procedures has increased considerably in the last few years. An occluded cerebral blood vessel can be reopened in a swift and efficient way with quite acceptable complication risk rates using stent retrievers and/or thrombosuction catheters. In this presentation, not only an illustration of different mechanical thrombectomy techniques will be provided, but, next to an introduction to intra-arterial primary stroke treatment, also an overview of several accessory matters, such as tandem lesions, stenting and complications, will be discussed.
1. To appreciate the structure that is necessary to organise interventional stroke treatment for a large population.
2. To understand the cost implications and their mitigation.
3. To become familiar with the associated ethical concerns (such as informed consent) and the different ways of addressing them.
While stroke has known advances both in imaging and treatment since the 1990s, it has been the breakthrough with the use of stentrievers that has caused the most response. We have seen that with these methods, it is now possible to on the one hand extract safely and quickly the thrombus without the adverse effects of secondary haemorrhage. While this is extremely encouraging, a few things need to be considered: on the one hand, there will be an enormous demand in a very strictly organized stroke treatment system based on stroke units and stroke centres. Some that will carry out the initial examination and maybe treatment while the patients that need endovascular treatment may be referred to centres that dispose of 24/7 state-of-the-art imaging and post-treatment setups. The costs incurred will be caused on the one hand by and increase in treated patients, then an increase in the management and treatment costs themselves due to the stents. However, this should be counterbalanced by a decrease in morbidity and mortality with decreased readaptation costs. One major concern is the case of the increased need for improved informed consent ways for these patients that may not be initially be able to agree or disagree to the treatment, which is critical due to the short time-window available. Also while the industry is necessary to continue to support the needed R&D in this field, it should allow physicians freedom to provide the best choice of materials adapted to the patient.