Advancing stroke treatment: current trends and developments along patient pathway systems of care - The Stryker Neurovascular symposium at ESOC 2019

 

physician experts discuss
Stryker Neurovascular brought together leading physician experts as part of their ESOC symposium to discuss current trends and recent developments in stroke care.

 

Chaired by Prof. Gary Ford from Oxford Academic Health Science Network, UK, the symposium touched on various topics ranging from the use of simulation training of the entire stroke team to improve  patient outcomes, the optimization of imaging choices for thrombectomy, cost-effectiveness in late and elderly stroke patients, and the recently released data from the WEAVE intracranial stent trial for the Wingspan device.

 

Dr Waltraud Pfeilschifter

 

Dr Waltraud Pfeilschifter from the University Hospital Frankfurt, Goethe University, Germany, discussed whether the combined intervention of workflow refinement and simulation training can improve process times of acute stroke care. She presented the STREAM (Simulation-Based Training of Rapid Evaluation And Management for Acute Stroke) trial results which have shown a positive impact, not only for patients, but also for the personnel involved in stroke care, with an overall reduction in stress and absenteeism.
The trial, which included highly experienced comprehensive stroke centers, demonstrated an increase in baseline performance leading to a statistically significant reduction of five minutes in treatment times - positive results which were attributed to changes not only on the organizational but also on the individual level at these institutions.

 

STREAM interventions

 

Dr. Amrou Sarraj, Associate Professor of  the Department of Neurology, UTHealth, Houston, TX, USA, presented  a review of the SELECT and upcoming SELECT 2 trials addressing imaging selection modalities for EVT, comparing CT and CT perfusion imaging in correlation with clinical outcomes and the relationship between imaging selection and time (0-6 hours) vs. >6 hours.

 

 

SELECT 2 conclusion
Following in the wake of the DAWN and DEFUSE 3 trial, Dr. Sarraj also discussed CT and CTP in relation to core size and introduced the initiation of the SELECT 2 trial, which will focus on the safety and efficacy of thrombectomy in patients with large core strokes.
Dr. Kyriakos Lobotesis from the Imperial College Healthcare NHS Trust, London, UK, presented on the subject of the cost-effectiveness of mechanical thrombectomy.
In the UK, where stroke is a leading cause of morbidity and mortality, the issue of long-term health and social care costs was addressed.
While pooled data from the five large RCTs confirms that there is no reason to withhold EVT, either from a medical or from an economic or societal perspective - irrespective of patient age - Dr. Lobotesis argued that we must still keep in mind the economics involved. “Economic evaluation provides a basis for guidelines, commissioning of services, access and availability. It doesn’t matter how great a treatment is if the ‘economics’ do not add up, as access and availability will be a real challenge”. He called on doctors and healthcare professionals to remain sensitive and informed about these issues.
Stryker’s final speaker was Dr. Michael J. Alexander of the Department of Neurosurgery at Cedars Sinai Medical Center, Los Angeles, CA, USA and principal investigator of the WEAVE Trial. The WEAVE Trial had the highest on-label enrollment of any stenting trial for ICAD in USA to date, with 152 patients and the lowest reported peri-procedural complication rate, far below what had been targeted by the FDA.

 

Dr. Michael J. Alexander

 

The incidence of intracranial atherosclerotic disease (ICAD) in stroke, is “regional” in terms of prevalence. Dr. Alexander pointed out that “8-10% of strokes in the United States are due to ICAD, mostly in the south and east of the country, while in China 22 - 40% of strokes are due to ICAD”;  the Wingspan device was designed specifically to be used in this population.
The WEAVE trial, which Dr. Alexander presented, was recently published and is a post-market surveillance of the novel Wingspan stent system ( https://www.ahajournals.org/doi/10.1161/STROKEAHA.118.023996 ). The WEAVE trial demonstrated clear and positive results, bringing into perspective the earlier SAMMPRIS trial which had put in question the safety of this approach.

 

WEAVE

 

Dr. Alexander explained that the negative peri-procedural results of SAMPRISS were seen by the WEAVE investigators as being due to a variety of reasons. These included off-label use of the device, low experience of the interventionalists, early stenting < 7 days, poor patient selection and inadequate antiplatelet therapy.

 

WEAVE balance

 

Moving the “pendulum of clinical options” to a more realistic point, Dr. Alexander showed that stenting with the Wingspan system was safe for the treatment of ICAD when used in properly selected patients by experienced operators and informed periprocedural medical management. Future publications will include subgroup analysis looking at antiplatelet therapy and time to treatment.
With a disciplined and stepwise approach to improve stroke care, a willingness to face both the success and challenges in a quickly evolving practice, the Styker symposium provided a broad and comprehensive overview of stroke care by leading physicians in the field.

 

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