Neuro News Educational Supplement | Medtronic January 2019

January 2019

E D U C AT I O N A L S U P P L E M E N T

ACUTE ISCHEMIC STROKE CARE CONTINUUM WITH STROKE PATIENTS EVERY STEP OF THE WAY

STROKE

SYSTEMS OF CARE

IN-HOSPITAL WORKFLOW

THERAPY TREATMENT

POST STROKE MONITORING

LONG TERM PATIENT MANAGEMENT

MEDTRONIC IS COMMITTED TO SUPPORTING PATIENTS THROUGHOUT THE CARE PATHWAY. UC201907321EE © Medtronic 2018 All rights reserved

neuronewsinternational.com

UC201907321EE - NEURO NEWS FRONT COVER ADVERT.indd 1

23/11/2018 15:29

In this supplement:

2

INTRODUCTION

3

COLLABORATION IS KEY IN THE FUTURE OF ACUTE ISCHAEMIC STROKE - PROF VALERIA CASO

5

REIMAGINING THE ACUTE ISCHAEMIC STROKE CARE CONTINUUM -D R NATALIA PEREZ DE LA OSSA

INTRODUCTION The fact that endovascular therapy is now well established for patients with acute ischaemic stroke, the face of stroke treatment has been changed forever. The last five years have been one of the most exciting times to be involved in the treatment of acute ischaemic stroke, with the paradigm still evolving and the community committed to discovering and implementing the most successful care continuum for patients.

The gravity of this task has meant that the whole community has had to join together in an effort to raise awareness, streamline services and implement the changes needed. We have witnessed the various different specialties involved in the treatment of stroke collaborate like never before for the benefit of the patients. We have also seen societies coming together to develop new guidelines and consensus documents to address this new era. And we have seen industry partners working closely with the whole community to play their part in the evolution of acute ischaemic stroke treatment.

In this supplement, Professor Valeria Caso speaks to NeuroNews about the major concerns that still need to be addressed, including the inequalities that still exist in stroke care in Europe; the importance of building strong relationships among all the stakeholders in the stroke community; the role of the wider community, including industry and organisations such as the Angels Initiative, which seeks to increase the number of patients being treated at stroke-ready hospitals, and the European Stroke Organisation, which has played a major role in coordinating the community’s response.

Next, in an in-depth interview, Dr Natalia Perez de la Ossa addresses what is being done to streamline the stroke care continuum in terms of pre-hospital organisation, comprehensive versus primary stroke care centres, and the technology that has been developed to ensure a rapid decision-making process.

Perez de la Ossa gives an update on the RACECAT trial and weighs on what she thinks should be the top focus areas to treat stroke patients in the current era.

All rights reserved. Published by BIBA Publishing, London T:+44 (0)20 7736 8788, publishing@bibamedical.com. The opinions expressed in this supplement are solely those of Medtronic and the featured physicians and may not reflect the views of NeuroNews.

22

Over the last five years, there has been a major shift in the treatment paradigm for patients with acute ischaemic stroke. With over 20 years’ experience working in a stroke unit and heavy involvement in the European Stroke Organisation, Professor Valeria Caso has had a front row seat to the changes and developments.

S

peaking to NeuroNews, Caso recalls when she had the privilege of successfully treating one of the first t-PA patients in Perugia, Italy. “It was a gratifying feeling, a mix of fear and excitement, as I realised that we were embarking on a new era in stroke care. With the publication of MR CLEAN (2014), EXTEND-IA, ESCAPE, REVASCAT, SWIFT PRIME (2015), demonstrating the superiority of thrombectomy plus t-PA over t-PA alone, the attitude that stroke was becoming beatable and treatable became stronger, not only to stroke physicians, but also healthcare stakeholders were giving higher priority to stroke care standards.

On a personal view, every time I see a recanalisation during a thrombectomy, I feel the “life coming back” to the patient. The restoration of cerebral circulation is like a beautiful art picture,” she explains.

Major concerns

Even with these advances, Caso makes clear that we still are facing too many inequalities in stroke care in Europe between and within countries. Specifically, she points out, while an overall decline in stroke mortality was observed in the last two decades, several Central Eastern European countries are still experiencing increasing rates of stroke incidence and stroke-related mortality.

The organisational models adopted at local and national levels may be influencing these differing stroke care performances.

Moreover, there are considerable variations in the quality of care for stroke patients in Europe, both between and within countries.

In response, the ESO, the European Society of Minimally Invasive Neurological Therapy (ESMINT), European Academy of Neurology (EAN) and the patient organisation Stroke Alliance for Europe (SAFE) performed a survey of scientific societies and stroke experts, in which the best available information on access to and delivery rates of these treatments was collected from 44 out of 51 European countries.

The estimated mean number of stroke units was 2.9 per million inhabitants (95% CI 2.3–3.6) and 1.5 per 1000 annual incident strokes (95% CI 1.1–1.9) 9.2 and 5.8, respectively. Intravenous thrombolysis was provided in 42/44 countries. The average treatment rate was 7.3% of incident ischaemic stroke patients for intravenous thrombolysis (95% CI 5.4–9.1), and 1.9% for endovascular treatment (95% CI 1.3–2.5).

PROFESSOR VALERIA CASO

Stroke neurologist, University of Perugia Stroke Unit, Perugia, Italy However, countries with the highest rates reached a proportion of 20% and 6% of treated patients, respectively, for intravenous thrombolysis and endovascular treatment.

“Despite scientific evidence and clinical guideline recommendations, these data show too many patients are not treated in stroke units and centres that can offer the best evidence-based treatment in the acute phase,” Caso maintains.

Building strong relationships

One of the ways that the stroke community is tackling the major concerns in acute ischaemic stroke treatment is focusing on the multidisciplinary approach and building strong relationships among the different specialties involved in stroke treatment. Caso explains that the benefit of recanalisation therapies in patients with acute ischaemic stroke is strongly dependent on multidisciplinary collaboration and time. Stroke care systems should, therefore, minimise the time to assessment and initiation of treatment before brain injury becomes irreversible. This goal can only be achieved if stroke specialists and neurointerventionalists act as a team. This collaboration is already standard of care in many stroke centres in Europe, and therefore it was important to structure this collaboration at the society levels.

This began in 2016 when the ESO’s General Secretary, Prof Urs Fischer from Bern, Switzerland, proposed the creation of the European Alliance for Endovascular Stroke Treatment formed of ESO, ESMINT, EAN and SAFE, and suggested that this alliance should meet during the preconference day in ESOC (the European Stroke Organisation Conference).

“I was enthusiastic about his idea, and I supported this immediately together

with Kennedy Lees who was still ESO president at that time. Moreover, I had the opportunity to participate at the ESOWinter School where Urs Fischer and Jan Gralla organised meetings with the leading European neurointerventionalists.

Since then we meet every year at ESOC to discuss implementation actions in endovascular treatment throughout Europe.

The first action was the multi-society survey in Europe which was published in the European Stroke Journal. Additionally, we have joint sessions at ESO and ESMINT annual conferences, and what is much more important, we collaborate on joint guidelines on thrombectomy. Currently, as past president, I will continue to be part of the endovascular taskforce,” Caso explains.

The benefits of these close working relationships between the disciplines lie in the fact that clinical decision-making for large vessel occlusion patient selection for thrombectomy is a complex and multifactorial process which needs to be performed by stroke specialists and neurointerventionalists at hyperacute and acute stages of stroke care. Clinical variables commonly considered include measures such as age, pre-stroke baseline functional status, and comorbidities, clinical stroke severity at presentation and time from last seen normal. Radiographic variables include measures of established core infarct on initial brain imaging brain tissue at risk of ischaemic damage (clinical-radiological mismatch or perfusion-based mismatch) and collateral status. To select the right patient for the right treatment and to speed up these specialists need to work together.

“The collaboration is not only for the selection of patients but also for the management during and after the endovascular treatment as the results of the ‘big five RCTs’ were only possible since included patients were managed in specialised stroke units,” Caso says.

ACUTE ISCHAEMIC STROKE

COLLABORATION IS KEY IN THE FUTURE OF ACUTE ISCHAEMIC STROKE

The role of the wider community

To address the burden of stroke, it falls not only on the stroke teams, but also the wider community involved in stroke care. A good example of this is the Angels Initiative which seeks to increase the number of patients treated in stroke-ready hospitals and to optimise the quality of treatment in all existing stroke centres. The European Angels Initiative, which was launched

by Boehringer Ingelheim and is aiming

3

to develop a community of at least 1,500 stroke centres and stroke-ready hospitals across Europe by May 2019. Angels is registered as a support of healthcare project according to Section 11.1 of Article 11 of the EFPIA HCP Code.

As ESO fully shares the declared objectives outlined in the Angels Project, the Executive Committee of ESO has agreed to endorse this initiative formally.

During ESOC 2017, it was announced that Medtronic had joined the Angels Initiative.

This project is now one of the pillars of ESO-activities.

In November 2016, the Registry of Stroke Care Quality (RES-Q) was launched as an ESO programme to provide a tool for monitoring the quality of stroke care. This project is led by Prof Robert Mikulik and Veronika Svobodova from the International Clinical Research Center (FNUSA-ICRC) St Anne’s University Hospital Brno Stroke Research Group. RES-Q collects internationally recognised quality of care metrics, based on “Cross-national key performance measures of the quality of acute stroke care in Western Europe”. After the first year of operation, feedback was gathered from all participating sites, and an updated version of the RES-Q questionnaire was decided on by both the ESO-EAST steering committee and national steering committees. Collection of quality of care metrics has been promoted by both ESO programmes as well as the Angels Initiative.

In this registry, more than 50,000 patients are enrolled in RES-Q (www.qualityregistry. eu). Over the past few years, there was a clear trend in the increase of endovascular treatment (see graph on page 5).

As for the importance of these types of initiatives, Caso explains how valuable it is to work closely with industry partners: “To best face stroke, we need a joint action of all stakeholders involved in stroke care which include ministries of health, other governmental bodies, scientific and stroke support organisations, healthcare professionals, clinical and preclinical researchers, and the pharmaceutical and medical device industry.”

Currently, in ESO there are several quality improvement projects with industry: 1. ESO-EAST “Enhancing and Accelerating Stroke Treatment.”

The ESO-EAST project, supported by independent and unrestricted educational grants from EVER Pharma and Boehringer Ingelheim, is a fiveyear collaboration uniting selected physicians from Eastern Europe with the aim and harmonising stroke care throughout that region.

2. The Angels Initiative is to increase the numbers of patients treated in stroke-ready hospitals and to optimise the quality of treatment in all existing stroke centres which supported by Boehringer Ingelheim and Medtronic.

44

3. The Quality in Acute Stroke Care (QASC), a nurse-initiated evidencebased stroke care project to manage fever, hyperglycaemia and swallow difficulties following an acute stroke.

Results showed that supported implementation of the Fever, Sugar, Swallow (FeSS). QASC is organised in collaboration with the Nursing Research Institute St Vincent’s Health Australia, Sydney – Australian Catholic University and Angels Initiative.

Standard of care—From phase I to V

The standard of care in ischaemic stroke, Caso explains, are thrombolysis, thrombectomy, hemicraniectomy, early secondary prevention, and dedicated care.

These treatments are only possible within a stroke unit care setting where patients are more likely to survive, be independent, and living at home at one year after stroke, without any observed systematic increase in the length of inpatient stay. Stroke unit care also includes comprehensive rehabilitation, which has been shown to contribute to better outcome and improved disability.

Stroke unit care treats stroke as an acute brain disease, by focusing on the assessment of neurovascular features. By treating stroke as a brain disease over the past 20 years, we have been able to organise a more coherent and effective approach to treatment, leading to improvements across all age groups and sex.

Stroke is a continuum of care from stroke awareness to acute treatment and life after a stroke. “We, as stroke specialists, need the collaboration of the population to recognise stroke symptoms, the emergency physicians to speed up the whole treatment chain together with the neurointerventionalists.

Moreover, acute stroke care includes skilled nursing care and rehabilitation specialists for occupational, physical, and speech and language therapy, with input from psychologists and social workers as necessary. This whole process should then continue in a multidisciplinary approach

from stroke unit to an ordered plan for discharge from hospital with documented responsibility for continuing rehabilitation needs in the community,” Caso maintains.

To structure this chain of treatment, in 2016, Caso, together with Prof Bo Norrvind, came up with the idea to update the 2006 Helsingborg Declaration on stroke strategies and targets in Europe, on behalf of ESO in cooperation with SAFE. The new initiative was named “European Action Plan for Stroke in Europe 2018 to 2030.” Therefore, the format of the previous Helsingborg Declarations was partially renewed including core supporting evidence as well as indications on the level and disparities in current stroke services. The documents include the WHO Global Action Plan on Non-communicable Diseases (NCDs) 2013–2020 that followed the United Nations (UN) Declaration Meeting on NCDs 2011, and the UN Declaration On Sustainable Development Goals (SDGs) released at the UN General Assembly in September 2015.

The Action Plan was organised in seven domain groups (two more than the 2006 edition): 1. Primary prevention 2. Organisation of stroke services 3. Management for acute stroke 4. Secondary prevention and organised follow-up 5. Rehabilitation 6. Evaluation of stroke outcome and quality assessment 7. Life after stroke In the ESAP, four overarching targets were identified: 1. To reduce the absolute number of strokes in Europe by 10%.

2. To treat 90% or more of all patients with stroke in Europe in a dedicated stroke unit as the first level of care.

3. To have national plans for stroke encompassing the entire chain of care from primary prevention to life after stroke.

4. To fully implement national

ACUTE ISCHAEMIC STROKE

strategies for multisector public health interventions to promote and facilitate a healthy lifestyle, and reduce environmental (including air pollution), socioeconomic, and educational factors that increase the risk of stroke.

Post-stroke monitoring

While a lot of attention is being paid to how best to treat patients directly following a stroke, focus is also being placed on poststroke monitoring and secondary stroke prevention. The introduction of long-term cardiac monitors is leading to changes in routine post-stroke management. Studies including the Cryptogenic Stroke and

Underlying AF (CRYSTAL-AF) trial and the 30-Day Cardiac Event Monitor Belt for Recording AF After a Cerebral Ischemic Event (EMBRACE) trial have shown that prolonged cardiac monitoring provides a higher probability of AF (atrial fibrillation) detection than the standard approach.

In CRYSTAL AF, an implantable loop recorder was used for up to three years, with a detection rate at six months of 8.9%, which increased to 12.4% at 12 months.

In EMBRACE, an external loop recorder was employed with a detection rate at 30 days of 16.1% if the patient does have occult and undetected AF and is indeed at high risk of future stroke. ReveaLinQ is a tool to identify the cryptogenic stroke

population at highest risk of developing AF. Several studies have examined clinical, cardiac, and radiological predictors of detection of atrial fibrillation. Age, the PR interval on ECG, premature atrial/ ventricular contractions, left atrial enlargement, the pattern of acute strokes on diffusion-weighted imaging, and the presence of silent ischaemic lesions on MRI have been reported to increase the likelihood of finding AF. After the results of the ESUS (Embolic Stroke of Unknown Source) trials where no efficacy was shown for rivaroxaban and Dabigatran in ESUS patients, we need to identify those patients with AF who clearly benefit from anticoagulation, Caso says.

REIMAGINING THE ACUTE ISCHAEMIC STROKE CARE CONTINUUM Now that the approach to the treatment of acute ischaemic stroke has evolved, the new challenge lies in the most efficient ways to do so. In this interview, Natalia Perez de la Ossa speaks to NeuroNews about what is being done to streamline the care continuum in terms of pre-hospital organisation, comprehensive versus primary stroke care centres, and the technology that should be used to ensure a rapid decision-making process.

What is the aim of the RACECAT trial?

The RACECAT trial aims to elucidate the following important question: for acute stroke patients with suspected large vessel occlusion (LVO) identified by emergency medical services in the field based on a RACE score of 5 or more, does direct transfer to an endovascular stroke (mother ship) compared to transfer to the closest

local stroke center (drip and ship) increase the likelihood of good outcome at three months?

The RACECAT trial design is based on a cluster randomised design, where patients that live in areas of Catalonia not covered by an endovascular centre are assigned to one of these two transfer options. The main outcome is a shift analysis of the Rankin score at three months, that is evaluated by a

DR NATALIA PEREZ DE LA OSSA

Stroke neurologist, Hospital Germans Trias i Pujol, Barcelona, Spain 5

blinded investigator through a phone call.

Secondary outcomes will analyse the differences on the rate of endovascular treatment, times from onset to recanalisation, and one of the most important questions, if benefit of a mother ship transfer protocol depends on particular factors related to the patient (as time from onset or eligibility for IV t-PA) or to the geographical circumstances (as the additional time to be transferred to an endovascular centre). We know from previous studies that patients living in remote areas that are transferred from referral centres based on a drip and ship paradigm have three times less opportunities to receive endovascular treatment, and time to treatment is about two hours longer since inter-facility transfers are time consuming.

Thus, a mother ship paradigm may improve their outcomes.

On the other hand, we do not know if we can properly select patients as candidates for endovascular treatment in the field, since pre-hospital tools to identify LVO patients are not specific enough and include about 50% of patients with non-LVO. Long transfers may be risky for haemorrhagic stroke patients and may confer a delay in the delivery of IV t-PA, that may be deleterious, especially in patients with no LVO. Thus, the results obtained in the RACECAT study will help the decision making process at the pre-hospital level regarding which transfer protocol is better for patients with a suspected LVO, and will guide decision makers about how to organise territories regarding access to endovascular treatment.

What is the status of the trial at the moment?

We started the RACECAT trial in March 2017. So far, a total of 769 patients have been included. Thanks to the collaboration of all EMS professionals in the entire region of Catalonia, the EMS coordinator centres and all the site investigators, and thanks to the support from Medtronic that is funding the study with an unrestricted grant, the progress of the trial has been excellent. The recruitment rate has been as expected, with about 40 patients per month. The screening log shows a very low rate of missed patients not included in the study and the adherence to the protocol, entering and monitoring data and followup, has been satisfactory.

Can you share any of the results of the study at this time?

Unfortunately, we do not have efficacy results at the moment. What we can say from the two safety analysis evaluated by the external DSMB after the first 100 and 400 patients is that there are no concerns related to safety. Currently, we are finishing the follow-up of the first 701 patients that will be included in the

66

first interim analysis of efficacy. In early 2019, the DSMB will receive this interim analysis and will give recommendations about the need to stop the trial if results are consistent or if we may continue the study until the second interim analysis that will be made after 1,228 patients. The total sample size is projected for 1,754 patients, but we hope to obtain results before achieving this number.

What do you believe should be the top focus areas to treat stroke patients in the current era?

One of the main problems is that many patients are still arriving too late to be recanalised, so we must focus on how to improve access to treatment, for example, in stroke patients with no witness or wake-up strokes. New technology may help in the rapid detection and alert of these patients. Another important area of research is neuroprotection, as it may help to maintain reversible tissue in the first hours, trying to minimise the number of patients with large infarct core, and also avoid reperfusion damage after recanalisation. It is also important to improve the current rate of complete recanalisation, for example by adding thrombolytic agents to current recanalisation techniques or developing other devices more effective for resistant thrombus. On the other side, we cannot forget the importance of secondary prevention to avoid vascular recurrences and complications related to anticoagulants, as well as searching new strategies to a better control of vascular risk factors.

Are there any guidelines for the pre-hospital organisation for stroke treatment? If so, what are the main recommendations?

Guidelines and recommendations are usually based on high level of evidence data, that actually is very scarce regarding pre-hospital organisation. The European Academy of Neurology and European Stroke Organization published a consensus statement and practical

guideline for pre-hospital management of stroke (Eur J Neurol 2018). Most of the recommendations are based on low quality of evidence, and mainly refers to performing educational public campaigns, implementing stroke code protocols with highest priority dispatch, pre-notification and rapid transfer to a ‘stroke-ready’ centres, or using EMS tools to identify acute stroke patients. However, there is not enough evidence about other innovations, such as using LVO scales, using biomarkers or neurosnology or other technology to distinguish between ischaemic, haemorrhagic and mimic stroke, implementing pre-hospital telemedicine systems or giving neuroprotective agents. There is room for investigation and innovation in this field. Regarding bypass protocols, some scientific societies recommend doing a mother ship transfer bypassing the local hospital for patients with suspicion of an LVO if additional time is no longer than 15–30 minutes. However, this cut-off is arbitrarily established and more evidence is needed to make strong recommendations.

What is the main priority in terms of pre-hospital organisation for stroke treatment?

In my opinion, health systems of care must concentrate its efforts on offering the more effective treatment to patients.

Thinking on endovascular treatment, in my opinion, the main priority is to implement LVO scales to triage patients that may benefit from a mother ship transfer, or at least, from a rapid drip-and-ship protocol prioritising inter-hospital transfer and shortening door-in door-out times. Many LVO scales have been proposed, showing similar accuracy. We recommend the RACE scale because there is evidence demonstrating its applicability in the real world, since it is the only one that has been validated in the field in a large cohort of patients. Another advantage is that the RACE scale gives a range of scores, so it allows for implementing a by-pass protocol by choosing a moderate score (RACE 5 or more) or being more conservative by choosing a higher score and avoiding so many false positives. Other scales are based on dichotomised result, so it is not possible to increment their specificity by using different cut-off points.

Implementing an LVO tool is not difficult or expensive, and may offer great benefit by shortening time to reperfusion and offering access to endovascular treatment to a higher amount of candidates. Interest in the implementation of mobile stroke units is increasing around the world. In my opinion, it may be a good solution for particular areas but its implementation and global impact is limited by the logistics and costs. Other future priorities are to improve pre-hospital LVO diagnostics by

In terms of setting up prehospital organisation, who should be involved?

Pre-hospital organisation is one of the most complex steps in the chain of stroke care.

It involves a lot of professionals that must be very sensitive to identify acute stroke patients, assure their clinical stabilisation and be quick in the decision making about where to transfer the patient, all of this performed on an emergency environment.

As if that was not enough, after the overwhelming evidence of the benefit of endovascular treatment over IV t-PA, stroke code protocols must be reorganised with the aim of offering the best treatment to each patient, so the next step is requesting our pre-hospital systems to be able to identify patients with a suspicion of an LVO or, in some cutting-edge regions, even being prepared to offer the first-step attention and starting IV t-PA in mobile stroke units. This challenge requires efforts in training EMS professionals (EMS technicians, paramedics, nurses and physicians) and requires a high level of coordination and protocolisation in order to be effective. Coordination is an art, and in my opinion is the most difficult aspect of health systems of care. Success is only possible if it is done based on working groups with members of all the levels of care, working all together to achieve goals and to obtain data about the progress and outcomes, that are very important to maintain motivation and implication of all the people involved. Moreover, only a strong pre-hospital structure allows the advance in innovation and research.

Implementation of the RACE scale in Catalonia and the RACECAT trial are some examples: it could not have been possible without the collaboration of a very specific working group with members of EMS, hospitals and health agencies.

What can be done to accelerate the process of getting the necessary infrastructure in place?

The first step is to analyse the current situation in each geographical area in order to detect the bottle-necks, by identifying all the stroke centres, analysing the flows of patients and times, and accelerating the process. It is not easy to generalise a particular experience from one region

Rapid Arterial oCclusion Evaluation (RACE) Scale An EMS Assessment Tool for Acute Ischemic Stroke (Sensitivity 85%, Specificity 68%)

TEST ITEM

SCORE = 0

SCORE = 1

SCORE = 2

Facial Palsy

Absent

Mild

Moderate/Severe

Arm Motor

Normal/Mild

Moderate

Severe

Leg Motor

Normal/Mild

Moderate

Severe

Head/Gaze Deviation

Absent

Present

N/A

Aphasia* (if right hemiparesis)

Performs Both Tasks

Performs 1 Task

Performs Neither Tasks

Agnosia+ (if left hemiparesis)

Patient Recognises Arm and Impairment

Unable to Recognise Arm or Impairment

Unable to Recognise BOTH Arm and Impairment

PATIENT SCORE

ACUTE ISCHAEMIC STROKE

using new technology such as as portable ultrasound or volumetric impedance, and also to develop software to improve the workflow of patients and share data between pre- and in-hospital, using prehospital telemedicine and geolocalisation, and including algorithms to help in the decision-making of where to transfer the patients depending on several factors (patient characteristics, distance or traffic conditions).

TOTAL SCORE = (0–9) *Aphasia: Ask the patient to: 1. "Close your Eyes" AND 2. "Make a Fist" +Agnosia: Ask the patient and evaluate recognition of deficit: 1. While showing paretic arm: "Whose arm is this?" 2. Ask patient: "Can you lift both arms and clap?"

If RACE Score = 5 or greater, patient may have an ischaemic stroke with a large vessel occlusion

to another, since it depends on the geographical and logistical characteristics, EMS transport resources, training level of EMS professionals and so on. For example, it is not comparable to implement a bypass protocol in urban regions where centres are less than 50km away or in rural areas with long distances between centres. However, sharing different experiences is very important to get helpful ideas and explore the feasibility of implementing new ways of thinking and doing things. Creating international committees may help to give recommendations that could be widely applied.

Should focus be placed on implementing comprehensive stroke centres or primary stroke centres? Why? In my opinion, it is obvious that new comprehensive stroke centres are needed.

International and European data show that overall, less than 2% of ischaemic stroke patients receive endovascular treatment, although in some countries this rate rises to 5%. One of the limitations for treating patients is the delay in the access to an endovascular centre, even if a mother ship protocol is established. Thus, endovascular treatment must be close to population and it is necessary to open comprehensive stroke centres with well trained and experienced neurointerventionalists and stroke teams. However, primary stroke centres are also necessary to offer acute attention to stroke patients who are not candidates for endovascular treatment and to receive patients treated at endovascular centres that need specialised sub-acute care. The question is more how to organise and coordinate the network between local centres—primary or telestroke—and comprehensive stroke centres, assuring an effective flow of patients, more than promote one or another.

Is CT appropriate for the assessment of eligibility for endovascular treatment?

Based on current evidence, CT with vascular imaging is the preferable imaging technique for patients within the first six hours. Very few patients within this time window have unfavourable imaging. In my opinion, it is not justified to spend time doing more advanced imaging on these patients, but to accelerate groin puncture and recanalisation.

Advanced neuroimaging make sense in patients that arrive in longer time windows, beyond six hours or unknown time of onset, in which the evidence in favour of thrombectomy is strong, but for the moment it is based on strict selection imaging criteria base on the DAWN and DEFUSE 3 trials. More evidence will come up soon about the convenience of treating patients with large infarct volume or selected with more basic imaging protocols in long time windows. In my opinion, an easy imaging algorithm is adequate for easy patients, but advance multimodal imaging is useful to indicate treatment in more complex patients, as vertebra-basilar, long time window, low severity despite LVO or fluctuating symptoms, etc.

Does the RAPID software help to integrate the whole stroke team in the diagnostic process?

RAPID software helps in rapid decisionmaking to indicate a revascularisation treatment, especially in patients arriving in long time window. The software offers an objective and validated information about the salvageable tissue in less than five minutes. Having protocols based on this information is crucial to a rapid decision in consensus with all the team, avoiding having discussions and doubts about radiological criteria, that at the end, is wasted time.

7

THE MOST COMPREHENSIVE, CLINICALLY PROVEN PORTFOLIO OF DEVICES AND SIZES

NAVIEN™ INTRACRANIAL SUPPORT CATHETER

CELLO™ BALLOON GUIDE CATHETER

SOLITAIRE™ PLATINUM REVASCULARIZATION DEVICE

FAMILY OF MICRO CATHETERS

AVIGO™ GUIDEWIRE

PROVIDING GREATER CHOICE AND SELECTION FOR ALL AIS APPROACHES. The Avigo™ hydrophilic guidewire is indicated for general intravascular use to aid in the selective placement of catheters in the peripheral and cerebral vasculature during diagnostic and/or therapeutic procedures. The device is not intended for use in the coronary arteries.

The Cello™ balloon guide catheter is intended to temporarily block blood flow by expanding a balloon inside blood vessels during operations, such as: urgent hemostasis, hemostasis for surgery, perfusion of blood to peripheral vessel and arterial injection for chemotherapy.

The Navien™ intracranial catheter is indicated for the introduction of interventional/diagnostic devices into the peripheral, coronary, and neuro vasculature. The Navien™ intracranial catheter is also indicated for the removal/aspiration of fresh, soft emboli and thrombi from selected blood vessels in the arterial system, including neurovasculature.

The Solitaire™ Platinum Revascularization Device is intended to restore blood flow by removing thrombus from a large intracranial vessel in patients experiencing ischemic stroke within 8 hour of symptom onset. Patients who are ineligible for intravenous tissue plasminogen activator (IV t-PA) or who fail IV t-PA therapy are candidates for treatment.

Indications, contraindications, warnings and instructions for use can be found in the product labeling supplied with each device.

UC201907320EE © Medtronic 2018 All rights reserved.

UC201907320EE - NEURO NEWS BACK COVER ADVERT.indd 1

23/11/2018 15:22