Call for improved treatments of stroke

Aug 22 2007

A coalition of physicians representing a wide range of medical specialties has issued a call to action to improve the treatment of stroke.

The group, which includes nationally recognized leaders in neurology, neuroradiology, neurosurgery, vascular surgery, and cardiology, was drawn together by the Society for Cardiovascular Angiography and Interventions (SCAI) to address one of the most pressing medical needs in this country the rapid treatment of stroke using catheter-based techniques.

"The only way to minimize the damage from a stroke is to restore blood flow to the brain and do it absolutely as quickly as possible," said Christopher J. White, M.D., chairman of cardiology at the Ochsner Clinic Foundation, New Orleans, and director of the Ochsner Heart and Vascular Institute. "There is a huge shortage of physicians trained in catheter-based treatments for stroke, and we need to do something about it."

A plan for solving that physician shortage is published online today and in the September 2007 issue of SCAI's official journal, Catheterization and Cardiovascular Interventions (CCI). The document is entitled, "Interventional Stroke Therapy: Current State of the Art and Needs Assessment." Dr. White is editor-in-chief of CCI.

Each year nearly three-quarters of a million people suffer a stroke in the United States. Stroke is the leading cause of disability in this country, and is responsible for 1 in 16 deaths.

The use of clot-busting drugs is a well-established therapy for stroke. However, only about 20 percent of stroke patients are considered eligible for clot-busters and only about 2 percent of stroke patients are actually treated with these medications. In part, this may be due to the narrow timeframe during which clot-busters are safe and effective within just 3 hours of the onset of stroke symptoms. Unfortunately, most patients arrive at the emergency room too late.

Catheter-based treatment, also known as endovascular stroke therapy, has been shown to be effective over a longer time period 6 to 8 hours after the onset of stroke symptoms. Using this approach, a slender tube, or catheter, is threaded from an artery in the groin into the aorta, then up through the carotid arteries in the neck and into the specific artery in the brain that is blocked by a blood clot. In some cases, clot-busting medications are injected directly into the clot in hopes that it will dissolve. More often, a retrieval device with a corkscrew-like tip is passed through the catheter into the clot. When the device is pulled back into the catheter, it brings the clot with it. A stent is also sometimes implanted to prop open the artery.

"Never before have we had the capability to manage this disease with such advanced techniques," said L. Nelson Hopkins, M.D., professor and chairman of neurosurgery and a professor of radiology at the State University of New York, Buffalo. "We need to get that capability broadly disseminated so we can do a better job for stroke patients. Stroke is a disaster for patients, families, and society."

The ranks of those performing catheter-based treatment of stroke are alarmingly thin. There are only 385 interventional neuroradiologists practicing in the United States, according to survey data. In 5 states, not a single physician is available to perform endovascular stroke therapy.

The new document calls for solving this critical shortage by tapping into a group already trained in using catheters to treat carotid artery disease and strokes that occur as a complication of carotid stent placement, a procedure known as neuro-rescue. By adapting and expanding neuro-rescue skills, interventional cardiologists, interventional radiologists, and vascular surgeons could markedly increase the number of physicians available 24 hours a day, 7 days a week, to treat stroke.

This broad-based physician group would bring not only experience in catheter-based techniques to the treatment of stroke, but also a history of rapid triage and treatment of patients with a life-threatening illness. Cardiologists, for example, currently set a target of 90 minutes for treatment of a blocked artery causing a heart attack. That same model could be applied to stroke therapy.

"It just makes sense," Dr. Hopkins said. "Cardiologists have advanced catheter skills, they are accustomed to dealing with blocked arteries on an emergency basis, and they could form multidisciplinary stroke teams that could be activated very quickly when a patient came to the emergency room with a stroke."

The authors of the new document see it as a call to action, and hope it will spark a broad-based movement to form stroke teams capable of providing interventional treatment of stroke 24 hours a day, 7 days a week in communities throughout the nation. According to Dr. White, the ultimate goal is to have a stroke treatment center in every community capable of catheter-based stroke intervention essentially, to offer the same level of care for a brain attack as for a heart attack.

by tapping into the physicians currently performing carotid stenting, we could more than double the number of people capable of performing catheter-based interventional treatment of stroke," Dr. White said. "Once you've seen the need, it's impossible to step back."

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