Stroke research, treatment and the need for institutional change

doctor helping woman having a stroke
© iStock/Juanmonino

Fellows of the European Stroke Organisation tell HEQ about Innovation, strategy and gender in stroke treatment

The European Stroke Organisation (ESO) is a Europe-wide NGO, comprising medical professionals, researchers, stroke societies and lay organisations. The primary goal of the ESO is to alleviate the burden of stroke through education, treatment and institutional policy change.

Fellows of the ESO Dr Valeria Caso, Dr Francesca Romana Pezzella, Associate Professor Christine Kremer and Dr Ulrike Waje-Andreassen explain the work of the organisation.

What are the key challenges currently facing the management and treatment of stroke?

Caso and Pezzella: Stroke is the third leading cause of death and the first cause of adult disability in Europe; and projections show that with a ‘business as usual’ approach, the burden of stroke will not decrease over the next decades.

One of the major risk factors for stroke is advancing age. By 2030, the number of people aged 60 and over in Europe is expected to increase by 23%. The total healthcare and non-healthcare related stroke care costs in the EU – an estimated €45bn in 2015 – are set to rise.

Current evidence clearly shows that Stroke Units care improves patients’ outcome in terms of both mortality and disability independently of stroke severity, age and sex. The Stroke Unit is defined as a dedicated ward staffed with a multidisciplinary team, where both medical and nursing stroke protocols are put in place to prevent and manage complications and stroke recurrence and to start the neurorehabilitation process. Moreover, highly specialised revascularisation treatments such as intravenous thrombolysis and thrombectomy are delivered in these centres.

Unfortunately, access to this high standard of care is not uniform throughout the WHO-defined Europe.

In fact, based on a 2016 European survey, the estimated mean number of Stroke Units was 2.9 per one million inhabitants, while thrombolysis treatment was accessible for less than 7.3 % of patients across Europe; and only 1.9% of all acute ischemic stroke patients in Europe received thrombectomy – well below the European Stroke Organisation’s targets above 15% and 5%, respectively.

These low treatment delivery rates are even lower in areas where universal healthcare system does not exist or where the establishment of Stroke Units is not a recognised priority.

How can public policy be updated to alleviate the burden of stroke and reduce the number of stroke-related deaths?

Caso and Pezzella: To reduce the burden of stroke, the European Stroke Organisation has prepared the European Stroke Action Plan for the years 2018 – 2030, in cooperation with the European Patient Organisation (SAFE).

The European Stroke Action Plan provides policymakers with a list of actions, targets, and other recommended interventions to improve upon the efficacy of primary and secondary prevention, care in acute and rehabilitation settings, and life after stroke by involving lay patient groups.

The European Stroke Action Plan includes seven domains: primary prevention; organisation of stroke services; management of acute stroke; secondary prevention; rehabilitation; evaluation of stroke outcome and quality assessment; and life after stroke. Research priorities for translational stroke research were also identified.

Specific targets are being set for each domain. Beyond these specific targets, four overarching targets for 2030 have been identified:

  • To reduce the absolute number of strokes in Europe by 10%;
  • To treat 90% or more of all patients with stroke in Europe in a dedicated stroke unit as the first level of care;
  • To have national plans for stroke encompassing the entire chain of care from primary prevention to life after stroke; and
  • To fully implement national 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.

The Stroke Action Plan for Europe 2018 to 2030 aligns to the WHO Global Action Plan on NCDs 2013-2020, the WHO-Europe NCD Action Plan, and the UN Sustainable Development Goals 2015 to 2030, providing a clear road map that has the potential to change drastically, from a European perspective, one of today’s and tomorrow’s major public health issues.

Since May 2019, the first steps on implementation were initiated by appointing an implementation committee which will be in charge until 2021, working on the following steps:

  • Definition of the strategy framework (ministries of health, other governmental bodies, scientific and stroke support organisations, healthcare professionals, clinical and preclinical researchers, and the pharmaceutical and device industries);
  • Definition of the Key Performance Indicators (KPIs) for monitoring the quality of care and reaching targets; and
  • Definition of the dissemination strategy.

The steering committee is responsible for collaborating with European quality registers, setting up a network of national stroke societies; and advocacy work.

Are there any notable developments or current issues in stroke research or treatment which you would like to highlight?

Caso and Pezzella: In the last 20 years, we have informed the population about stroke prevention and treatment, focusing on the importance of timeliness of the intervention. ‘Time is the brain’ has been the stroke neurologist mantra.

The restricted time window for thrombolysis and thrombectomy has foreclosed access to revascularisation therapy for stroke victims who had a stroke at wake up, as well as to those with an unwitnessed onset of focal neurological deficits. The vascular neurology scientific community has engaged the wake-up stroke rebus since the early days of reperfusion therapy trials.

The WAKE–UP stroke trial has successfully demonstrated that in patients with acute stroke with an unknown time of onset, intravenous alteplase guided by a mismatch between diffusion-weighted imaging and FLAIR in the region of ischemia resulted in a significantly better functional outcome than placebo at 90 days.

More recent endovascular studies – the DAWN study and the DEFUSE 3 – have shown that perfusion-based imaging can show potentially viable brain tissue beyond the 4.5-hour mark in patients with large vessel occlusions and result in good neurologic outcomes.

Specifically, among patients with acute stroke who had last been known to be well 6 to 24 hours earlier and had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone. For patients who are arriving late to the hospitals, the concept of ‘time is brain’ shifts towards ‘brain is imaging’, offering these patients the best available acute treatment option.

However, this treatment window extension applies only to selected cases where the brain tissue metabolic state and collaterals extend the viable tissue duration, and the selection of those cases requires advanced and costly 24/7 neuroimaging techniques that are not available in all European countries.

Tell me about the goals of the ESO’s Women Initiative for Stroke in Europe (WISE) – how does stroke affect women differently to men and what are the key factors affecting the treatment of female stroke patients?

Kremer: Due to their longer life expectancy and a general older population more women than men will suffer a stroke in the future. Women show a worse outcome after stroke. This is partly explained by their higher age and different stroke aetiology, with more frequent and more severe strokes due to atrial fibrillation; but even adjusting for these factors, women fare worse.

Regarding acute stroke therapies, women tend to arrive later with the risk of being beyond the time windows for acute stroke therapies such as IV thrombolysis and thrombectomy, and in some countries do not have the same access to acute stroke treatment as men do. In the post-stroke period, women show more signs of post-stroke depressions and can have worse rehabilitation results.

The goals of ESO WISE are to identify risk factors more common in women with a focus on secondary prevention and to prevent stroke in women, and to ensure women and men have the same timely access to acute treatment. In the post-stroke period, occurrences of depression should be adequately treated, and special rehabilitation efforts should be addressed.

Women are underrepresented in clinical trials, contributing to less optimal prevention and treatment for stroke in women. Stroke research on sex-specific risk factors and treatment should be encouraged: WISE supports trials on research on stroke in women, including a recent trial on stroke in pregnancy and the postpartum period.

What are the key benefits of ESO’s Stroke Unit Certification programme for patients and healthcare providers?

Waje-Andreassen: As the chain of stroke care from acute intervention to rehabilitation and annotation of outcome is very long, the certification criteria are meant as a tool for collaboration with local leaders and health authorities to improve the quality of patient care as European benchmark for quality of stroke management.

As numbers of patients are related to the type of diagnostics and numbers of available personnel in the stroke team, certification means that the hospital has a cohesive clinical team with a strong quality of providing stroke care. This should also strengthen community confidence in quality and safety of care, diagnostics and treatment.

Authors

  • Valeria Caso, MD, PhD, ESO Past President Stroke Unit, Perugia, Italy
  • Francesca Romana Pezzella, MD, PhD, BSc, MBA Co-Chair (ESO) Stroke Action Plan Implementation Committee Stroke Unit, AO S Camillo Forlnini, Rome, Italy
  • Christine Kremer, Associate Professor Chair, WISE Neurology Department, Skåne University Hospital, Department of Clinical Sciences, Lund University, Jan Waldenströms Gata 15 20502 Malmö, Sweden
  • Ulrike Waje-Andreassen MD, PhD, Professor of Neurology Chair, ESO Stroke Unit Committee Centre for Neurovascular Diseases, Department of Neurology, Haukeland University Hospital, N-5021 Bergen, Norway

European Stroke Organisation
esoinfo@eso-stroke.org
https://eso-stroke.org/

Please note, this article will appear in issue 12 of Health Europa Quarterly, which is available to read now.

 

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