Time is Brain
Regardless of where you are in the world, the most important principle in treating acute stroke is “time is brain”. In 2014, the World Health Organization (WHO) published figures showing 17 million new stroke cases each year of which about six million of these result in death. The World Stroke Organisation (WSO) also says that an estimated 1.9 million neurons can be salvaged with each minute saved in stroke management. This is why rapid treatment is crucial to patient recovery and to subsequent quality of life. A new technology for hospital stroke units could significantly speed up treatment. Recent publications show promising initial results for an “angio-only” workflow.
Today’s standard stroke workflow involves a neurological exam when the patient arrives at the hospital, followed by transfer to either a computed tomography (CT) or magnetic resonance imaging (MRI) facility for a diagnostic brain scan. This determines whether the patient has suffered a hemorrhagic stroke (bleeding in the brain) or an ischemic stroke (an interruption of the blood supply to the brain caused by a blood clot). Depending on the results, the patient might be sent to the angiography suite for treatment. Thrombectomies are becoming an increasingly frequent choice for treating ischemic stroke.
Together, all these steps can put 130 minutes between the patient’s arrival at the hospital and reperfusion of the brain. In order to save time, the first logical step is to bring diagnosis (CT/MRI) and treatment (angio) closer together – ideally into the same room. A combined solution consisting of a CT and an angio system, is starting to attract market attention in this specific field. Angio-CTs provide the potential to save valuable time and are expected to gain traction at stroke centers around the world.
Interventional treatment is the preferred choice in many stroke cases
In recent years, several studies have focused on thrombectomy in stroke treatment. MR CLEAN, a multicenter randomized clinical trail, proved that interventional treatment is the preferred choice in many stroke cases.1 The study comes to the following conclusion: “Our results show that patients with acute ischemic stroke (…) benefit with respect to functional recovery when intra-arterial treatment is administered within six hours after stroke onset. This treatment leads to a clinically significant increase in functional independence in daily life by three months, without an increase in mortality. Our findings stand in clear distinction to those of recent randomized, controlled trials that failed to show the benefit of intraarterial treatment.”
One-stop stroke management with angio-only approach
MR CLEAN and all subsequent trials amply demonstrate the overwhelming efficacy of intra-arterial treatment for acute ischemic stroke. A combined solution might not be necessary in every case, because patients who score highly on the National Institute of Health Stroke Scale (NIHSS) could be taken directly to the angio suite for diagnosis with a cone-beam CT and receive immediate endovascular treatment if necessary. This is why an angio-only stroke workflow opens up new and exciting potential for shortening door-to-groin times. The stroke research group headed by Marios Psychogios, MD, in Göttingen, Germany has produced very promising early results.2
Stroke research group substantially reduces door-to-groin times
The Göttingen team developed and implemented a onestop approach to stroke management which bypasses the usual multidetector CT (MDCT) scan. Patients presenting with an NIHSS score ≥ 7 (as of January 2017) are transferred straight to the angio suite. They are examined with a cone-beam CT and treated by endovascular means in the event of a large vessel occlusion. The Göttingen team
began using the approach with transfer patients back in January 2016. Since most of these patients were treated with thrombolysis during transport to the comprehensive stroke center, repeated imaging was justified to exclude
an intracranial hemorrhage. The next step was to use the approach with direct-admission patients, which the team began doing in June 2016. At first, they only applied it to patients with an NIHSS score ≥ 10. Thirty patients were treated in this way. The findings are currently under review, but the initial experience shows that the team significantly reduced door-to-groin times while successfully differentiating ischemic from hemorrhagic stroke. In January 2017, the team lowered the threshold for onestop management to an NIHSS score of ≥ 7.
Psychogios draws a promising preliminary conclusion:
“We’ve demonstrated to the best of our ability the first stroke patients triaged and treated in the angio suite with one-stop management. The ability to image and treat
stroke patients in the same room without needing to transport them between modalities resulted in a door-to-groin time of 23 minutes, and a door-to-reperfusion time of 59 minutes. Both times are below the recently propagated ideal target intervals of 60 minutes and 90 minutes for door-to-groin and door-to-reperfusion.”
Will angio-only prevail?
Angio-only is a promising approach to optimizing the management of stroke patients. It could soon find itself on equal footing with the established modality, because it benefits both patients and hospital administrators. For patients, faster treatment and short intervals between hospital admission and reperfusion are expected to positively influence clinical outcomes. For hospitals, the angio-only workflow could eliminate patient transfers from conventional CT to the angio suite in many cases. This would make logistics and coordination much simpler – a clear advantage in terms of cost efficiency.
About the Author
Andrea Lutz is a journalist and business trainer specializing in medicine, technology, and healthcare IT. She lives in Nuremberg, Germany.
1Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo A, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015; 372(1): 11-20.
2Stroke Research Group Göttingen (GER). One Stop in Stroke [Internet]. Göttingen (Germany): Stroke Research Group Göttingen; [cited August 2017]. Available from: http://onestopinstroke.eu/.
The statements by Siemens’ customers described herein are based on results that were achieved in the customer's unique setting. Since there is no "typical" hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.