1 S T CONGRESS OF THE EUROPEAN ACADEMY OF NEUROLOGY
Berlin, Germany, June 20 -23, 2015
Stroke therapy: Thrombectomy confirmed as a safe and efficient
procedure, use "with discretion" specified
Approximately 1.3 million new cases of stroke per year are recorded in Europe – with a rising tendency.
There is increasing scientific evidence to support thrombectomy – the mechanical removal of blood clots – as
a safe and efficient procedure in acute therapy. Experts at the Congress of the European Academy of
Neurolgy in Berlin are discussing which patient groups might profit most from the new procedure and what
current insights stroke research provides for other fields.
Berlin, 22 June 2015 – Stroke is among those neurological disorders which are developing into an increasingly
widespread disease: A total of more than 8.2 million persons in the EU are affected; around 1.3 million new
cases are recorded every year – with a rising tendency due to demographic developments, since the illness is
more common in old age. „Medicine is making major advances in the prevention, therapy and rehabilitation of
stroke. Nonetheless, this disorder still poses major challenges to us“, EAN Vice President Prof Franz Fazekas,
Medical University Graz, stated at the 1st Congress of the European Academy of Neurology (EAN) in Berlin.
More than 6,500 experts from all over the world are discussing current trends in their field from 20 to 23 June
in the German capital city.
Good efficacy and safety for selected patient groups
„Among the most important developments in acute stroke therapy is the increasing scientific evidence
regarding the mechanical removal of thrombi from the brain vessels“, Prof Fazekas reported. Recently
published study results not only document the high efficacy and safety of thrombectomy, but for the first time,
they also show its superiority to standard thrombolysis therapy in specific patient groups. „The procedure
makes sense particularly in large thrombi which cannot be dissolved, or can only be partly dissolved with
pharmacological therapy, and which occlude large brain supplying blood vessels“, Prof Fazekas stated. „The
advances of the new method are indeed promising, but it is clear that mechanical thrombectomy cannot
restore circulation in all affected persons either. Revascularisation is ineffective if brain tissues have already
died. The challange will be to apply the procedure specifically in those patients who can profit from it und to
provide the organisational structures and workflows necessary for this complex type of treatment.”
Recommendations by European associations
It is precisely for this purpose that the relevant European medical and scientific associations1 are preparing a
joint recommendation on thrombectomy, which is intended to ensure that this innovative procedure will be
utilised with the greatest possible benefit for patients. Discussions so far indicate that thrombolysis remains
the main treatment for acute ischaemic strokes. „In occlusions of large brain vessels, however, it should be
complemented by thrombectomy. If intravenous thrombolysis is contraindicated, thrombectomy undoubtedly
represents the first line treatment option in large vessel occlusions", Prof Fazekas said. „Old age alone should
not be a reason to withhold this procedure from patients. If the brain has already suffered significant previous
damage, however, or in the case of large infarcts and severe damage of other organs, its use may not lead to
the desired results.”
Regarding technologies, efficacy data is available mainly for stent retrievers. The use of other systems depends
on the respective situation and requires case-by-case assessment. „The time factor is important for the
outcome. Thrombectomy should be performed within a maximum of three to six hours. However, the earlier
the intervention is performed, the better the treatment results“,Prof Fazekas stated.
Multidisciplinary cooperation in acute stroke therapy is a key factor for success. The decision to undertake
thrombectomy should always be made by a team which includes at least a clinical and an interventional stroke
specialist. In many European countries, the team is coordinated by a neurologist who is responsible for
differantial diagnosis and other therapeutic steps. „Not only clinical, interventional or neuroanaesthetic
1
European Stroke Organisation, ESO; European Society of Minimally Invasive Neurological Therapy, ESMINT; European Society of
Neuroradiology, ESNR; European Academy of Neurology
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1 S T CONGRESS OF THE EUROPEAN ACADEMY OF NEUROLOGY
Berlin, Germany, June 20 -23, 2015
experience are most relevant for successful thrombectomy; imaging also plays an important role, for example
in determining the vessel occlusion, the size of the stroke or the penumbra size to identify suitable patients“,
Prof Fazekas explained. Aside from multidisciplinarity, specialisation is also an important factor. Thrombectomy
should only be performed at specialised stroke centres. In this regard, experts call upon health policy makers to
ensure comprehensive coverage with such centres so that stroke patients have timely access to thrombectomy
when needed.
Thrombolysis has established itself throughout Europe
Despite the latest developments in the field of mechanical thrombectomy, intravenous thrombolysis (IVT) still
remains a central instrument in acute stroke treatment. „An important new trend in this respect is that we are
treating more and more patient groups with thrombolysis, and specifically penetrate higher age categories“,
Prof Fazekas emphasised. „This development should be undertaken with care and consideration.“
A Portuguese study presented at the EAN Congress shows that therapeutic limits are being pushed in various
directions. The results suggest that individual patients may benefit from intravenous thrombolysis even when
relative contraindications such as cancer, dementia or a recent myocardial infarction exist.
Intravenous thrombolysis has meanwhile become established throughout Europe – successfully, as shown by a
French-Serbian study presented at the EAN Congress: The outcome of IVT was investigated in around 250
stroke patients with atrial fibrillation in Lille and Belgrade. Despite the differing socio-economic prerequisites,
the procedure is bringing about comparably good treatment results in both countries and centres. Patients
from Belgrade were ten years younger, more likely to be male and more often smokers. Prof Fazekas: „It is
good news that treatment quality shows comparable parameters in very different countries – a concern which
we at the EAN pursue across all sectors.”
Implanted event recorders discover atrial fibrillation
There are important developments in stroke prevention as well. Atrial fibrillation is among the most common
causes of a severe stroke. It is important to identify this condition because patients exposed to this risk factor
need to receive anticoagulant treatment where novel oral anticoagulants (NOACs) have also opened extended
treatment options. New data indicates that atrial fibrillation may be responsible for strokes far more frequently
than previously assumed.
It can be difficult to identify intermittent atrial fibrillation in stroke patients because it may be easily missed
with ECG recordings only. New monitoring systems have a lot of potential, as indicated by a US study presented
at the EAN Congress. Prof Fazekas: „In fact, ten out of the 58 patients in this investigation suffered from atrial
fibrillation after cryptogenic stroke – significantly more than one would generally assume. The use of
implantable event recorders is suited to detecting the dangerous cardiac arrhythmias in patients after
cryptogenic stroke.“ At the same time, research teams are trying to identify those factors which are associated
with atrial fibrillation particularly likely, especially in embolic stroke due to unknown sources (ESUS). A study by
French researchers which was also presented at the EAN conference reports special echocardiography findings
which may serve to advance this purpose.
Sources: BrainFacts.org, Brain Disease in Europe, November 2013; Olesen et al.: The economic cost of brain disorders in Europe. European
Journal of Neurology 2012, 19: 1998;101:515-520; EAN-Abstracts: Padjen et al, Effect of intravenous thrombolysis on stroke patients with
atrial fibrillation treated in Lille (France) and Belgrade (Serbia); Alves et al, Intravenous Thrombolysis in “grey areas”; Seiler et al,
Surveillance for Atrial Fibrillation in patients with cryptogenic stroke using an implantable loop recorder in a community hospital setting :
Real world validation of Crystal AF; Sabben et al, Predictors of new onset atrial fibrillation after an ischemic stroke.
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E-mail: kofler@bkkommunikation.com
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