Stents, Scans and Stem Cells: Current and Future Stroke Treatment and Research

Transcription

1 Stents, Scans and Stem Cells: Current and Future Stroke Treatment and Research Prof Keith W Muir Institute of Neuroscience & Psychology University of Glasgow Institute of Neurological Sciences Queen Elizabeth University Hospital Glasgow Stroke, big or small, is a medical emergency Time is Brain! 1

2 Educating People to Recognise Symptoms and Act Stroke : Same Symptoms but Different Causes Haemorrhage (10%) Ischaemic (90%) 2

3 Acute Ischaemic Stroke Around 90% of stroke Blocked vessel leads to brain ischaemia(loss of oxygen and nutrients) Tissue progresses to permanent damage at a variable rate over a few hours at most Restoring blood flow (quickly) prevents damage Restoring Blood Supply Saves Brain 3

4 Stroke Units Avoid Bad Outcomes Benefit 4.1% 5.4% 4.7% Number Needed to Treat Cochrane Database of Systematic Reviews 2003 And in Scotland? Proportion of People Alive Turner M, et al. J Neurol Neurosurg Psychiatry 2015;86:

5 What Do Stroke Units Have to Do? 1 Year Disability (modified Rankin Scale) Kalra et al. Lancet 2000; 356; Other Disturbances Affect Outcome In the first 72 hours, did someone have Low Oxygen levels? High Blood glucose? High Temperature? Dehydration? Langhorne et al. Stroke 2000;31:

6 Squeezing the Legs Stops Deep Vein Thrombosis Dennis et al. Lancet 2013, 382: The Benefit (and Risk) of Clot-busting Treatment For every 100 people treated within 3 hours Saver et al. Stroke. 2010;41:

7 The Benefit (and Risk) of Clot-busting Treatment For every 100 patients treated with IV rtpa within 3 hours Recanalisation of occluded blood vessel with IV rtpa The Downside of Recanalisation: Intracerebral Haemorrhage Saver et al. Stroke. 2010;41: Why Do We Say Time is Brain? 10 minutes delay = 1 month life lost Chances of Good Recovery Window 1.5h 1.5-3h 3-4.5h 4.5-6h NNT Emberson et al. Lancet 2014;384:

8 If You Think You Have Longer, You Take Longer Time from Arrival at Hospital to Treatment Time from Symptom Onset to Hospital Arrival Saver et al. Stroke. 2010;41: Changing Practice and Behaviour in Hospitals: Helsinki Experience Meretoja et al. Neurology 2012;79:

9 Changing Practice and Behaviour in Hospitals: Helsinki Experience Meretoja et al. Neurology 2012;79: Changing Practice and Behaviour in Hospitals: Helsinki Experience In Glasgow? Limited No No Yes No Yes Yes No No No No No Meretoja et al. Neurology 2012;79:

10 Big Clots Respond Poorly to Drug Treatment Chance of opening artery with drug treatment alone MCA M3 66% ICA 9% MCA M1 35% MCA M2 54% Del Zoppo et al Ann Neurol 1992;32:78-86 Removing Large Clots Physically Gralla et al. Stroke 2012;43:

11 Clot Removal in Action Gralla et al. Stroke 2012;43: MR CLEAN: Effect of clot removal on recovery Berkhemer et al. New Engl J Med 2015;372:

12 The PISTE Trial: Centres Where the Trial took place HSRC n UCLH + 18 Newcastle Royal Victoria Infirmary + 13 St George's Hospital, London + 12 University Hospital N Staffordshire + 6 Charing Cross Hospital + 5 Salford Royal Hospital + 5 King s College Hospital + 2 Leeds General Infirmary - 2 Nottingham City Hospital + 1 QE Hospital Birmingham - 1 Outcome in the UK PISTE trial 12

13 Can Clot Removal be Done Everywhere? MR CLEAN REVASCAT EXTEND-IA ESCAPE SWIFT-Prime MR CLEAN REVASCAT EXTEND-IA ESCAPE SWIFT-Prime Patients Centres How Representative of Real Life? 13

14 Speed is the Key for Clot Removal Stroke has Many Different Causes A Arteries in the neck B Brain small blood vessels D Don t know (yet) C Cardiac 14

15 Smoking and Stroke Risk O Donnell et al. Lancet 2010: 376; Blood Pressure and Secondary Stroke Risk Rodgers et al. BMJ 1996;313:

16 What Research is Going On? Immediate care Better clot-busting drug treatments? Clot-busting treatment for more people? Other ways of protecting the brain from damage? Treating brain haemorrhages? Prevention Testing which treatments work best when the cause of stroke isn t known Recovery Stem cells Brain stimulation More Reasons Why Patients Are Not Treated with IV rtpa Clinical Anxiety: Are these patients bad enough to warrant any risk? Too Little Information: Timing uncertain, wake-up Barber et al Neurology 2001;56;

17 Can More Brain Scanning Help Decisions? 60 year old man Sudden left sided weakness, but improved by 3 hours after onset Should he be given clot-busting drug treatment? Blood Flow Scan Blood Vessel Scan 17

18 Using an MRI Scanner as a Stopwatch 87% <4.5 hours 13% <4.5 hours Thomalla et al. Lancet Neurol 2011;10: WAKE-UP Trial 18

19 Are There Better Clot-busting Drug Treatments? ATTEST-2: Coming Soon! 19

20 Stem Cell Trials in Stroke and the Media Translation for West of Scotland STEM CELLS JAB 'CURE' FOR STROKE; Scots boffins in world first. 20

21 Some Improvement in Function Even in Chronic Stroke Patients Better Worse Median, range Stroke Treatment in 2016 Stroke is a medical emergency and services are increasingly treating it as such Speed of treatment is the key and hospital services still have a lot of work to do to improve this Clot removal is a major new treatment Trials are exploring a variety of new treatment options We have come a long way but we have a lot further to go! 21