October 29 is World Stroke Day - and stroke therapy is also one of the core topics at the 93rd Congress of the German Society of Neurology (German acronym: DGN). Although stroke mortality in Germany has been halved in the past 15 years, the goal has not yet been reached: DGN Congress President Prof. Dr. Matthias Endres (Charité University Hospital, Berlin) discussed strategies to further reduce stroke mortality. This is possible, he says, by getting more patients to be treated faster, and whenever possible within the 'golden hour'.
A quarter of a million people in Germany suffer a stroke every year. If left untreated, one third of these people would die, one third would have severe disabilities and only one third would be lucky enough to survive the disease largely unharmed. "We can break this 'rule of thirds' with acute therapy. With modern stroke therapy in Germany, we have succeeded in significantly reducing mortality and the proportion of patients who suffer from severe disabilities. We have even been able to halve the mortality rate over the last 15 years," explains DGN Congress President Prof. Dr. Matthias Endres (Charité University Hospital, Berlin). This is a remarkable success, but ultimately only a partial one. "We must now continue to work on further reducing the number of stroke victims and patients with disabilities" Prof. Dr. Endres added.
The expert sees the reason for the success achieved so far in an improved care structure, especially through the creation of stroke units throughout the country, and in the new treatment options. It is now possible to treat patients who come to the hospital after the 4.5 hour window for thrombolysis ("lysis"), that is the conventional therapy with a thrombus-dissolving drug, has expired.
The WAKE-UP study1, which was conducted by the Hamburg Neurological University Hospital (Neurologischen Universitätsklinik Hamburg) , had shown that it is possible to use modern imaging to identify patients who still benefit from lysis after the 4.5 hours timeframe. In addition, if large brain arteries are blocked, the clot can also be removed in specialised centres through catheter surgery. This interventional thrombectomy is particularly helpful in severe strokes, and in some cases is still possible many hours after the onset of symptoms.
"However, the scientific insight 'Time is Brain' still holds true, time plays the essential role in the treatment of strokes and is crucial for the success of the therapy," explains Prof. Dr. Endres, who is the Director of the Clinic for Neurology with Experimental Neurology at the Charité University Hospital, and points out the great importance of comprehensive care.
Prof. Dr. Endres explains the key issue with a timely access: "In order to be able to provide patients with optimal and rapid treatment, a clinic must have a stroke team and the appropriate technology available 24/7, i.e. a neurologist and an interventional neuroradiologist, but also MRI and CT perfusion imaging and an intensive care unit - and it is clear that not every hospital can provide this. What is currently occupying us neurologists is how to get this specialised stroke therapy into mainstream care. The German Society of Neurology and the German Stroke Society are working together on this challenge".
The importance of the time factor is illustrated by a Berlin pilot project: three “STroke Einsatz-MObile” which translates as “Stroke Operation Mobile Unit”, known as STEMOs, are specially designed ambulances equipped with a computer tomograph and a minilab which are currently in use in the capital. An initial evaluation has shown that the rate of patients who can still receive lysis within the 4.5-hour window has increased by up to 40% - and that's not all: "We are also bringing a whole range of patients into the so-called 'golden hour', i.e. we are able to treat them within one hour of the onset of symptoms. These patients then have a high chance of surviving the stroke completely unharmed.
Reaching the 'golden hour' is normally hardly possible, even if the patient dials 112 soon after the onset of symptoms. At least 20-30 minutes usually elapse before the emergency ambulance reaches the clinic, and only then can the comprehensive patient examination with imaging begin. This instead takes place in the STEMO while driving. Patients then arrive at the hospital with the completed diagnosis and thrombolysis can already be started in the ambulance.
As Prof. Dr. Endres reports, a large study has recently been completed which compared the use of STEMO with the regular use in Berlin in terms of treatment outcome. In the course of the study, the outcome of those affected was assessed after three months using the modified Rankin scale (0 points = no complaints, 6 points = death; good outcome after stroke is considered to be 0 and 1). Initial results were presented at the International Stroke Conference (ISC) in the USA and Prof. Dr. Endres explained that the rate of disability and death was significantly lower in patients for whom STEMO was available. "In view of the fact that the care structure in Berlin is extremely high, the distance to a hospital is not far, but better treatment results were nevertheless achieved with the use of STEMO, it shows that every minute counts," the expert said. "We hope that we can convince the cost bearers with our data to have such mobile units available in other German regions as well".
1. Thomalla G, Simonsen CZ, Boutitie F, et al MRI-guided thrombolysis for stroke with unknown time of onset. N Engl J Med 2018; 379: 611-622