Stroke in Europe

Brugge. Nov. 28th, 2013

Stroke in Europe

___________________________________Disclosures : • No stocks from pharmaceutical / device companies. • No travel paid by pharmaceutical /device companies. • Participation during the last 5 years to trials, advisory boards, or symposia sponsored by Sanofi Aventis, BMS,

Astrazeneca, Boeringher-Ingelheim, Servier, Ebewe, CoLucid Pharm, Brainsgate, Photothera, Lundbeck, GSK, Bayer and Allergan (honoraria paid to Adrinord).

• Served as editor of the Journal of neurology, neurosurgery and psychiatry until 2010 (personal incomes).

Prof. Didier LeysUniversity Lille North of France

Department of NeurologyStroke centre

Background

• Stroke: major public health issue

– Frequent – Important killer– Often leave patients with residual disability– High risk of delayed complications– Most are preventable– Many are treatable– Leads to important direct and indirect costs

Types of strokes

• Ischaemic strokes

Large-vessel atherosclerosis Cardio-embolism Small-vessel occlusion Other definite causes Unknown and undetermined

Types of strokes

• Intra cerebral haemorrhages

Deep- Lipohyalinosis +++- Focal lesions (tumours, AVM, cavernomas …)

Lobar- Cerebral venous thrombosis- Amyloid angiopathy- Focal lesions (tumours, AVM, cavernomas …)

Burden of stroke

Incidence

• 2,400 new cases / 1 million inhabitants / year• Higher than that of myocardial infarction

01002003004005006007008009001000

Cerebral MI Acuteperipheral

Suddendeath

Prevalence

• 12,000 prevalent cases / million inhabitants

Prevalence of major diseases in the elderly (%) in Rotterdam

Stroke TIA MI PAD AAAD PD

55-64 2.0 0.9 2.6 0.9 1.20.2 0.3

65-74 4.2 1.7 5.6 2.0 2.50.9 1.0

75-84 7.8 2.3 6.2 2.9 4.77.4 3.1

85 + 11.0 2.2 4.4 4.1 6.226.8 4.3

Mortality

Time-trends

• What is expected for the next years ?– Increase in incidence

• Increased survival after coronary events• Increased survival after stroke when adjusted on age• Ageing of EU population

– Stability in case-fatality rates• Decreased case-fatality rate per age-category

– Decreased severity (prevention)– Improvement of acute care– Changes in case-mix over time

• Ageing of EU population

Risk factors

• Non-modifiable• Increasing age• Male gender• Non-white ethnicity• Genetics• Migraine

• Modifiable• High blood pressure• High cholesterol (LDL)• Smoking• Diabetes• Overweight• Alcohol• Oral contraceptive therapy• Hormonal replacement therapy• SAS

Acute stroke therapies

Acute ischaemic stroke therapies

Events prevented /1,000

pts treated

Target population

Events prevented /1M2

inhabitantsStroke unit care 50 100% 120

Aspirin 12 80% 23Rt-PA <3h 143 15% 51

Rt-PA 3h-4h30 71 5% 8Hemicraniectomy 500 ε ε

Thrombolysis

N=2776End point: mRS 0-1

3h001h30 4h30 6h00

Decompressive surgery

Volume : 259 cc

Experimental therapies

Acute ICH therapies

• Correction of haemostatic disorders (no evidence)

Acute ICH therapies

• Control or blood pressure (some evidence)

Acute ICH therapies

• Sometimes surgery (no evidence)

Stroke prevention

Stroke prevention.

Long-term complications

Late epileptic seizures

Lanceman 1993

Berges2000

Lamy 2003

Meta-analysis

N 219 3205 581 4005Follow-up (months) 11.5 47 37.8Late seizures 4.5% 3.2% 3.4% 3.3%

Dementia

• 1/10 first-ever stroke patients is already demented • 3/10 with recurrent strokes are already demented• 1/3 patient was or will be demented after stroke• 50% of dementia after stroke are of Alzheimer type

Depression

• More than 50% of stroke patients will develop depressive symptoms

• Depressive syndromes are rare however (< 10%)

What is available in the E.U. for stroke care ?

Stroke care in the E.U.

• UK (120)• Ireland (6)

• Denmark (8)• Finland (8)• Norway (8)• Sweden (14)

• Estonia (6)• Latvia (11)• Lithuania

(11)• Czech Republic (15)• Hungary (15)• Poland (77)• Slovakia (8)• Slovenia (3)

• Belgium (9)• Netherlands

(20)• Luxemburg (2)

• Spain (86)• Portugal (16)

• France (121)• Switzerland (11)

• Germany (166)• Austria (12)

• Italy (116)• Greece (17)

Facilities Not availableMultidisciplinary team 341 (42.0%)Stroke trained nurses 290 (35.8%)Brain CT scan 24/7 161 (19.9%)CT priority for stroke patients 200 (24.7%)Extracranial Doppler sonography 194 (23.9%)Automated ECG monitoring at bed-side 132 (16.3%)Intravenous rt-PA protocols 24/7 432 (53.3%)Emergency department (in-house) 84 (10.4%)

100150200250300350400450500

CSC PSC AHW None

Is Europe the appropriate level ?

Priorities for the next decade

• Cliquez pour modifier les styles du texte du masque– Deuxième niveau

• Troisième niveau– Quatrième niveau

o Cinquième niveau

• Aim of the synergium : – To devise and prioritise new ways of accelerating progress

in reducing the risks, effects and consequences of stroke

• Method : – Preliminary work was performed by 7 working groups of stroke

leaders followed by a synergium (a forum for working synergistically together) with approximately 100 additional participants.

– The resulting draft document had further input from contributors outside the synergium

• Basic science, drug development and technology– There is a need to develop

• New systems of working together to break down the prevalent “silo” mentality

• New models of vertically integrated basic, clinical, and epidemiological disciplines

• Efficient methods of identifying other relevant areas of science.

• Stroke prevention– There is a need to develop

• Establish a global chronic disease prevention initiative with stroke as a major focus.

• Recognize not only abrupt clinical stroke, but subtle subclinical stroke, the commonest type of cerebrovascular disease, leading to impairments of executive function.

• Develop, implement and evaluate a population approach for stroke prevention.

• Develop public health communication strategies using traditional and novel (eg, social media/marketing) techniques.

• Acute Stroke management– There is a need to continue the establishment of

• Stroke centers,• Regional systems of emergency stroke care• Telestroke networks.

• Brain recovery and rehabilitation– There is a need to:

• Translate best neuroscience, including animal and human studies, into poststroke recovery research and clinical care.

• Standardise poststroke rehabilitation based on best evidence. • Develop consensus on, then implementation of, standardized

clinical and surrogate assessments. • Carry out rigorous clinical research to advance stroke recovery.

• Into the 21st century : web, technology, communication– There is a need to:

• Work toward global unrestricted access to stroke-related information.• Build centralised electronic archives and registries

• Foster cooperation amongst stakeholders to enhance stroke care:– large stroke organisations, nongovernmental organisations, governments,

patient organisations and industry• Educate professionals, patients, public, and policy makers

• The cost of underfunding stroke care

For more informationhttp://www.eso-stroke.org

Stroke in Europe

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