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


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


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.


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%)

43 32

356

455

050

100150200250300350400450500

CSC PSC AHW None


Is Europe the appropriate level ?


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



• The cost of underfunding stroke care



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


Documents

Stroke in Europe