Stroke management insights from Dr. Lučev: A conversation with an expert
In early August, CIRSE spoke with Dr. Jernej Lučev, the local host of the December ESIR course on acute ischaemic stroke intervention which will take place at the University Medical Centre in Maribor. Dr. Lucev gave us an overview of his 24/7 stroke care team, sharing insights into its expansion, multidisciplinary approach, effective outcomes and how the December ESIR course can help IRs prepare for their increasingly vital role in stroke intervention.
Come meet the Maribor course faculty, Dr. Lucev, Dr. Breznik and Prof. Hausegger and check out the latest thrombectomy devices at the ESIR booth at CIRSE in Copenhagen, on Sunday, September 10 from 09:30 – 12:00. Want to delve further into acute ischaemic stroke intervention? Register today for the course taking place December 6-7 in Maribor, Slovenia. You can still enjoy the early bird discount until October 12!
CIRSE: How is acute ischaemic stroke practice organized in your hospital?
Lučev: We have a team of seven radiologists performing endovascular treatment of stroke and we provide 24/7 service.
We began with endovascular treatment of stroke with two neuro-interventional radiologists in 2015. Soon the demand for endovascular treatment increased and we discovered we needed to expand the team. As a relatively small centre for neurovascular and neuro-interventional procedures, it was decided that three interventional radiologists should join the team. We decided that the five of us (two neuro-interventional radiologists and three interventional radiologists) would be sufficient to cover 24/7 service. It took approximately two years for the three interventional radiologists joining our neuro-interventionalists to become confident enough to perform the procedures on their own.
We utilize a multidisciplinary approach involving emergency room doctors and neurologists. Neurologists located in the emergency room perform the initial exam upon the patients’ arrival. We then perform the CT/CT Angio and then we’re quite assertive in our decisions about whom to treat. The major contraindication is if the patient had poor performance status prior to the stroke.
We don’t have any major imaging contraindications, except haemorrhage. We normally treat patients within a 24-hour window, however, this is always decided case by case with the neurologists.
Last year we performed approximately 125 stroke procedures. This year we are expecting around 170 procedures, and next year we expect the number to increase even more because we are planning to start covering the eastern part of Slovenia in its entirety. This is approximately half of the population, around 1 million people.
CIRSE: What kind of outcomes do you achieve?
Lučev: Approximately sixty percent end up with a Rankin score of zero to three, a desirable outcome where patients have no major impairments and relative independence after treatment. Ten percent of our patients end up with Rankin score of four or five, which means these patients have major impairment and are dependent on other people. The rest of our patients have higher scores.
Our response time from door to needle is now approximately 60 minutes. This is something that we must improve and we are currently working on that with our emergency room team and neurology team, analysing where we lose time and trying to optimize the process. For example, we now perform the majority of our cases using local anaesthesia because we learned that we lost time when patients first underwent general anaesthesia. We are also analysing how to optimize the patient workflow, so that transport from the CT room to angio is optimized to be as short as possible.
CIRSE: Do you think that stroke management is something that every IR should know how to perform?
Lučev: Yes, endovascular thrombectomy provides better clinical outcomes for patients with ischaemic stroke compared to the other best medical treatments. Further, endovascular therapy is comparatively cost-effective.
That said, however, there is a problem with stroke centre accessibility. Patients can be treated in local centres with intravenous thrombolytics and then transferred to a neuro-interventional centre, but time is lost here. The other option is that the patient is directly transferred to a neuro-interventional centre, however, in this case, they won’t receive thrombolytic therapy.
The lack of interventional neuroradiologists who perform endovascular treatment of stroke is a problem. The interventional radiology community is much larger and we have centres where 24/7 interventional radiology teams are available. In my opinion, these are the centres that can help in increasing the accessibility of endovascular stroke management. Of course, additional training for interventional radiologists is also necessary. They need to learn the clinical and technical factors unique to stroke patients. Moreover, this training should provide interventional radiologists with the technical skills necessary to treat patients and obtain outcomes that meet international standards.
CIRSE: What are your observations about how the field of ischaemic stroke therapy has evolved in recent years?
Lučev: Since the publication of several major stroke trials, interventional radiology teams have become much more aggressive in treating stroke patients. We are treating patients in extended time windows now, all the way up to 24 hours or even longer. As indications for acute stroke therapy widen and public awareness increases, we predict more patients will be treated in the future. There are even attempts now for stroke patients to be worked up in the angio suite with a direct angio approach to shorten the reperfusion time. So, the teams will need to be available more often and perform more quickly. Therefore, it will be crucial to train enough interventional radiologists in the future and to develop adequate support networks that can help patients.
The tools for mechanical thrombectomy have become much better in the last few years. But there is still room to improve our ability to reliably achieve first-pass reperfusion and to remove more distal emboli and thrombus. Companies are pushing the limits here and the patients are the beneficiaries.
CIRSE: Will the December ESIR course focus on widely used technologies, or also on novel devices?
Lučev: Both, but of course we will mostly focus on widely used techniques. All major industry partners have confirmed their participation, which we are very grateful for. We are planning to have stem flow models and simulators where the participants can learn how to perform endovascular stroke management. The course is mainly focused on practical training, but our distinguished faculty will also provide expert theoretical knowledge. We will also cover future trends and discuss interesting recorded cases.
CIRSE: What are you most looking forward to for the course?
Lučev: I’m looking forward, firstly, to meeting and hosting our IR colleagues who will come to the course. I’m also looking forward to hearing the discussions between the participants and the faculty. Hopefully this will result in some new ideas, and who knows what will result from that. I love hearing different experiences from participants, these are always the best discussions.
CIRSE: Why should IRs travel to Maribor for this course?
Lučev: I know that Maribor is a little off the beaten path; but this is the course that will give you a comprehensive overview of stroke, from how to organize a stroke centre to how to perform procedures. You’ll learn different techniques, learn about different materials, and how to use and compare them. It’s a great opportunity for every IR who would like to start performing stroke management, and also for the experienced IR who would like to improve their technique, have profound discussions about stroke, and push their knowledge even further.