Global News MT2020 – Mission Thrombectomy

Daniel Vela-Duarte, MD, MSCR

Vascular Neurologist
NeuroEndovascular surgery / Interventional Neurology fellow. Miami, US

The recently published RESILIENT* trial demonstrated the benefit of mechanical thrombectomy for acute ischemic stroke in a variety of health care settings, demonstrating that despite constrained resources, endovascular therapy was not only achievable but most importantly, efficacious.  Brazil has surely paved the road towards an equal and accessible stroke care. From SVIN, we talked to leaders in stroke in both Chile and Colombia, and applaud their efforts aimed to improve systems of care

*Martins SO et al. N Engl J Med 2020 Jun 11

German Pérez-Romero, MD

Vascular Neurologist
Profesor of Neurology
Universidad Nacional De Colombia
Bogotá, Colombia

Tell us a little bit about the beginnings of your career in neurology and what drew you to the field of stroke? It was probably 1988 when I was doing a master’s in epidemiology and biostatistics at the Université libre de Bruxelles (Belgium). A friend from residency contacted me to help in creating a neurology service in a well-recognized cardiovascular institution in the city of Bogotá at that time. I began working developing a program to offer a multidisciplinary approach to the neurological patients. This group of specialists would later standardize a translated version of the NIHSS and introduce treatment with IV tPA for the first time in Colombia.

Given the recent landmark trials on mechanical thrombectomy, guidelines modification and research in advance neuroimaging, what do you feel were the challenges to incorporate these changes, and how did they impact your practice? I feel the recent contribution from trials will help to universalize stroke care leading to benefit more patients from medical and neuroendovascular reperfusion therapies. Bringing the recent developments to medical education becomes essential to continue promoting rational treatments in every corner of the country. We recently created “RecaVar”, (Red Colombiana contra el ataque cerebrovascular) a non-governmental organization committed to educate on how to recognize stroke. 

If you were able to define your team with two words, what would they be? Tell us about a recent accomplishment of you team. Action and dedication define our group. The pandemic has unfortunately affected the perception of patients towards going to the ED when experiencing stroke symptoms. We are currently working in designing strategies to educate and reassure the population.

What do you see as the most important barriers to overcome in stroke care in your country in the next 5 years? Eliminating the limitations to access adequate acute stroke care and enforcing that insurance companies cover treatment and rehabilitation is one of the obstacles we must remove to improve care. A senate health bill is being proposed by “RecaVar” and Asociación Colombiana de Neurología to ensure timely and optimal attention as happened in Brazil and Chile’s change of policies.

Where do you feel the future direction of treatment and prevention of stroke will go? The future of stroke care relies on campaigns oriented towards education on stroke manifestations, and risk factors reduction earlier on. Educating on understanding and promoting a healthy lifestyle should start in elementary school.

Hernan Bayona Ortiz, MD, FAHA

Vascular Neurologist
Stroke Medical Director
Hospital Universitario Fundación Santa Fe de Bogotá. Colombia

Tell us a little bit about the beginnings of your career in neurology and what drew you to the field of stroke? I decided to become a neurologist in my second year of med-school. During my internship, I had the opportunity to share a rotation with one my senior residents at that time, Javier Romero, who would later become director of the neurovascular lab at MGH in Boston. The memories of patients severely affected by ICH, the lack of effective therapies and availability of neuroimaging would follow me during my first years of residency. Years later, I worked on the translation of the NIHSS to Spanish and got involved in the training of residents and nurses. The opportunity of participating of an International Stroke Fellowship at MUSC (South Carolina), under the mentorship of Wayne Feng and Bruce Ovbiagele changed my perspective and provided me with the tools needed to develop a stroke program in my country.  

Given the recent landmark trials on mechanical thrombectomy, guidelines modification and research in advance neuroimaging, what do you feel were the challenges to incorporate these changes, and how did they impact your practice? After the developments in 2015, the treatment of stroke changed notoriously. Even when mechanical thrombectomy became standard of care, there are yet barriers and an underdeveloped network of hospitals where MT is not offered. EMS services lack the training to recognize an individual with LVO. The rural areas are the ones who suffer the most as we are not able to offer aerial emergent transportation.  One of my goals is obtaining advanced artificial intelligence imaging processing (RAPID – VizAI) to guide therapy, and to incorporate the use of Telestroke in areas of the country where the presence of a neurologist is unheard of 

If you were able to define your team with two words, what would they be? Tell us about a recent accomplishment of you team. Committed and positive. Since opening our stroke center in 2008, I have met many people with a positive attitude towards helping others to fight stroke. Our Stroke Center was recertified by the Joint Commission International in December 2019. we also participate in the Angels Awards (sponsored by ESO) and we received platinum recognition twice this 2020.

What do you see as the most important barriers to overcome in stroke care in your country in the next 5 years? We are working hard in developing a well-organized stroke network for Bogotá with pre-hospital notification and certification of stroke centers. We want to initiate a Colombian stroke registry combining information from as many hospitals possible. The registry is aimed to analyze the behavior of the disease around the country, and to tackle down inequalities in access and care.  We also want to increase the visibility of Colombian leaders in stroke research to participate of international trials.

Where do you feel the future direction of treatment and prevention of stroke will go? The future is brilliant for stroke. The combination of neuroimaging and biomarkers will help selecting subjects’ candidates for different therapies. Telestroke will continue improving access of care with different lytic therapies and even telerehabilitation. The use of mHealth resources is key to provide access to big population with a low-cost approach. The use of a polypill and personalized medicine will reduce intervention costs.

Juan Andres Mejía, MD

Interventional Neuroradiologist
AngioTeam.
Medellín, Colombia

Tell us a little bit about the beginnings of your career in NeuroIR and what drew you to the field of stroke? I was passionate about neurosciences and radiology. The Fascination for the brain and the idea of studying it through the scope of diagnostic imaging brought me where I am. I did my residency in diagnostic radiology in Spain where I fell in love with interventional neuroradiology. It is the field where I found my calling as a physician. It was only in this field where I found an inspiring life, where the love for what I do meets what I can return to the society. A great example of that is treating patients with stroke.

Given the recent landmark trials on mechanical thrombectomy, guidelines modification and research in advance neuroimaging, what do you feel were the challenges to incorporate these changes, and how did they impact your practice?  I believe novel therapies will keep coming, but what it’s important is optimizing detection of those at a higher risk of stroke. Only this type of approach will attain an impact on reducing disability.

If you were able to define your team with two words, what would they be? Tell us about a recent accomplishment of you team. Commitment and responsibility; within our team, different specialties converge. Emergency physicians, anesthesiologists, neurologists, neurosurgeons and interventional neuroradiologists resonate at the same frequency. As an individual, you can perhaps get where you want faster, but as a team, you get further.

What do you see as the most important barriers to overcome in stroke care in your country in the next 5 years? The first and most important barrier in stroke care is the lack of education of the general population. That’s what delays treatments considerable. There are still misunderstandings of cerebrovascular disease across specialties. We need massive outreach and help from the government to get this education around the country. Despite significant efforts and improvement of health-care systems, there is still so much to do in terms of intensive care, transportation of patients, and rehab.

Where do you feel the future direction of treatment and prevention of stroke will go? I believe the future of stroke is in the design of devices for mechanical thrombectomy. Other developments will target new drugs against intracranial thrombotic events.

Rodrigo Guerrero, MD

Vascular Neurologist
Clinica Santa Maria.
Santiago, Chile.

Tell us a little bit about the beginnings of your career in neurology and what drew you to the field of stroke? I knew I wanted to pursue a career in neurology right after finishing med-school. While in residency, most of our patients had stroke. Every stroke survivor had a unique story, specific goals for rehab, and a particular social background. I soon realized that stroke was a major cause of disability in my country and decided to focus my efforts and career in vascular neurology towards primary prevention and acute care of stroke.

Given the recent landmark trials on mechanical thrombectomy, guidelines modification and research in advance neuroimaging, what do you feel were the challenges to incorporate these changes, and how did they impact your practice?  I think that as in many Low-and-Middle income countries, the most important challenge is to offer equal treatment to all patients. Chiles does not have comprehensive stroke centers or thrombectomy-capable centers in every region. There are no more than 4 centers outside the capital city, -Santiago-. Moreover, there is a lack of neurointerventionists and advanced neuroimaging in many hospitals. We are currently working on policies to address this gap. Our Brazilian colleagues have already demonstrated that mechanical thrombectomy offered in a public health-care system leads to better outcomes.

If you were able to define your team with two words, what would they be? Tell us about a recent accomplishment of you team. I work for both a private and public hospitals which gives me the opportunity to see two different worlds on a daily basis. The first works similarly to a comprehensive center. The latter works based on the patient supportive network. We receive a less educated population that often present too late after stroke symptoms. Promoting education is therefore our priority. Our hospital was part of the first public pilot of endovascular therapy demonstrating that a publicly funded MT program in Chile could achieve similar outcomes as in randomized clinical trials.

What do you see as the most important barriers to overcome in stroke care in your country in the next 5 years? The current health-care system has made the creation of stroke units difficult. A growing number of neurology departments around the country is trying to present stroke unit projects, which is ultimately the heart of the network model we are preparing. I am positive that the health minister and several stakeholders will provide the resources needed to increased coverage and stroke care.

Where do you feel the future direction of treatment and prevention of stroke will go? I advocate for individualized treatments. Mechanical thrombectomy must be offered to every patient regardless the location and insurance. We are very close to get to a patient-centered care and patient-reported outcomes model.

Rodrigo Rivera, MD

Interventional Neuroradiologist
Instituto de Neurocirugia Dr. Asenjo
Santiago, Chile

Tell us a little bit about the beginnings of your career in NeuroIR and what drew you to the field of stroke? I trained in neurosurgery in Valparaiso (Chile) and worked as a general neurosurgeon in the north of the country for some years. I trained later in diagnostic and interventional neuroradiology at the Instituto de Neurocirugia Dr. Asenjo from 2005 to 2008. Then, I had the opportunity of a fellowship with Prof. Jacques Moret and his team at the Rothschild Foundation in Paris, France. It was then in 2013 that we developed a stroke program at our institute. Although it took several years, public funding from the government was obtained proving that mechanical thrombectomy was safe and effective.

Given the recent landmark trials on mechanical thrombectomy, guidelines modification and research in advance neuroimaging, what do you feel were the challenges to incorporate these changes, and how did they impact your practice?  Countries like Chile, -as well as other Latin American countries-, run on a limited budget for stroke care. Technologies such as artificial intelligence imaging processing are difficult to obtain. There are marked differences in the public health system and barriers such as the establishment of a network for referral of patients. There are major limitations in patient’s awareness and what to do in case of stroke.

If you were able to define your team with two words, what would they be? Tell us about a recent accomplishment of you team. Commitment and motivation. We count with a wonderful team for mechanical thrombectomy. We recently published our experience on the first 100 thrombectomies since our stroke unit was established, showing our teamwork and good outcomes.

What do you see as the most important barriers to overcome in stroke care in your country in the next 5 years? It is probably the number of neuronterventionists required to meet the case demand. We have a significant gap in trained personnel that needs to be filled within the next 10 years. We are not only committed to our patients, but also to train the future neurointerventionists. It is therefore clear that our capacity to do cases is limited for now.

Where do you feel the future direction of treatment and prevention of stroke will go?  The future of stroke treatment is in delineating earlier detection of large vessel occlusion with devices or gadgets to expedite patient transfer to a vascular/stroke unit. Drugs and devices to enhance collateral circulation and revascularization times will come for sure. In our center, we are planning an expansion to a new hospital, which will be ready in 2027 and focus in stroke care. We expect to become the largest advanced stroke center of our country.