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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
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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
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Types of strokes
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Types of strokes
• Ischaemic strokes
Large-vessel atherosclerosis Cardio-embolism Small-vessel occlusion Other definite causes Unknown and undetermined
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Types of strokes
• Intra cerebral haemorrhages
Deep- Lipohyalinosis +++- Focal lesions (tumours, AVM, cavernomas …)
Lobar- Cerebral venous thrombosis- Amyloid angiopathy- Focal lesions (tumours, AVM, cavernomas …)
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Burden of stroke
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Incidence
• 2,400 new cases / 1 million inhabitants / year• Higher than that of myocardial infarction
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Cerebral MI Acuteperipheral
Suddendeath
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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
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Mortality
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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
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Risk factors
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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
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Acute stroke therapies
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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
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Thrombolysis
N=2776End point: mRS 0-1
3h001h30 4h30 6h00
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Decompressive surgery
Volume : 259 cc
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Experimental therapies
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Acute ICH therapies
• Correction of haemostatic disorders (no evidence)
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Acute ICH therapies
• Control or blood pressure (some evidence)
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Acute ICH therapies
• Sometimes surgery (no evidence)
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Stroke prevention
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Stroke prevention.
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Stroke prevention.
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Long-term complications
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Lanceman 1993
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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%
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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
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Depression
• More than 50% of stroke patients will develop depressive symptoms
• Depressive syndromes are rare however (< 10%)
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What is available in the E.U. for stroke care ?
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Stroke care in the E.U.
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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)
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Stroke care in the E.U.
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
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Is Europe the appropriate level ?
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Is Europe the appropriate level ?
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Priorities for the next decade
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Priorities for the next decade
• Cliquez pour modifier les styles du texte du masque– Deuxième niveau
• Troisième niveau– Quatrième niveau
o Cinquième niveau
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• 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
Priorities for the next decade
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• 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.
Priorities for the next decade
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• 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.
Priorities for the next decade
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• Acute Stroke management– There is a need to continue the establishment of
• Stroke centers,• Regional systems of emergency stroke care• Telestroke networks.
Priorities for the next decade
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• 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.
Priorities for the next decade
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• 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
Priorities for the next decade
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• The cost of underfunding stroke care
Priorities for the next decade
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• The cost of underfunding stroke care
Priorities for the next decade
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For more informationhttp://www.eso-stroke.org
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