By Dr Zdravka Poljakovic
ESOC 2023 Session Report – Organising the Acute Chain of Stroke Care
The session began with two lectures, given by Professors Lars-Pedersen Pallesen and Bojana Zvan dealing with important topic of stroke care in distant parts of the country, and in centres who are not experienced in recanalization therapy where the role of telemedicine and even telethrombolysis makes a change. The lectures clearly showed that telemedical approach can help stroke patients in distant parts of the land to have the same possibility for adequate treatment. Professor Zvan showed even the results from telethrombolysis project in her country, where the outcomes for patients in distant hospitals as well as door-to-needle time were impressive. The main advantages of this approach are constant and progressive increase in the absolute number of patients treated with systemic recanalization therapy due to the possibility of capturing large areas of a country as well as accurate diagnosis of stroke itself .
Professor Rajiv Advani in his lecture emphasized the importance of doing the right things for the stroke patient in the Emergency room, which according to his presentation should contain proper evaluation, diagnostics, therapeutic approach (basically thrombolysis at this point), stabilization and team work. For the evaluation part, the knowledge and clinical setting of prehospital care should be taken into account very seriously he stressed. Also, diagnostic part, which consists of clinical and radiological part, should be done in parallel way, without wasting time for unnecessary actions so that thrombolytic therapy can be delivered as soon as possible, even during the process. The lecture raised some questions about the timeline of the whole process which were discussed in details.
Especially challenging was the lecture of professor Silvia Schonenberger about managing the patient in the angio-suite during which she discussed and presented papers presenting dilemmas about performing thrombectomy in conscious sedation or general anesthesia (GA), which still do not offer a final conclusion, and which my have implication to the blood pressure values. As blood pressure drops and extensive changes may directly influence outcome, they must be avoided and taken care of even in decision making process in choosing the GA or not. Some studies did namely show that decreased blood pressure prior recanalization is associated with larger infarct volume and worse outcome, prof Schonenberger stated. Her team actually made their own algorithm for stroke patients before and after thrombectomy with a clear message about the importance of quick end of sedation/extubation after the procedure. In conclusion, prof Schonenberger stressed the importance of SOP which can prevent complications and save time prior to the intervention, of specialized neurocritical/neurointerventional/neuroanesthesiological team during the intervention who will take care of the patient especially avoiding hypotension and hypocapnia and of avoiding prolonged ventilation and ICU stay after the procedure.
Finally, professor Valeria Caso gave a comprehensive, but also deeply touching lecture about the importance of organizing stroke care in all European countries, but with special tribute to stroke care organization in Ukraine. She stressed the importance of keeping detailed data about stroke care in order to improve the stroke care system, of having educated prehospital service and network of dedicated hospitals and of keeping records of the treatment results especially mortality, where big differences in rates based on type of the hospital where patients were treated can be observed. Coming to the end of her lecture, prof Caso gave an overview of the situation in Ukraine which is an admirable country being constantly improving its stroke care in spite of the already longlasting and devastating war. The number of hospitals with stroke units constantly grows, and keeps growing. Just as an illustration for this statement, the number of stroke units in 2016 was 21, and today there are 260 units in Ukraine. prof Caso showed. The session ended with this very emotive and motivating presentation which illustrated the importance of keeping the goal even in difficult situations.