The Feb 2015 issue of the Neurointerventional Newsletter is now available for download by clicking the button below.
Provided to ESMINT by Prof Michael Forsting & Stryker Neurovascular
Joint statement of the European Stroke Organisation (ESO), the European Society of Minimally Invasive Neurological Therapy (ESMINT) and the European Society of Neuroradiology (ESNR):-
Stroke resulting from rupture or interruption of blood flow in brain vessels can lead to devastating consequences for patients, their families and society. Steady progress has been achieved in the last 20 years in stroke treatment through better prevention, establishment of stroke care units and the use of clot-busting drugs (intravenous thrombolysis).
Last week, new scientific evidence from four major stroke studies was presented at the International Stroke Conference in Nashville, USA. It proved that rapid mechanical thrombectomy (clot retrieval) improves patient function after acute ischemic stroke. To achieve this benefit, patients were treated by interventional neuroradiologists in stroke centers with multidisciplinary stroke teams. This treatment should be performed as rapidly as possible in conjunction with standard intravenous thrombolysis.
ESO, ESMINT and ESNR acknowledge this significant progress in acute stroke treatment and strongly support its application in appropriately selected patients in well equipped stroke centers by properly trained neurointerventionists. Further randomized trials of thrombectomy and more detailed analysis of the current trials will help to optimize patient selection and treatment algorithms.
Detailed guidelines on mechanical thrombectomy are currently being prepared by the key European societies involved in acute stroke care. Before these detailed guidelines become available, ESO, ESMINT and ESNR have jointly updated and support the consensus statement on thrombectomy by the ESO-Karolinska Stroke Update.
The European Stroke Organisation (ESO) is a society of stroke physicians, researchers, societies and patient organizations with the goal of optimizing and harmonizing the management of stroke in Europe by supporting medical education and stroke projects.
More on www.eso-stroke.org
The European Society of Minimally Invasive Neurological Therapy (ESMINT) is a multidisciplinary society of individuals and groups working or training in the field of minimally invasive neurological therapy in geographical Europe. It has been established in order to promote the benefits of minimally invasive neurological therapies through education, training and support for high quality scientific research.
More on www.esmint.eu
Contact email: email@example.com
The European Society of Neuroradiology / ESNR Diagnostic and Interventional is a professional society organising European neuroradiologists. The Society organises Annual Scientific meetings - ESNR Congress, common European Training courses in neuroradiology - European Course of Neuroradiology (ECNR) and is a forum for professional development of European Neuroradiology.
More on www.esnr.org
Contact email : firstname.lastname@example.org
The 2nd ESO ESMINT ESNR stroke winter school was held in Bern, Switzerland from the 3rd to 6th of February 2015. The local organizing committee were Prof. Jan Gralla, Prof. Heinrich Mattle, PD Dr. Pasquale Mordasini and Prof. Urs Fischer. They were actively supported by Katharina Wenger, Martin Zbinden, Daniela Miescher and Helena Gerber.
The first difficult task was to select 44 participants from many more applicants, but eventually 44 enthusiastic young doctors – 20 pairs of rising neurologists and neuroradiologists - arrived in Bern from 19 different countries: UK, Serbia, Germany, France, Lithuania, Slovakia, Italy, Austria, Denmark, Belgium, Portugal, Finland, Czech Republic, Hungary, Ireland, India, South Africa, Ukraine and Switzerland.
The primary aim of the second ESO ESMINT ESNR stroke winter school was bringing together young European stroke physicians and neuroradiologists in order to enhance interdisciplinary management of patients with acute ischaemic stroke.
The stroke winter school started on the 3rd of February 2015 with the welcome of the president elect of the European Stroke Organisation (ESO), Prof. Valeria Caso, the president of the European Society of Minimal Invasive Neurological Therapy (ESMINT), Prof. Istvan Szikora, and the committee member of the Interventional Neuroradiology Section of the European Society of Neuroradiology (ESNR), Prof. Jan Gralla on behalf of Prof. Olav Jansen.
The 32 speakers (12 from EU, 20 from Switzerland) including neurologists, interventional and non-interventional neuroradiologists, neurosurgeons, internal medicine specialists, and rehabilitation specialists led challenging discussions. The teaching program included 32 lectures and 8 tutorials. The main focus of the lectures was interdisciplinary treatment of acute stroke. There were sessions on acute stroke imaging, acute treatment strategies including endovascular approaches, stroke treatment in difficult circumstances and needs to set up an interdisciplinary stroke center. In the afternoon tutorials were given separately for neuroradiologists and neurologists. Neuroradiologists had the opportunity for structured hands-on teaching in small groups on endovascular procedures with animal models and management of complications of endovascular treatment. Neurologists could learn neuroangiography on a model and were taught CT and MRI interpretations by neuroradiologists. Both groups visited the stroke unit and had interdisciplinary case discussion.
A special highlight for the interventional neuroradiologists were the hands-on teaching sessions with the animal model. Small groups of 5 participants were given the opportunity to perform diagnostic angiography and endovascular treatment procedures such as thrombectomy with multiple devices.
During the stroke winter school a faculty meeting was held with members of the ESO, ESMINT and ESNR in order to discuss future common strategies to enhance the quality of stroke management. Topics were guideline papers, studies, potential joint conferences and workshops.
During the stroke winter school participants and faculty had three joint dinners to favour socialization.
The following sponsors contributed to the realization of the stroke winter school: Covidien, Stryker, MicroVention, Penumbra, Daichii-Sankyo, Johnson&Johnson/Codman, Siemens Neuravi, Boehringer Ingelheim and 1a medical ag.
The local organizing committee thanks all the invited speakers for giving time and efforts to the winter school, for coming to Bern, and for delivering high quality lectures. Their interest and passion to teach the upcoming generation of neurologists and neuroradiologists was clearly visible.
After the success of the first and second ESO ESMINT ESNR stroke winter school there will be a 3rd ESO ESMINT ESNR stroke winter school from the 9th to 12th of February 2016 in Bern!
Urs Fischer, Pasquale Mordasini, Jan Gralla
Faculty and participants of the 2nd ESO ESMINT ESNR Stroke Winter School in Bern
Neuro-Interventionalists training in the animal lab
Prof. Gralla teaching neuro-interventionalists in the animal lab
Neuro-Interventionalists training in the animal lab
Neuro-Interventionalists training with the simulator
Neuro-Interventionalists training with the simulator
ECMINT 1.1 - Embolisation of Tumours and Arteriovenous Fistulas - was held at St Anne’s college, Oxford last December (2014). There was a truly international feel to the course with 41 students attending from 19 countries and a pan-European teaching faculty.
Students were subjected to ‘formative’ and ‘summative’ quizzes. The former are intended to help them consolidate the teaching and took place at the end of 2nd and 4th day of the course. The final summative quiz was held on the last day and included questions on the entire content of the taught curriculum. Thirty-nine students achieved scores over 60% despite the concern of several that the questions were too hard. Dr. Shelley Renowden, chairman of the ESMINT Training Committee, set the tests. She is standing back-centre in the picture below. One of the highlights of the course was the conference dinner held in the great hall at Balliol College, Oxford, which looked as if it was the set for a “Harry Potter” film.
The next course in the program (ECMINT 1.2 – Aneurysms) will be in June 2015 and students who attended ECMINT 1.1 have been given the opportunity to register in advance of others. The number of places will be increased to 60. New students will be able to complete the 2 year program when this first course (Embolisation of Tumours and Arteriovenous Fistulas) is repeated in 2016.
Dr Viccy Young, INR Fellow
“A well organised, informative course at a great venue, with an excellent panel of speakers from across the field. The mixture of lectures and tutorials covered the topics thoroughly and provided the opportunity to take advantage of the vast experience of the speakers. I will certainly be attending the other parts of the course.”
February 11, 2015 will be an important milestone in the history of Interventional Neuroradiology. Three positive trials (ESCAPE, EXTEND-IA, and SWIFT-PRIME) evaluating mechanical thrombectomy in acute ischemic stroke were presented under the applause of a large audience. Both ESCAPE and EXTEND-IA trials were published online in NEJM the day of ISC presentation (February 11, 2014).
The positive results of MR CLEAN presented at the World Stroke Conference in Istanbul in October 2014 was prompting the performance of interim analyses in several running RCTs evaluating mechanical thrombectomy (ESCAPE, EXTEND-IA, SWIFT-PRIME) that were all positive.
The ESCAPE (Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times) trial (presented by Michael D Hill, Calgary, Canada) was interrupted after randomization of 315 patients. Inclusion criteria were NIHSS > 5, occlusion of the middle cerebral artery trunk and its immediate branches with or without ICA occlusion, small infarct core (ASPECT 6 to 10), moderate to good collaterals on CTA. Enrollment was possible up to 12 hours. The patients received rtPA if they were eligible for this treatment.
A total of 316 patients underwent randomization before the trial was stopped: 165 in the thrombectomy group and 150 in the control group (1 patient was excluded). About 75% of patients received IV rt-PA and stent-retrievers were used in 86.1% of patients in the thrombectomy group. The adjusted risk ratio for a mRS shift with thrombectomy at 90 days was 3.1. A mRS of 0-2 at 90 days was observed in 53.0% in thrombectomy vs. 29.3% in controls (p<0.001). Mortality was significantly lower in intervention group (10.4%) compared to 19.0% in control group. All subgroups of patients had similar benefit, including the elderly.
The EXTEND-IA (EXtending the time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial therapy) trial (presented by Stephen M Davis, Parkville, Australia) was prematurely stopped because of a positive interim analysis of the first 70 randomized patients (35 in the intervention group and 35 in the control group). Patients were eligible if they could receive rt-PA within 4.5 hours after the onset of anterior circulation ischemic stroke and had occlusion of the internal carotid artery or of the first or second segment of the middle cerebral artery on CTA or MRA, to have received IV thrombolysis < 4.5 hours. CT perfusion imaging (use of the fully automated software RAPID) was used to identify potentially salvageable brain tissue. Endovascular therapy had to be initiated (groin puncture) within 6 hours after stroke onset and completed within 8 hours after onset.
A total of 70 patients were included in the trial (35 in intervention arm and 35 in IV rt-PA arm). All patients in the intervention group were treated with Solitaire. Early reperfusion of the ischemic tissue at 24h hours was 100% in intervention group vs. 37% in the control group (p<0.001). Early neurologic improvement (NIHSS reduction ≥ 8 points or NIHSS 0-1 at 3 days) was 80% in intervention group vs 37% in the control group (p<0.001). mRS 0-2 at 90 days was 71% in thrombectomy patients and 40% in controls (p<0.01). There was a trend towards reduction of mortality (9% in intervention group; 20% in control group; p=0.18).
The SWIFT PRIME (Solitaire™ With the Intention For Thrombectomy as PRIMary treatment for acute ischemic strokE) trial (presented by Jeffrey L Saver) was prematurely stopped after a positive interim analysis of the first 196 patients. To be included, patients have to receive IV thrombolysis 4.5 hours after stroke onset, a NIHSS between 8 and 29, CTA or MRA confirmation of large vessel occlusion (intracranial internal carotid artery or M1 segment of the MCA), and an ASPECTS > 6.
As ESCAPE and EXTEND-IA, SWIFT-PRIME was prematurely halted due to positive interim analysis. A total of 196 patients were randomized, 98 in each group (intervention and IV rt-PA). In Intervention group, TICI 2b/3 was obtained in 88.0% of patients. The OR for a mRS shift at 90 days with thrombectomy using the Solitaire™ FR stent retriever was highly significant (p= 0.0002). Good functional outcome (mRS 0-2 at 90 days) was obtained in 60.2% in intervention group and 35.5% in IV rt-PA group (p < 0.001). Death at 90 days was 9.2% in intervention group and 12.4% in rt-PA group (p=0.5).
In summary, following the positive results of MR CLEAN, a further 3 positive trials have validated the use of mechanical thrombectomy for patients with acute ischemic stroke with large vessel occlusion in the anterior circulation. Indeed, these results will have a tremendous impact on the management of these patients and also on the organization of stroke care.
All investigators and sponsors of these trials should be congratulated for their tremendous work!
Laurent Pierot – Reims - France
Dear Colleagues, Friends, dear Members of the Society,
The ESMINT would like to take this opportunity to wish all members, families, friends and all collaborative partners Seasonal Greetings and best wishes for the New Year.
Five years have passed since the inauguration of our Society. Due to the meaningful work of all of you we grew from 100 to more than 500 members, we established a highly successful Annual Congress in Nice and managed to establish a strong and still growing cooperation with the neurosurgical and neurological communities in Europe. Our website is active and providing a worldwide unique service: the Device Directory.
The most significant recent milestone is the launch of ESMINT’s curriculum based, structured training in neurointerventional therapy. The first ECMINT course was held in Oxford this December, organized by the ESMINT Educational Committee (chaired by Dr. Shelley Renowden) and directed by Prof. James Byrne.
On behalf of the Executive Board, I would like to thank you very much for your support throughout 2014 and we look forward to an exciting and successful 2015.
Today, December 17th 2014, the New England Journal of Medicine published the results of the MrCLEAN trial (Multicentre Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands). This prospective randomised trial was designed to show the potential of intra arterial (endovascular) treatment of ischemic stroke in comparison to conventional treatment with intravenous thrombolysis. The results of this trial are strongly positive towards intra arterial therapy, and will have a major impact on the future treatment of ischemic stroke.
The ESMINT (European Society of Minimally Invasive Neurological Therapies) strives towards a scientifically funded use of endovascular techniques in neurovascular pathology, by suitably trained and skilled medical specialists. In this respect the ESMINT applauds the researchers for their work and welcomes the outcome of the trial wholeheartedly.
Having said this, the ESMINT also warrants restraint since these complex endovascular procedures are highly operator dependent and should not be executed by persons without appropriate training and neurovascular knowledge. Execution of these procedures by anyone other than endovascularly trained neurovascular specialists poses a risk, both for the patients and the future of this technique. Awareness of these risks is of the utmost important to both legislators and hospital administrations that may consider employing doctors lacking the necessary training. Centralization of this particular service needs to be considered and may well be the only way to achieve the trial results in routine practice.
For more information please contact ESMINT directly.
The article can be read online here:
On October 24th the results of the MrCLEAN trial were presented orally at the World Stroke Congress in Istanbul.
The ESMINT board recognizes that the outcome of the trial has many implications for our field and as soon as the peer-reviewed MrCLEAN data is published a formal statement and press release will be released.
We can now announce that the December ECMINT training course in Oxford is now full. We will shortly be announcing some new dates for 2015. If you have completed the registration form but were not allocated a place in December your application will be prioritised when the new dates are announced.
Dear Colleagues, dear Friends,
This is to let you know, that registration for the ECMINT 1 course to be held in Oxford, December 15- 19 has been very successful. All available places were booked by the end of October, so the organizers have closed registration.
We consider this as a success. The strong interest in the course confirms that ESMINT has moved in the right direction in its educational strategy. It is our intention to keep moving in this direction and increase our capacity in the near future. We would like to reassure those who did not have a chance to get attend this first course that they can start their cycle in June, 2015 at ESMINT 2.
Keep an eye at the Website, registration will start again early next year!
On behalf of the Board of ESMINT we all look forward seeing you in Oxford.