AlexeyP rotopopov IC-2017– M arch9th 2017 Some facts about Stroke in Russian Federation Population 144,6 millions Neurovascular death rate 299 493 (15,7%) Oncological death rate 291 819 (15,3%) 550 000 new strokesperyear(3,803 per1 m illionperyear) 2nd placeincardiovasculardeathrate 2nd placeinoverallmortality 1st placeamongthecausesofdisability theannualdeathratefrom strokeinR ussiaisoneofthehighestinthew orld only20% ofpatientsreturntow ork thetotalcosts- upto22 billions$annually Skvortsova V., Stakhovskaya L., 2009, 2014 Ministry of Healthcare, 2017 Central statistical data base, 2014 Some facts about Stroke in USA 5th leadingcauseofdeath intheU nitedS tates killingm orethan130,000 Am ericanseachyear- that’s1 ofevery20 deaths. S omeoneintheU nited S tateshasastrokeevery 40 seconds.Everyfour m inutes,someonediesof stroke 795,000 peopleinthe U nitedS tateshaveastroke (app.2,500 permillion) 610,000 ofthesearefirstor new strokes 185,000 arerecurrent strokes S trokereducesmobility in m orethanhalfofstroke survivorsage65andover C en tersforD isease C on trolan d P reven tion ,Nation alC en terforH ealthStatistics.Un d erlyin g C ause of D eath1 999-201 3on C D C W O ND ER O n lin e D atabase,released 201 5.Dataarefrom the M ultipleC ause of D eathFiles,1999-201 3,ascom piled from d ata provid ed by the 57 vitalstatisticsjurisdiction sthrough the VitalStatisticsCooperative P rogram : h ttp://w on d er.cd c.gov/ucd - S trokecoststhenation$33 icd 1 0.html.A ccessed on Feb 3,201 5. billionannually M ozzafarian D ,B en jam in EJ,Go A S,etal.on beh alfof the A m erican H eartAssociation StatisticsC om m ittee an d Stroke Statistics Subcom m ittee.H eartdisease an d stroke statistics—201 6upd ate: a reportfrom the A m erican H eartAssociation .C irculation . 201 6;133:e38-e360. Epidemiology of Stroke Russia Czech Republic Germany 3803 strokes per 2394 strokes per 2455 strokes per 1 million/year 1 million/year 1 million/year KrogiasC .etal.Tren d sof (M in istry of H ealthcare, W id im sky P.,IC C A -2016, P rague,23/04/2016 h ospitalized acutestroke care 2017 ) in German y (…) Journalof the Neurological Scien ces345(2014)202–208 Negative dynamics of Stroke epidemiology in Russia T otalnum berofallstrokes(peryear) 560000 549970 550000 540000 534245 535549 530000 523263 520000 514869 510000 504577 500000 490000 480000 2010 2011 2012 2013 2014 2016 Ministry of Healthcare, 2017 Acutecoronarysyndromevs.S trokeinR ussia (thetotalamountofinterventionsandestimatedneed) ACS S troke Incidenceperyear 520 524 550 000 Koncevaya A, 2011 Skvortsova V., Stakhovskaya L., 2009, 2014 N um berofpercutaneous 97879 -ACS < 100 interventions 46356-ST EM I Bokeria L, Alekyan B., 2016 N ecessaryamountofprocedures 214 500 -ACS 72 600 85800 -ST EM I Based on S tentforlifedata 13,2% of total Stroke number – based on incidence of LVO Currentstatus 45,6% -ACS < 0,2% 54,0% -ST EM I Un til2016the n um berof A IS in terven tion sw asin feriorto the totalam oun tof coron aryin terven tion s in 1000 times Th e effective treatmen tmetless than 0,2% of needed amount How manypatientsshouldreceivereperfusiontherapy inacuteischemicstroke? Catheterbasedtherapyofacutestroke: Currentevidence. P .W idimsky,2016 100% pts with acute stroke 85% ischemic stroke 15% hemorrhagic pts stroke pts. 45% pts with a minor 40% pts with moderate stroke or TIA: or large ischemic stroke reperfusion therapy not indicated (risks outweight benefits) 10% pts.presenting w ithin<4,5hoursof 30% pts. presenting symptom onset: late: reperfusion reperfusiontherapy therapy not indicated Dynamics of the main indicators of the stroke services in Russia in 2010-2015 T otal P atients T heproportionofpatients num ber hospitalized w ithin4,5 Year w ithstrokein IV-rtP A within ofstrokes hours 24 hours, IV-rtPA, thefirst24 4,5 peryear hours % % hours, % 504 557 2010 288 618 150 337 6361 57,2 29,8 1,3 514U pto33,7% 869 2011 311 ofpatientsareadmittedtohospital 496 168 779 5914 60,5 32,4 1,1 534 245 2012 340 848w ithin4,5hours 181 947 7268 63,8 34,1 1,4 523 263 2013 344 830 174 983 7107 65,9 33,5 1,4 535549 2014 346500 174 972 7978 64,9 32,7 1,5 549 970 2015 367380 185285 10631 66,8 33,7 1,9 How manypatientsshouldreceivereperfusiontherapy inacuteischemicstrokeinR ussia(per1million/year)? Catheterbasedtherapyofacutestroke: Currentevidence. P .W idimsky,2016 100% pts with 3803acute stroke acute Assessmentoftheproper strokecases amountofAIS interventions inR ussia 85% ischemic stroke 15% hemorrhagic 2232pts pts.w ith stroke pts. AIS 45% pts with a minor stroke or TIA: 40%1521 pts with pts.w moderate ith reperfusion therapy not basedon or large ischemic stroke m oderateor indicated (risks current outweight benefits) statistics largeAIS 13,2% 502pts.presenting pts. 26,8% pts. presenting w ithin<4,5hoursof presentingw ithin late: reperfusion symptom onset: therapy not indicated <4,5h.ofsymptomreperfusiontherapy onset P ossiblecausesof the low am oun tof in terven tion al treatmen tof acuteisch em ic stroke Complex multi-stage logistics and interdisciplinary interaction A small number of eligible patients = lack of trained personnel Delays in the logistics and in the treatment decisions Complex pharmacotherapy including high risk of intracranial bleeding complications The narrow therapeutic window (when treatment can be effective and safe) Technology of the procedure Lack of specialists able to perform endovascular procedures Im pactof geograph icalfactorson the d evelopm en tan d fun ction in g of stroke caresystem Russia is a huge country with very low population density Population:144554993people Land area:17 125191 sq.km (11 time zones) Density:8,6 persons per sq. km of land area For example… Germany Krasnoyarsk region Population:8 2 17 57 00 Population:2 8 7 57 90 Land area:357 021 sq.km x 6 = Land area:2 3397 00 sq.km Density:230 persons persq. Density:1,22 persons persq.km of km of lan d area lan d area 2455 strokes per 1 mln/year 3100 strokes per 1 mln/year B ackgroun d of successfuldevelopm en tof the stroke caresystem in Russia The evidence base for mechanical thrombectomy using the latest generation of stents retrievers The highest class of recommendations and level of evidence Availability of the latest generation of stents retrievers in Russia The presence of the advanced STEMI network which can become the platform for the endovascular treatment of AIS in 24/7/365 regimen T heevidencebaseofreperfusiontherapyinacute ischemicstroke T hepossibilitiesandlimitationsofthrombolytictherapy rtPA vs.placebo M eta-analysisof12 R CT s T hrombolysissignificantlyimprovetreatment outcomesinacuteischemicstroke T hepossibilitiesandlimitationsofthrombolytictherapy rtPA vs.placebo M eta-analysisof12 R CT s T hrombolysisincreasesearlymortality(upto7days)duetothe 7,7% riskofintracranialbleeding T hepossibilitiesandlimitationsofthrombolytictherapy rtPA vs.placebo M eta-analysisof12 R CT s T hrombolysisiseffectiveinthefirst3 hoursfrom thesymptoms onset eeea. troke2011,42: R iedeletal.S rmoyiaoe aynotbeenoughforeffective T hrombolysisalonem T heprobabilityofrecanalization 1775-1777 ehobsimtrm ) T hethrombusdiameter(mm treatment recanalization the likelihood of The large 0% ofrecanalization Clot clot reduces > 8 m m The evolution of technology and the evidence base of endovascular treatment of stroke (S troke2015 46:909-914) T heevidencebaseformechanicalthrombectomyin2013 3 RCTs comparing thrombolysis and endovascular thrombectomy demonstrated nosignificantdifferencesintheresults: IM S III S YN T HESISEXP AN S ION MR R ESCU E T heevidencebaseformechanicalthrombectomyin2013 IMS III SYNTHESIS MR RESCUE (N=629) (N=362) (N=118) Primary intervention Selective thrombolysis O utdated MERCI MERCI / device or clot fragmentation technology LVO (ICA, M1): 33% 34% 81% Successful recanalization (TICI 44% n/a 27% 2b/3): Good clinical 43% 42% 13% outcome (mRS 0-2): Симптоматичное внутримозговое 6% 6% 5% кровоизлияние: Смерть (90 день): 19% 8% 19% T heevidencebaseformechanicalthrombectomyin2013 IMS III SYNTHESIS MR RESCUE (N=629) (N=362) (N=118) Primary intervention Selective thrombolysis MERCI MERCI / device or clot fragmentation L ow num ber LVO (ICA, M1): 33% 34% 81% ofconfirmedLVO s Successful recanalization (TICI 44% n/a 27% 2b/3): Good clinical 43% 42% 13% outcome (mRS 0-2): Симптоматичное внутримозговое 6% 6% 5% кровоизлияние: Смерть (90 день): 19% 8% 19% T heevidencebaseformechanicalthrombectomyin2013 IMS III SYNTHESIS MR RESCUE (N=629) (N=362) (N=118) Primary intervention Selective thrombolysis MERCI MERCI / device or clot fragmentation LVO (ICA, M1): 33% 34% 81% Successful S uccessful recanalization (TICI 44% n/a 27% recanalization 2b/3): ratew aslow Good clinical 43% 42% 13% outcome (mRS 0-2): Симптоматичное внутримозговое 6% 6% 5% кровоизлияние: Смерть (90 день): 19% 8% 19% R ecentadvancesofendovasculartreatmenthave ledto: -thehigherfrequencyofsuccessfulrecanalization - significantreductionintheproceduralduration DingD.,Endovascularmechanicalthrombectomy foracuteischemicstroke:anew standardofcare. JournalofS troke2015;17(2):123-126 The evidence base for mechanical thrombectomy in 2015 5largerandomizedtrialsofmechanical thrombectomy publishedin T heN ew EnglandJournalofM edicine in2015 T ICI2b/3 m R S 0-2at90 Deathrate rate days MR CLEAN 59% 32.6% v. 19.1% 21% v 22% ESCAPE 72% 53% v. 29% 10% v. 19% EXTEND-IA 86% 71% v. 40% 9% v. 20% SWIFT PRIME 88% 60% v. 36% 9% v. 12% REVASCAT 66% 44% v 28% 18% v 16% The negative results in 2013 - O utdatedtechnology - L ow num berofconfirmedL VO s - S uccessfulrecanalizationratew aslow