This meeting, held at the Royal Society of Medicine (RSM) in London, sponsored by the Brain and Spine Foundation and Clinical Neurosciences Section of the RSM was chaired by Professor Peter Hutchinson, President of the Section, and comprised updates on the latest treatments and best practice, with talks giving perspective on all aspects of the patient’s journey, from diagnosis to acute management and long term rehabilitation. Particular emphasis was placed on a holistic discussion of neurovascular disorders, with talks from surgeons, radiologists, physicians, therapists and neuropsychologists.
Mr Trivedi from Cambridge began with the pathophysiology of neurovascular disorders, focusing on acute ischemic stroke. He advised that we have to act faster and suggested to change the term ‘stroke’ to ‘brain attack’.
He discussed the concept of ischemic penumbra, that portion of the ischemic territory that could be saved from progressing to irreversible infarction if re-perfused in a timely manner (within 60 minutes or less from the time of arrival). Mechanical thrombectomy (MT) can do so with a number needed to treat of less than 3 for an improved functional outcome, which is unmatched by any previous therapy in stroke medicine. The challenge now is to implement accessible and safe MT services.
Mr Kitchen, President-elect of the Society of British Neurological Surgeons, followed with a talk on cavernomas. The highlight of this session was the uncertainty that still persists with regards to which patients should be treated promptly and which ones we should “watch and wait”. The imminent need for accurate estimates of haemorrhage risk in the natural untreated CCM led to the development of a list of unanswered research questions by the James Lind Alliance, a partnership between clinicians and patients. At the top of their research priorities are understanding whether treatment (with microsurgical excision or stereotactic neurosurgery) improves outcomes, and identifying the risk factors that predispose to bleeding. In the absence of Class I evidence, the best current treatment is to counsel the patients and explain to them the uncertainties of surgical and conservative managements.
Mr Nelson, previous SBNS President, discussed the role of bypass in the management of complex intracranial aneurysms. 20 years ago he predicted the standard of care would shift towards endovascular coil embolisation rather than microsurgical clipping, but this means often the most complex cases require surgical management. He presented his extensive experience of high flow bypass surgery for giant, fusiform and dissecting aneurysms, including combined surgical and radiological procedures which exclude the aneurysm from the circulation whilst maintaining distal flow.
Dr Joshi, an interventional neuroradiologist at Cambridge, described recent advances in neuro-interventional techniques including flow diverting stents WEB devices for example. He discussed the evidence base which remains strongest for simple coiling of ruptured aneurysms. He also described the interesting correlation that the rate of successful coiling increases in those units where a large number of aneurysms are clipped. This suggests that the expertise of the multidisciplinary team is key to a good outcome. The UKs first insertion of a steerable catheter into the radial artery to exclude an aneurysm was performed in Cambridge earlier this year and proved successful.
The panel discussion was followed by two patient perspectives, stroke survivor Mrs Printer, and AVM patient, Mrs Brown. These sessions offered a unique insight into life after a bleed in the brain.
Mrs Printer is a high profile judge who had to medically retire following an intracerebral bleed suffered whilst preparing for the London Marathon. She described the difficulties she had encountered getting the care she required, whilst maintaining her family and pursuing new directions in her professional and personal life. She explained the psychological and physical impact of specific disabilities such as hemianopia, and the artwork that she uses to give unique perspectives on this was available to view in lobby.
Mrs Brown gave an insightful talk on her life with an AVM. She has undertaken a Psychology degree to better understand the brain and also to be able to pursue a role in which she can draw from her own experience in order to help others. She gave an inspiring account of how dealing with her AVM has pushed her to take on new roles and challenges that she might not have done otherwise in her life before it was diagnosed.
The afternoon session started with some thought-provoking talks by the neuropsychologists, Dr Woodberry and Dr Browne, occupational therapist Ms Simpson and Lead Vascular CNS Ms Stoneley who highlighted how the key element for a good rehabilitation is making a daily plan with achievable goals. One of the most exciting tools they presented is a camera that the patient can carry with themselves to record their daily activities so that they can easily retrieve their memories. They explained the crucial role of focusing on patient’s individual needs on the long road to recovery, and how to support patients through the ups and downs that characterise this journey.
The hot topic, AVMs, was presented by Mr Bulters, Consultant at the Wessex Neurological Centre. With a 2-4% annual risk of AVM rupture, the decision when and if to treat is carefully considered. The results of the ARUBA trial, in particular, are contentious, and Mr Bulters urged us to consider their conclusions with care due to selection and treatment bias. He concluded that due to the life-long nature of the disease, randomised controlled trials had proved to be impractical, and in the future registry data could be used instead to monitor and inform best practice.
Dr Gholkar, OBE reminded us that in his first days as a Consultant Neuro-radiologist in Newcastle, his senior colleagues taught him that stroke patients were not to be scanned. Clearly there has been a sea-change in management since then. He reviewed the array of non-invasive imaging techniques available today and discussed 3D angiograms which produce extremely accurate aneurysm reconstructions for planning complex coiling techniques.
The last presentation was a mix of basic sciences and clinical applications in the field of neuro-immunology by Mr Hiren Patel, Consultant Neurosurgeon at the Salford Royal. He undertook his PhD on neuroinflammation under the supervision of Professor Dame Rothwell, in an attempt to reduce brain injury in patients after aneurysmal subarachnoid haemorrhage. IL-1 induced inflammation of the brain is an important contributor to cerebral ischaemia. They have conducted a randomised, open-label, single-blinded study that supports the role of an interleukin-1 receptor antagonist (IL1-Ra) in an attempt to reduce peripheral inflammation after aneurysmal subarachnoid haemorrhage. These data support a Phase III study investigating the effect of IL-1Ra on outcome following aSAH.
To conclude, the presenters addressed the importance of a multidisciplinary approach to patient management, and innovation through collaboration to improve the lives of those with Neurovascular disorders. The day provided a unique perspective from a great variety of professionals and patients into the nature of such diseases, and optimism for their future management.
- Evans M, White P, Cowley P and Werring, D. Revolution in acute ischaemic stroke care: a practical guide to mechanical thrombectomy. Practical Neurology, 2017;17(4):252-65