Stroke care pathways at CHU de Montpellier

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Multiple randomized controlled trials have recently proved the superiority of mechanical thrombectomy compared to the best medical therapy in patients with recent cerebral infarct and large vessel occlusion in the anterior circulation. There are 6 Stroke Units in the Occitanie-East region, formerly Languedoc-Roussillon. Only one of these units, the Comprehensive Stroke Center (CSC) of the Montpellier hospital, has a centre of interventional neuroradiology (NRI) that can perform mechanical thrombectomy.

Patients with a suspicion of stroke are referred to the nearest stroke unit, then the candidates for mechanical thrombectomy are transferred secondarily to the CSC in Montpellier. Currently, there is no evidence that initial management in a proximity stroke unit and a secondary transfer for a mechanical thrombectomy is associated with a less positive outcome, compared to patients initially treated at the regional stroke centre.

The objective of our local clinical research registry is to compare the clinical outcome of patients first admitted in the CSC of Montpellier with those transferred from the Proximity Stroke Unit. In this way, the implementation of a local database will allow us to generate information and knowledge about stroke patients’ management in our region in order to contribute to the achievement of Ictusnet objectives.

The aim of CHU Montpellier’s participation in ICTUSnet as partners is to describe the management of suspicion of large vessel occlusion in our region, compared to other participating regions. In order to improve stroke patients’ management, we need to evaluate the delay of mechanical thrombectomy and clinical outcome of patients after 3 months

What should we do to overcome barriers in Stroke care and urgent prehospital care?

The organization of acute stroke treatment services at the regional/national level is key to guaranteeing reperfusion therapies reach the whole population.

A recent paper published in the European Stroke Journal (1), the scientific journal of the European Stroke Organization (ESO), describes the results of a recent survey performed in 44 European countries. The majority of the countries have stroke care plans and most of them take responsibility for the organisation/implementation of stroke systems of care (86%), quality of care assessment (77%), and act as a liaison between emergency medical systems and stroke physicians (79%). As for stroke systems of care, the focus is mainly on prehospital and in-hospital acute stroke care (the Code Stroke systems are available in the 84%). The survey also shows that the preferred urgent transport is via non-medicalised ambulances. The paper highlights that the presence of stroke care plans, the availability of stroke registries, the transport of urgent stroke patients via non-medicalised ambulances, and the drip-and-ship routing (the route where patients are firstly assisted at the reference stroke centre, and then sent to the comprehensive stroke centres) of acute patients showed higher reperfusion treatment rates.

However, stroke is not yet a priority everywhere in Europe, which is a barrier to the spread and delivery of high-quality stroke care.

This April, ICTUSnet members will discuss Acute Stroke Care Plans among the different South-western regions in the first ICTUSnet workshop, to be held in Palma de Mallorca. We believe that ICTUSnet project will overcome different barriers by creating a permanent network that promotes collaborative research, incorporates new technologies for data analysis, and fosters mutual learning across SUDOE regions.

  • Abilleira S et al. Planning of stroke care and urgent prehospital care across Europe: Results of the ESO/ESMINT/EAN/SAFE Survey. European Stroke Journal 0(0) 1–8. (Available Online).

Towards a better stroke rehabilitation strategy

According to the paper “Stroke rehabilitation: clinical picture, assessment, and therapeutic challenge” (1), there are many factors that can affect the recovery process after stroke, such as the type of brain lesion, the severity of the stroke, the age of the patient, previous health and functional abilities, social environment and personal motivation. Thus, there is an ongoing need to find the most optimal existing rehabilitation services and therapeutic interventions.

A successful stroke rehabilitation strategy is on the World Health Organisation’s (WHO) agenda. On 2017, WHO made a call for action named “Rehabilitation 2030” with the aim of bringing stakeholders together to discuss the strategic direction for coordinated actions and establishing joint commitments to stress the role of rehabilitation as a health strategy. In line with that, the European Stroke Organisation (ESO), together with the Stroke Alliance For Europe (SAFE), recently released the Action Plan for Stroke in Europe 2018 – 2030, which includes the state of art of stroke rehabilitation in Europe, the research and development priorities in the field, and the targets for 2030.

Rehabilitation is part of the ICTUSnet scope of research. One of the outcomes of the project will be an analysis and comparison of different stroke care models, including rehabilitation and secondary prevention. In particular, this study will result on a report providing detailed information on the gaps and best practices retrieved from the stroke rehabilitation plans of the ICTUSnet regions, covering an area of 20 M inhabitants where strokes are being treated daily.

(1) Richards, C. L., Malouin, F., & Nadeau, S. (2015). Stroke rehabilitation: clinical picture, assessment, and therapeutic challenge. In Progress in brain research (Vol. 218, pp. 253-280). Elsevier.