october 2009 interventional quarter issue 2 - july 2010 iq€¦ · has established the efficacy of...

O c t o b e r 2 0 0 9

Developing Excellence:Dedicated Radiographers

5 minutes with… Dr. Robert Morgan

Remapping the Boundariesof Patient Care

6-Hour Window - Why Time is of the Essence

Stopping Stroke Damage Cold

I S S U E 2 - J u l y 2 0 1 0I n t e r v e n t i o n a l Q u a r t e r

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StrokeInterventions

IQI n t e r v e n t i o nY o u r p o r t a l t o m o d e r n m e d i c i n e

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A Welcome from the Editor

Dear Readers,

A warm welcome to yet another informative installment ofInterventional Quarter!

This issue delves into stroke, one of the most prevalentand poorly understood conditions affecting our societytoday, and offers you an exclusive look into how image-guided minimally invasive therapy can help reduce its impact.

As worrying as the official stroke statistics are, the nu -mer ous preventative and rehabilitative options availablepaint quite another picture. Far from being an inevitableconsequence of life, the burden of stroke can be signifi-cantly minimised and successfully treated. This can berealised through lifestyle changes and appropriate andtimely interdisciplinary management incorporating valu-able interventional radiology techniques. These possibili-ties illustrate how the statistics are to be conquered, notto be feared.

IQ brings you revealing interviews and reports from someof the leading physicians and authorities in the field. Ourthanks to all our contributors, and in particular to DanielRüfenacht, Ralf Baumgartner and John Mangiardi, whokindly offered us their insights and expertise in neuro -interventions.

We are pleased to introduce a field of innovators dedi-cated to excellence, whose contributions have already hada major impact and promise many more down the road.

The idea of IQ was born with one clear goal in mind: forevery patient to have the most appropriate medical treat-ment advised and available to them. For this, everybody’shelp is needed - not only physicians but also hospital administrators, healthcare providers, such as insurancecompanies, and politicians. They should all be aware ofthe huge influence of minimally invasive techniques onthe progression of modern medicine.

To implement best medical practice, a team effort is required. We strongly encourage you to pass IQ on toany individual who would benefit from its message. Alternatively, if you pass their details on to us, we willgladly make sure they receive a copy free-of-charge.Please refer to the online subscription form on www.intervention-iq.org or contact the editorial office [email protected].

As always, your feedback is gratefully received!

Wishing you a pleasant read,

Professor Jim A. ReekersEditor-in-Chief

❜

I Q | I n t e r v e n t i o n a l Q u a r t e r

Editorial OfficeGonzagagasse 16/337AT-1010 Vienna, AustriaTel: +43 (0)1 904 2003Fax: +43 (0)1 904 2003 30E-mail: [email protected]

ISSN: 2075-5813

Cover Image © Sebastian Kaulitzki

© All rights reserved by Next Publishing Research & Media / 2010The reproduction of whole or parts of articles is prohib-ited without the consent of the Publisher. The Publisherretains the right to republish all contributions and submit-ted materials via the internet and other media.

The Publisher, Editor-in-Chief, Editorial Team and their re -spective employees make every effort to ensure that noin accurate or misleading data, opinion or statement ap -pears in this publication. Contributed articles do not neces -sarily reflect the views of Interventional Quarter. This isnot a peer-reviewed journal, and professional medical ad-vice should always be sought before following or discon-tinuing any course of treatment. Therefore, the Publisher,Editor-in-Chief, Editorial Team and their respective em-ployees accept no liability for the consequences of anysuch inaccurate or misleading data, opinions or statements.

Interventional Quarter is published three times a year. To add an address to the mailing list, please [email protected] or refer to www.intervention-iq.org.

General Information

Editor-in-ChiefProf. Jim A. Reekers (Amsterdam, Netherlands)

Managing EditorNadja Alomar

Editorial TeamCiara Madden, Tochi Ugbor

Our special thanks to all Reviewers and Contributors

Reviewers:Prof. Ralf Baumgartner (Zurich, Switzerland)Prof. Klaus Hausegger (Klagenfurt, Austria)Prof. Antonin Krajina (Hradec Králové, Czech Republic)Dr. John Mangiardi (Zurich, Switzerland)Prof. Daniel Rüfenacht (Zurich, Switzerland)

Contributors:Mr. Euthimios Agadakos (Athens, Greece)Dr. Tommy Andersson (Stockholm, Sweden)Prof. Ralf Baumgartner (Zurich, Switzerland)Mr. Cestmír David (Prague, Czech Republic)Dr. Joe Harbison (Dublin, Ireland)Dr. John Mangiardi (Zurich, Switzerland)Dr. Robert Morgan (London, United Kingdom)Prof. Jan Peregrin (Prague, Czech Republic)Prof. Daniel Rüfenacht (Zurich, Switzerland)Dr. Mark Ryan (Dublin, Ireland)Dr. Alice Sheffet (New Jersey, USA)

Graphical DesignL O O P. E N T E R P R I S E S media EU / Austriawww.loop-enterprises.com

IQ is your magazine, and we would welcome yourviews and your news. Readers who wish to commenton any of the issues raised (or who would like toraise any of their own) are most welcome to submitletters to the Editor. Likewise, if you have any promo-tions, awards, honorary lectures or other tit-bitsyou’d like to share with the interventional community,please send them to us by post or by email.

We look forward to hearing from you!IQ Editorial Team

Email: [email protected] to: Gonzagagasse 16/337, AT-1010 Vienna, Austria

An invitation to our readers ✱

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Stroke InterventionsThe facts behind the conditionWhat is a stroke - risk factors - diagnosis - available treatments - why IR is gaining ground

Remapping the Boundaries of Patient CareThe success story of the St. James’ Stroke Unit, Dublin

WorldviewStroke projects and news at a glance

6-Hour Window - Why Time is of the EssenceThe reasons behind the drive for awareness

Stroke Management, Swedish StyleWhat lessons can be learned from the successful Swedish model

Stopping Stroke Damage ColdHypothermic therapy and its use as a neuroprotector

Making a World of DifferenceHow advances in imaging are revolutionising stroke therapy

The Evolution of TherapyAll eyes on minimally invasive, image-guided therapy

Clinical Pathways for StrokeStandardising the decision tree for consistent care

The Stroke RegistryFollowing the data to improve stroke care

Stroke Interventions Trials and RegistriesA selection of current trials and registries

5 minutes with… Dr. Robert MorganRespected British IR, Dr. Robert Morgan, on training, collaboration and patient safety

Developing Excellence: Dedicated RadiographersExamining this growing trend

Featured Trials: CREST and SAPPHIRE StudiesLatest results from two major trials examining stenting in carotid artery disease

Trials and RegistriesA selection of current trials and registries

The Early Days of IRHow the Seldinger technique paved the way for interventional radiology

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Contents

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StrokeInterventionsThe medical affliction of stroke has been known for almost 2,500 years,being described by Hippocrates (then called apoplexy). However, all thatwas known until recently were the symptoms - the sudden onset ofparalysis. The cause and the cure remained outside the influence of medi-cine for many, many centuries. Therapy has only become available in re-cent years as doctors discovered more about the causes and mechanismsof stroke. Currently, many stroke patients can experience no or few dis-abilities - provided they get treated promptly.

What is a stroke?

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A stroke occurs when a blood vessel carrying oxygen tothe brain is blocked or bursts. Deprived of oxygen andglucose, the brain cells start to die, potentially causingparalysis, speech or language difficulties, vision problemsor diminished motor skills, depending on what region ofthe brain is affected (see image, page 10).

According to the WHO, stroke is the leading cause oflong-term disability worldwide, as well as being the sec-ond most important cause of cognitive impairment afterAlzheimer’s disease. This can have a terrible effect onthe quality of life of the affected individual and their fami-lies, and results in massive healthcare and pensioncosts. It is also the third greatest cause of death world-wide, after coronary heart disease and cancer1. But farfrom being untreatable, a substantial body of evidencehas established the efficacy of various strategies for theprevention and treatment of stroke.

Ischaemic stroke

Ischaemic stroke is caused by a blockage of blood vessels which irrigate the brain, and accounts for 80% of strokes. Ischaemic stroke can result from differentcauses, but large artery atherosclerosis is generally themost frequent cause.

· Cerebral embolism is the most commonly treatedform of ischae mic stroke. An embolus (plateletthrombi, lipids and/or pieces of plaque) breaks freeand is carried to the brain in the bloodstream.

· Lacunar stroke affects a single vessel, which sup-plies the brainstem or subcortical areas. It is typicallydue to small artery occlusion, but may also result fromcerebral embolism.

Ischaemic stroke affects both a core area and the sur-rounding tissue (penumbra). The core area is usuallydamaged irreparably, but the penumbra can often be sal-vaged, if blood supply is re-established in time. Savingthis tissue is the focus of most treatments (see page 26).

A subgroup of “minor” ischaemic events also exist. These may only have a short-term effect, but shouldnonetheless be taken seriously, as they may act as awarning of more events to come:

A Reversible Ischaemic Neurological Deficit (RIND) isa stroke that lasts at least 24 hours and a maximum of 3 days. A Prolonged RIND (PRIND) lasts at least 24 hours and a maximum of 7 days. Both are usually classi-fied as an ischaemic stroke.

A Transient Ischaemic Attack (TIA) persists for lessthan 24 hours, in most cases for less than 1 hour. Al-though it may cause no lasting damage, it is usually awarning sign that a larger stroke is pending, and soshould be taken seriously. Preventative measures canthen be implemented by medical staff. TIA patients havebeen shown to have an 8% risk of stroke in the followingweek, which rises to 17.3% at 3 months2.

Stroke is the leading causeof long-term disabilityworldwide, as well as … the third greatest cause ofdeath worldwide

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Forms of strokeThere are two categories of stroke:

Ischaemic StrokeHaemorrhagic Stroke

Causes of Ischaemic Stroke

Large artery atherosclerosisSmall artery occlusion

80%

20%

Cardiac embolismOther

36%

27%

13%

24%

Ischaemic figures according to the Trial of ORG 10172 in Acute Stroke

Treatment (TOAST). The incidence of these stroke subtypes varies

according to the population under investigation.

1 American Stroke Association; WHO; Irish Heart Foundation;

Department of Health (UK)

2 Heartwise, Spring 2007

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Stroke Intervent ions


The most important thingwhen faced with stroke orTIA is to seek urgent medical attention

Haemorrhagic stroke is caused by rupture of a blood ves-sel, either within the brain (intracerebral or ICH) or justbe low it (subarachnoid or SAH). The outcome for patientswith ICH is worse than after ischaemic stroke, with 35-52%of patients deceased at 1 month and only 20% function-ally independent at 6 months. The outcome after SAH isat least as poor, with population-based mortality rates ashigh as 45% and significant morbidity among survivors.

Risk factorsRisk factors for stroke are either non-modifiable (age,sex, race/ethnicity, family history) or modifiable. Modifi-able factors include cigarette smoking, arterial hyperten-sion, diabetes mellitus, hypercholesterolemia, obesity,contraceptive pill or hormone replacement therapy, atrialfibrilla tion and other cardiac diseases, and stenosis andocclusion of cerebral arteries.

Stroke is a disease of the elderly, as almost three quartersof patients are at least 65 years of age. However, of the28% of stroke patients who are under 653, many are link -ed to risk factors such as diabetes, heavy smoking anddrug abuse. Others result from vascular disorders or trau - ma. Stroke in children is usually caused by heart or blooddisorders (such as sickle cell anaemia), vascular mal forma -tions, or is a complication of another infection or trauma.

SymptomsHaemorrhagic stroke

Stroke cuts off blood supply to the brain, which is respon-sible for many different motor functions such as speech,movement and vision. The signs of stroke appear suddenly, and include:

· Slurred speech or difficulty with language (productionor reception)

· Numbness, weakness or paralysis on one side of thebody

· Severe headache · Confusion or unsteadiness

Accordingly, the Face Arm Speech Test (FAST) is a simple way to recognise if someone has suffered a strokeor TIA. Any of these signs can indicate stroke:

Face: Mouth or eye drooping, inability to smile normallyArms: Weakness, inability to raise both arms properlySpeech: Slurred or unintelligible speech, inability to understand speech of others➡ Time to call the emergency services

The most important thing when faced with stroke or TIAis to seek urgent medical attention. The longer the brainis deprived of oxygen, the less chance that the brain willsurvive unharmed. For this reason, hospitals and para-medic teams are now treating stroke as a medical emer-gency (see page 20).

3 WHO, www.who.int

Haemorrhagic Stroke Locations

SubarachnoidDeep brainCerebellumLobarBrain stem

25% 26%

4%

37%

Haemorrhagic figures taken from one population study of 1041 ICHs.

8%

Preventat i ve measures

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Surgery

Carotid endarterectomy (CEA) - a procedure where thevessel is surgically opened and the plaque build-up ismechanically removed. Trials comparing carotid endart -erectomy and interventional radiology methods are ongo-ing. CEA is currently used as the standard treatment forsuitable patients, but trial data4 released in early 2010 in-dicates that stenting is a safe and efficacious alternative.

Neurovascular surgery can address bleeding disorders(aneurysms, vascular malformations) and allow for re -vascularisation in case of the need to increase brain perfusion (stenoses, occlusions).

Interventional Radiology

Endovascular therapy - access and treatment optionsfor neurovascular diseases have rapidly evolved over thelast two decades. Access is mostly from the groin, andwith the advent of telescopic coaxial catheter systems,lesions can now be reached and treated rapidly. Methodsof endovascular flow corrections include occlusion by im-plants or unblocking using a variety of tools, includingballoon, stent, retriever or aspiration systems. For in-tracranial lesions, there is a need for very flexible, atrau-matic devices requiring special training.

Possible preventative measures

Stroke is often seen as something unpreventable, butin truth, there are a number of preventative measuresthat can be taken. According to the WHO, treating hypertension (high blood pressure) can reduce therisk of stroke by up to 40%. Being aware of the modi-fiable risk factors and taking appropriate measurescan help people lower their risk of stroke.

· Stop smoking (makes blood thicker, raises blood pressure, chemicals damage blood vessel walls)

· Reduce fatty and salty foods (clogs arteries, raisesblood pressure)

· Maintain a healthy weight (extra strain on heart)· Don’t drink heavily (raises blood pressure)· Exercise (to keep heart and bloodstream healthy)· Have blood pressure checked regularly

Medication

For those at high risk, various medications can help protect against stroke:

· Antiplatelet drugssuch as aspirin prevent platelet aggregation (processof scab formation).

· Anticoagulantssuch as heparin or warfarin can thin the blood andprevent clotting. Heparin is introduced to the blood-stream by injection in-hospital. Warfarin is usuallygiven orally over a longer term.

· Beta blockersand various angiotensin drugs can help lower bloodpressure.

· Statinscan help control soaring cholesterol levels.

For patients exhibiting >60% carotid stenosis, mechani-cal unblocking of the artery can help counter the risk ofstroke. This can be done by surgical or interventionalmethods:

Being aware of the modifiable risk factors and taking appropriatemeasures can help peoplelower their risk of stroke

PlaqueCatheterVessel

Stent

1 Catheter de-

ployed to site of

plaque build-up

2 Stent delivered

over catheter

3 Balloon inflat ed

to expand stent

and widen vessel4 CREST and SAPPHIRE trials (see page 37)

28% of stroke patients …are under 65

>

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Emergency management of stroke patients includes theassessment of neurological and medical history, a clinicaland neurological examination including the determinationof stroke severity with the National Institute of HealthStroke Scale (NIHSS) and the Glasgow Coma Scale(GCS), an electrocardiogram, laboratory studies andbrain imaging.

Emergency management of stroke patients

Diagnostic imaging for strokes is crucial to stroke man-agement and should be carried out as soon as the pa-tient arrives in the hospital. Imaging can be used to helpdetermine the cause and extent of damage that resultsfrom a stroke. It is important to distinguish betweenhaemorrhagic and ischaemic strokes, as each requires adistinct treatment process. When a stroke patient arrivesin the hospital, Computer Tomography (CT) is often thefirst imaging modality used.

Diagnostic brain imagingThere are numerous imaging modalities available for usein stroke imaging. While smaller stoke units may onlyhave one or two modalities at their disposal, larger unitsmay be able to make use of the wealth of modalities thatexist. However, it is widely agreed that CT imaging mustbe available for the normal functioning of any stroke unit,and MRI and Diffusion Weighted Imaging (DWI) are ex-tremely beneficial in many cases. The various modalitiesthat exist are listed below:

Diagnostic imaging shouldbe carried out as soon asthe patient arrives in thehospital

Usually the first modality used on patients as they enter the stroke unit. CT can be used todistinguish between ischaemic and haemorrhagic strokes.

CTA is used to identify vascular anatomy, site of vessel obstruction and impact on perfusion or type of lesion leading to bleeding (aneurysm, vascular malformation).

Provide a high level of anatomic detail, which helps physicians determine the areas of thebrain that have been damaged by strokes more easily.

MRA can provide similar information to CTA, but without exposing the patient to x-ray. It can add information on flow but usually fails to demonstrate vessel calcification.

New technologies that were developed for the early detection of stroke and can be used todetect the areas of the brain that have been damaged by stroke.

Can be used to visualise any narrowing or clotting in the extracranial carotid arteries aswell as how fast blood is flowing through them to the brain.

A variation of the ultrasound procedure using a small probe that is placed against the skull.The images produced show the flow of blood through the cerebral blood vessels.

PET scans can be used to quantitatively assess blood flow to the brain (perfusion) to identify brain at risk of hypoperfusion.

Produces a detailed view of the blood vessels using x-rays. It provides images of highesttemporal and spatial resolution and is key to successful endovascular treatment.

An ultrasound of the heart to help determine if the patient has atrial fibrillation or a patentforamen ovale.

Modality Uses

Computer Tomography(CT)

CT Angiography (CTA)

Magnetic ResonanceImaging (MR/MRI)

MR Angiography (MRA)

Diffusion/PerfusionWeighted Imaging

Carotid Ultrasonography

Transcranial Doppler(TCD)

Positron Emission Tomography (PET)

Arteriography

Echocardiogram (ECG)

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Treatment measures

Treatment measures

“Time is brain” - up to 2 million brain cells can dieevery minute that oxygenperfusion is cut off

Having suffered a stroke, the most important thing is toget medical attention as quickly as possible. The longerthe brain goes without oxygen, the worse the chancesare of a full recovery. As the experts say, “time is brain” -up to 2 million brain cells can die every minute that oxygen perfusion is cut off.

Ischaemic stroke

Thrombolytic drugs (tissue plasminogen activator or t-PA)can often dissolve a clot, returning blood flow to normal.Studies have shown that intravenous thrombolysis(IVT) given within 4.5 hours of symptom onset is benefi-cial in selected stroke patients. This medication carries aslight risk of symptomatic haemorrhage (about 5% inroutine clinical practice), but used correctly by experi-enced doctors, the benefits usually outweigh the risks.

This 4.5-hour window can be extended up to 6 hours byintra-arterial thrombolysis (IAT) or up to 8 hours bymechanical thrombectomy (MT), performed by an inter-ventional radiologist. IAT uses a catheter to deliver thedrugs directly to the clot site. Many centres also use"bridging" - a two-step thrombolytic treatment where thefirst dose is delivered intravenously and the remainingone intra-arterially.

The findings of two small-scale studies suggest thatIAT removes the large clots occluding basal cerebralarteries more efficiently compared with IVT. Conse-quently, many centres use IAT and/or MT in patientswith middle cerebral artery occlusion who would becandidates for IVT.

Thrombectomy can be used in non-responsive cases.This involves mechanically fragmenting, dislodging or extracting the thrombus (clot) by means of catheter techniques or endovascular instruments.

Extraction of clot: Achieved by aspiration (suction) or by use of instruments that allow for extracting embolicmaterial (e.g. pincers, non-detachable self-expanding, retrievable stents and "cork-screw" devices [MERCI Retrieval System, Penumbra System]).

Recanalisation and local clot trapping: Microcatheteraccess to the occluded vessel and clot allows for deliveryof a stent, rapidly establishing blood flow and enhancingin-situ lysis of the clot.

Fragmentation and dislodging: Achieved by using aballoon to fragment and dislodge the clot in smaller ves-sels. This method was met with initial enthusiasm, but iscurrently not widely employed.

Simultaneous treatment of underlying stenotic disease(causing narrowing of the vessel) or dissection (tears) mayequire emergency vessel repair by stenting procedures(carotid artery stenting - CAS, intracranial stenting - ICS).

Haemorrhagic stroke

Haemorrhages within the skull are difficult to treat, andmanagement of intercerebral haemorrhage (ICH) in-cludes the treatment of hypertension and medical com-plications, and the prevention of recurrent ICH.

There are two main alternatives when treating an aneurys - mal subarachnoid haemorrhage (bleed below the brain):

· Surgical (metal clip to clamp aneurysm)· Interventional (coil embolisation to stem blood flow)

Studies such as the ISAT trial clearly demonstrate aclinical advantage to coil embolisation. Surgery per-formed on the brain region is risky, and entails a long ecovery process, but delivering an agent such ascoils via catheter to block the blood flow gives thepa tient a less invasive option. Thanks to further re-search in the field, a new liquid embolic agent hasbeen developed that is showing promise (see World-view, page 18).

>

Penumbra aspiration. Courtesy of Penumbra Inc., Alameda, CA/USA

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As these outcomes can often be temporary, physiothera-pists and occupational or speech therapists can workwith patients to recover control of the affected body parts. They can help patients with the process of “re-learning” skills that may have been affected by theirstroke. Once brain cells are dead, they cannot regener-ate. However, the surrounding cells may not be fullydead, but merely damaged, and with proper treatment,they can often recover. Sometimes these cells may eventake on the function of the dead cells. The work ofspeech and physiotherapists is invaluable in helping thisrecovery.

For those patients whose disability is long-term or per-manent, palliative care and support systems are essen-tial. Those with stroke-induced visual disabilities mayrequire a white cane, guide dog or coaching to help themreadjust their daily life and learn new skills, such as read-ing Braille. Like those who incur disabilities causing mo-bility problems, their homes may need to be adapted tomake them more user-friendly. This is especially true ofsplit-level housing, as patients who retain a degree of independent movement often find stairs difficult to negoti - ate. However, some patients may find their mobility totallyreduced, and may become dependent on home-carers ornursing homes. Home help may also be required by lessdisabled patients, who nonetheless require extra assis-tance with household chores, such as cleaning andshopping.

Once brain cells are dead,they cannot regenerate.However, the surroundingcells may be merely damaged, and with propertreatment, can often recover

As stroke results from the occlusion of blood vessels orfrom blood clot formation, it is highly probable that theunderlying causes remain, even after the stroke itself hasbeen managed. If arteries remain narrowed, anotherstroke may be just around the corner. Thus, post-strokemanagement broadly correlates with preventative meas-ures, such as antithrombotic therapy, carotid revasculari-sation or closure of a patent foramen ovale, andtreatment of vascular risk factors.

Stroke can often have a negative impact on a patient’snormal functions. Due to the lack of oxygen damagingbrain cells, control over certain bodily functions may bereduced or absent, either short-term or permanently.Common examples include visual disturbance (such asblurred vision, tunnel vision or blindness), loss of controlover limbs and/or face on one side of the body, or prob-lems with speech (vocabulary, understanding or slurredspeech). These outcomes are frightening and debilitatingfor the patient, and care must be taken to reduce thisburden as much as possible.

Post-stroke measures

Soundanalysisand inter-pretation

Behaviour andpersonality

Voluntarymovements

Speech

Coordination

© Korat_cn

www.stroke.org.uk (The Stroke Association/UK) www.irishheart.ie (Irish Heart Foundation/IE)www.world-stroke.org (World Stroke Organisation/WSO) www.eso-stroke.org (European Stroke Organisation/ESO)www.safestroke.org (Stroke Alliance for Europe/SAFE) www.strokeassociation.org (American Stroke Association/US)

>

Why IR is gaining ground

11

Why IR is gaining ground

According to current WHO data, between 1981 and2001, the number of minimally invasive preventativestroke treatments performed increased steadily,while surgical treatment numbers remained constantor declined. This clearly shows the growing impor-tance of interventional treatments in stroke therapy.Given that there has been a phenomenal increase inthe number of dedicated stroke units since this datawas collected, it can only be assumed that this trendhas continued even more steeply.

This is both fuelled by and fuelling the revolution in stroke care that has been gathering momentum for the lastthree decades. The advent of thrombolytic drugs and ad-vances in medical understanding of the condition, as wellas advances in diagnostic imaging, have enabled manymedical specialities to contribute to stroke care.

This has mainly been driven by neurologists, but includes cardiologists, internists, general practitioners, emergencyspecialists, anaesthesiologists, ICU physicians, para-medics and neuroradiologists. IR physicians have joinedthis group, with their increasing armamentarium of mini-mally invasive image-guided therapies allowing for amore comprehensive approach to stroke care.

This group effort facilitates the treatment of many differ-ent categories of stroke. In raising awareness of thisavailability, more GPs and paramedics are immediatelyreferring stroke patients to hospitals, and more strokesufferers know to seek emergency care. This leads tomore treatment of the condition generally.

Dedicated stroke units

With increased patient volumes, hospitals are in a posi-tion to dedicate resources to this patient population.Many hospitals are establishing dedicated stroke units,which adhere to increasingly uniform treatment protocolsand standards for ensuring swift and suitable treatment.

In larger hospitals with appropriate interventional radiol-ogy staffing arrangements, IR techniques such as intra-arterial thrombolysis and thrombectomy can be offeredon a 24-hour basis. However, both in terms of availabilityof staff, and in terms of quality standards and costs, it isnot feasible to offer the full range of available treatmentsin every hospital.

These considerations have led to the “ComprehensiveStroke Centre” (CSC) concept, introduced in 1995, givingrise to the next step in the evolution of the stroke careparadigm; one that allows for a more cost-effective andproductive use of IR manpower resources.

It goes without saying that patient outcomes improve incentres that are capable of achieving a case volume thatensures a threshold level of technical and clinical experi-ence.

Of the total number of stroke patients who present to astroke centre for acute therapy, an estimated 10-20% re-quires IR intervention. By concentrating IR resources incentralised CSCs, patients requiring IR intervention willbenefit from more appropriate and concentrated care.

In larger hospitals … IR techniques such as intra-arterial thrombolysis andthrombectomy can be offered on a 24-hour basis

The “Comprehensive StrokeCentre” (CSC) concept …allows for a more cost-effective and productive useof IR manpower resources

>

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IR techniques are particularly valuable for large vesselocclusion, which can rarely be attacked with successusing IVT alone. The direct access to large vessel occlu-sion has become increasingly feasible and safe, allowingdoctors to treat a greater percentage of patients than pre-viously.

In certain cases, such as carotid artery dissection, IRcatheter treatments give doctors the opportunity oftreating both the emergency problem and its sourcesimultaneously - when removing the clot, structuraldamage within the vessel can also be repaired. Thisis of huge benefit for both patient and clinic, as it re-duces both the need for a repeat procedure, and thelikelihood of stroke recurrence.

Haemorrhagic strokeIR has a large contribution to make in the managementof haemorrhagic stroke. While large haemorrhages arestill removed surgically, IR therapies for aneurysm repair,AVM embolisation, and stenting of arterial dissectionsand aneurysms are becoming increasingly available. Therole of the IR physician is therefore becoming more im-portant, as there is a need for early treatment of such lesions, due to the higher risk of re-rupture in the daysfollowing haemorrhage.

In treating subarachnoid haemorrhage, trials haveshown that coil embolisation has markedly betterclinical outcomes than using surgical clips to stemthe flow of blood, and in many centres, it is the standard treatment given.

Direct access to large vesselocclusion has become increasingly feasible andsafe, allowing doctors totreat a greater percentageof patients than previously

On the other hand, the “time is brain” imperative de-mands that stroke care occurs as swiftly as possible, requiring intravenous thrombolytic therapy to be ad -ministered at a stroke centre that is as physically close tothe location of the event as possible.

For this reason, CSCs should ideally be located in a cen-tralised geographical location to allow for multiple strokecentres to efficiently transfer such patients after havingbeen evaluated locally. Countries with well-integrated hel-icopter ambulance programmes are particularly suited tograpple with this solution in a timely way.

The benefits of IR

New imaging modalities make accurate diagnosis of thecauses, location and type of stroke, which allows formore tailored treatment. Specifically, it can help doctorsdetermine which patients will respond well to the stan-dard ischaemic treatment of intravenous thrombolysis(IVT), and which require more active treatments such asthrombectomy or local (intra-arterial) thrombolysis.

IR can also help to pre-emptively treat non-symptomaticvascular problems, increasing the demand for trained interventional neuroradiologists.

Ischaemic strokeThere are a number of clinical situations where IR treat-ment is required. Firstly, there is the issue of the timewindow - as there are often some delays (patient beingdiscovered and reported; transport to hospital; diagno-sis), many of these patients are outside the time windowthat exists for systemic thrombolysis, but are still candi-dates for local thrombolysis and for thrombectomy, bothof which are facilitated by IRs.

Of the total number of strokepatients who present to astroke centre for acute therapy, an estimated 10-20% requires IR intervention

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Increased demand

Other research has shown that interventional procedureshold many of the advantages now expected from mini-mally invasive therapy - avoids the use of general anaes-thetic; is less painful for the patient and entails shorterrecovery time; can be used in patients who are not candi-dates for surgery; avoids surgical complications such ascranial nerve injury, haematoma and wound infection;and specific to the delicate brain region, it can treat nar-rowed arteries that are difficult to access or treat surgi-cally. However, this must be factored against a slightlyhigher risk of intra-operative stroke, so doctors must al-ways consider all their patients’ options before selectingthe best course of action.

As new IR technologies become available, the need totrain stroke team members and increase awareness ofthese therapeutic capabilities has grown. This need for IRmanpower has resulted in training programmes for bothneuroradiologists and neurosurgeons, leading to the newsubspecialty of the hybrid neurointerventionalist, but thedemand is growing faster than these specialists can berecruited.

This represents an opportunity for IRs to specialise inthese technologies, as well as for the European radiological societies who provide education, to establishquality standards, and ensure availability of the proce-dures throughout Europe. IRs are in a position to have ahugely positive impact on patient outcomes in this field.

Health economics

Some of these treatments may be costly (coil embolisa-tion, being in its infancy, is currently markedly more ex-pensive than its surgical alternative), but the bottom lineis that stroke treatment is nearly always a money-savingventure. Without treatment, patients who are luckyenough to survive their stroke inevitably face some de-gree of disability. As the underlying conditions remain,stroke can follow stroke, and the toll this takes on the pa-tient’s independence can be staggering. With reducedcapacity, a stroke survivor may require full-time care, and

whether this is provided by a nursing home, or homesupport for the family, this is an expensive and tragic out-come for the patient, the relatives and the healthproviders.

Accordingly, we should view immediate treatment ofstroke, and failing that, physio- and speech therapy asbeing a top priority, both from a humanitarian and aneconomic point of view. The cost of any one proceduremay be expensive, but will always compare favourablywith the cost of years of full-time nursing care - a likelyoutcome, given that stroke is the leading cause of dis-ability in the industrialised world.

As such, minimally invasive stroke treatment optionsprovide both patient and health provider with opportunities that could not have been dreamed of 30 years ago. Incorporating their potential into therange of treatments made available to patients is essential if the burden of stroke is to be counteredand reduced. Advances in medicine are continuallyoffering patients new options, and interventional radiology is certainly playing its part.

IRs are in a position tohave a hugely positive impact on patient outcomesin this field

With thanks to Prof. Ralf Baumgartner, Dr. John Mangiardi and Prof. Daniel

Rüfenacht

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Remapping the Boundaries of Patient CareThe Acute Stroke Unit, St. James’ Hospital, Dublin

Introducing Dr. Joe HarbisonFour years ago, Ireland had the poorest stroke outcomesin Western Europe, and St. James’ Hospital was no ex-ception. However, this situation has rapidly changed,largely led by one of the country’s leading stroke experts,Dr. Harbison. Due to his work, he, together with Dr. PeterKelly of the Mater Hospital in Dublin, has been namedjoint national Clinical Lead in Stroke Management, advis-ing the government on stroke policy.

Welcome to St. James’Dr. Harbison came to St. James’ Hospital in 2006, osten-sibly as a consultant geriatrician. Stroke experts were notreally prioritised, and due to the traditional training struc-tures in the UK (Harbison’s native land), stroke is lumpedinto the category of geriatric medicine. Although the ma-jority who suffer stroke are indeed older, it is, points outHarbison, by no means an exclusively “older” disease.“The average age of first stroke is 73, but it can happenany time. At the moment, my youngest “geriatric” patientis 33,” he laughs.

The reasons for doing so are clear: “Studies have shownthat stroke patients treated in a dedicated unit have 25%better outcomes, and that’s without factoring in thrombol-ysis or extra resources - merely having a dedicated areaseems to be enough to improve outcomes.” Interestingly,the Stroke Unit is the first unit in Ireland to have both anintra-arterial thrombolysis (IAT) protocol, and to provide a24-hour IAT service.

“Time is Brain”The whole point of this improved arrangement is to treatpatients as quickly as possible. Dr. Harbison clarifies whythis is: “Every minute your artery remains blocked, youlose 2 million brain cells, and this has the potential to in-jure every function that makes you ‘you’. If you suffer aminor or ordinary stroke and get immediate treatment,you can expect to make a good recovery; alternatively, inthe case of delayed treatment, some form of disability islikely.”

Awareness-raising: Paramedics & GPsIn order to implement this, the stroke unit has put a lot ofwork into awareness-raising. The first ports of call werethe paramedics and GPs. “Our paramedics are fullyaware that stroke is a blue light situation, and do tremen-dous work bringing them in promptly. Likewise, local GPshave been made aware that suspected strokes are to bereferred to the unit immediately,” explained Dr. Harbison.

Logistics & 24-hour Stroke Care“We see all stroke patients within an hour of admission,usually less. Our fastest door-to-needle time was 23 min-utes - granted, their timing was impeccable, they arrivedat the same time as all our consultants did, so they wereessentially all in the right place at the right time, but that’s a very rare occurrence. Unfortunately, there’s no way ofpredicting when a stroke patient is going to come in.” Dueto this, the hospital ensures that there is 24-hour strokecare available.

IQ spoke to Dr. Joe Harbison, head of theAcute Stroke Unit in St. James’ Hospital,Dublin, and interventional radiologist Dr. MarkRyan, to find out why their stroke unit is mak-ing such a difference.

Setting up the Stroke Unit - Hospital ManagementThe hospital has a catchment area of roughly 300,000people, many of whom in the immediate locality, explainsDr. Harbison, are older and poorer, a population which isdisproportionately affected by stroke and worse out-comes. So, when asked about setting up the stroke unit,he points out that the hospital was already dealing withmany stroke cases, and streamlining those resources toimprove services was not such a radical departure andwas strongly supported by hospital management.

The hospital ensures thatthere is 24-hour stroke careavailable... This includesround-the-clock availability of IR

A vital element of stroke therapy is the rise of thestroke unit - a dedicated medical team that ensuresoptimal and immediate treatment for suspectedstroke patients.

Remapping the Boundaries of Pat ient Care

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Interventional RadiologyThis includes round-the-clock availability of interventionalradiology, which can be used to deliver intra-arterialthrombolysis or to mechanically remove a clot. Interven-tional radiology is a useful ally to have in stroke treat-ment because there are some situations whereintravenous thrombolysis, or indeed, any thrombolysismay not work. “Only recently, we had a young patientwith a severe blockage - IV thrombolysis wasn’t going toshift it, nothing was going to shift it, and we knew just bylooking at the angiograms that the only thing that wouldimprove his outcomes was letting the IRs go in with theircrocodiles and fish it out mechanically. Ten years ago, ifhe’d survived, he would have been severely disabled,

and would have been looking at many years of depend-ent living. Now he’s gone home with no complications,”smiles Dr. Harbison.

Available TreatmentsSt. James’ Hospital uses both intravenous and intra-arter-ial thrombolysis to tackle ischaemic stroke, and Dr. Harbison is very enthusiastic about it. "In certaincases, thrombolysis can be a cure for stroke," he says."How many diseases can you say that about?" By offer-ing this and other therapies, the great majority of strokepatients admitted to the unit have improved outcomes,with 80% returning home.

>REFERRALS

Once in the Emergency Department, suspected strokepatients are given the same priority as suspected heartattacks - they are immediately imaged and assessed,and treatment is then decided upon. Haemorrhagicstrokes are transferred to the neurointerventional centreat Beaumont Hospital for treatment. Ischaemic strokesare immediately moved to the Acute Stroke Unit housedin the neighbouring Acute Medical Admissions Unit.

ACUTE STROKE UNIT

BedsThe unit has 6 priority stroke beds.

Patient monitoringStroke patients are monitored wirelessly for heart rateand respiration, allowing them to receive physiotherapywithout being hindered, but patient cognition is also es-sential, and nurses regularly check that patients are alertand well.Dedicated staff· Consultant· Clinical nurse manager and secretary· Shared registrar· Senior house officer and intern· Half-time senior physiotherapist· Half-time occupational therapistOther staff· Rotational general staff· Speech and language therapy provided by rehabilitation wards

Additional staff and beds can be brought in from otherdepartments when needed, and likewise, during quiettimes, stroke unit staff and unoccupied beds can be usedfor other purposes. “There’s no strict arrangement, it’sjust a question of practicality,” explains Dr. Harbison.

Dr. Joe Harbison is Directorof the Acute Stroke Unit atSt. James’ Hospital. He isalso Secretary of the IrishHeart Foundation’s Councilon Stroke (see page 21).

EMERGENCY DEPARTMENT

The St. James’ Acute Stroke Unit is based on the Goteborg model

ACUTE MEDICAL ADMISSIONS

Acute StrokeUnit

Medicine forthe Elderly

Physiotherapy

FACT BOX

As it stands, since 2006:· bed occupancy reduced by 40%· mortality reduced by over a third· average length of stay cut by a week

Seeing that a bed in the ward costs an average of €250a night and the unit admits 400 patients a year, a savingof €700,000 annually can be achieved on this last factoralone.

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>FundingSo far, the hospital has achieved great results with verylittle extra investment, but now the stroke unit is lookingto expand their outcomes by investing in specialised carefacilities. However, the economic downturn of the pasttwo years has not helped the issue of funding. Money islargely being raised through donations: the unit has a setgoal of equipment they want to acquire, and have set thetarget at a modest €250,000. They have recently ac-quired enough funds to purchase a new TranscranialDoppler (see page 8), and have prioritised therapeuticseating and a rehabilitation gym. This equipment is es-sential to maximising the potential of physiotherapy, andgetting patients back to living their lives as normally aspossible. In addition, money goes towards equipmentsuch as proper hoists that help staff work more efficiently,lightening the load somewhat. Donations to the unit arealso used to fund master’s studies, as training new physiotherapists represents a long-term investment inpatient care.

agrees: “If you delay imaging and diagnosis, you’re goingto end up with higher costs.” He adds that from an eco-nomic standpoint, even though treatment may necessar-ily be an expensive interventional procedure, the costs ofthe disability will normally far outweigh that of treatment.

The Story So FarThis data seems to speak for itself, and it is no wonderthat hospitals throughout Ireland are eager to experiencethe benefits that a dedicated stroke unit can offer. Threeyears ago, Ireland had one dedicated stroke unit at theMater Hospital. Two years ago, that grew to two units,and now 14 of the 32 acute hospitals in Ireland havesome form of stroke unit.

Dr. Harbison once said that therapeutic nihilism was thegreatest challenge facing stroke patients. When con-fronted with this statement, he laughs and says, “Notanymore. Now there is great awareness among the med-ical community, and it’s growing all the time. But aware-ness is still poor among non-medics. A lot of people havea vague idea what a stroke is, but most couldn’t nameone symptom. This is what the Irish Heart Foundationawareness scheme* is trying to tackle.”

“Personally, I approach each case with the belief that Ican do something to improve the outcomes of the pa-tient. In the vast majority of cases, that belief is justifiedby the results achieved, and I think it’s very importantthat clinicians have a positive approach.”

The St. James’ Foundation runs fund-raising initiatives to improve the hospital’s services. For more information,please see www.stjames.ie/AboutUs/Donations.

*The Irish Heart Foundation launched their “FAST” StrokeAction campaign in May 2010. For more information,please visit www.stroke.ie, or turn to page 21.

Hospital management knowthat this is a tremendous initiative and a tremendousservice to have in the hospi-

Studies have shown thatstroke patients treated in adedicated unit have 25% better outcomes

Value-for-moneyThe hospital management at St. James’ Hospital hasfrom the outset been very supportive of the Acute StrokeUnit, and Dr. Ryan explains why this is: “They know thatthis is a tremendous initiative and a tremendous serviceto have in the hospital, and if you can cut down the in-hospital stay of the patient from six months to threeweeks, that’s a massive saving for the hospital.”

We ask the doctors how the stroke unit fares in a value-for-money analysis in light of the sordid but unavoidableelement of financial restrictions. Dr. Ryan asserts: “If youcan treat patients early, the disease process is much lesssevere and the rehabilitation is much quicker, less costly,and they can get back out to independent living. It’s a no-brainer to invest resources up front, because you getpay-back many times over at the other end.” Dr. Harbison

The multidisciplinary team at St. James' provides a wide range of support services for stroke patients. Images courtesy of Anthony Edwards (Senior Clinical Photographer, St. James' Hospital).

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Strokes can happen at any time. Dr. Ryan explainshow emergency cover is provided:

"We act as a liaison service to the Stroke Unit, and there’san agreement, whereby an interventional radiologist isavailable at all times for stroke emergencies. I’m one ofthree interventional radiologists here at St. James’, so therewill always be one of us in the IR suite during the day.

We are a busy hospital, so our interventional list is full allthe time. If anything, we could do with more IRs and an-other endovascular room and we could probably doubleour daily workload without any difficulty. When the occa-sion arises where an acute stroke presents to the hospi-tal and intra-arterial thrombolysis (IAT) is considered tobe the optimal treatment, this takes precedence overeverything else and the decks are cleared to deal with itimmediate ly. An IR is available for emergencies 24/7.Working with a dedicated and incredibly motivated stroketeam, as we do here in St James' Hospital, has been afantastic ex perience."

Most effective stroke units offer interventional treat-ments on top of the standard intravenous thromboly-sis: if the latter doesn’t work, the dosage can’t simp lybe topped up indefinitely, as there are risks of bleedingassociated with it. For this reason, it is important thatpatients receive suitable diagnosis and treatment.

"All stroke patients immediately upon arriving in theEmergency Department will have a CT brain scan - weare using perfusion CT to assess how much of the brainis inadequately perfused and based upon that, and as-sessment of their status by the stroke team, some wouldend up coming for IAT where we immediately go to thearea of the blockage and deliver tPA to try to quickly lysethe thrombus.

This intra-arterial approach also gives us an opportunityto treat some of the causes of these patients’ stroke,such as an acute carotid artery or basilar artery dissec-tion. This is done at the same time as the thrombolysis,giving patients the best chance of a positive outcome.

There are various different windows of opportunity for gi -ving intra-arterial or intravenous, and the indications forgiving thrombolysis are expanding all the time as we learnmore and more about it. We don’t treat as many patientsas we would like using IAT, due to delayed presentation,but the numbers are increasing, and have been since westarted. There is a major natio nal awareness campaignunderway in Ireland at present and community doctorsand patients are becoming more alert to the necessity forearly presentation to a Stroke Unit. We would expect tosee our workload to continue to increase, as the aware-ness campaign continues to be rolled out."

Dr. Mark Ryan, Consultant Interventional Radiologist at St. James’ Hospital, on the role IRis playing within the Stroke Unit

New technologies offer more scope for intervention-ists to treat patients, but the procedural costs can bequite high. What constitutes value-for-money is acomplex calculation, and one where IR proves attimes to be the more reasonable option:

"One area where we have found some difficulty is in ac-cessing a few of the newer mechanical thrombolytic de-vices, such as the MERCI device, because they areexpensive. But there are times when pharmacologicalthrombolysis isn’t appropriate, but mechanical thrombusremoval would be, so we have put together a businessplan in order to have these immediately available to us.

If you look at the benefits for the patient, the high cost forthe devices that IRs use can be justified: less patienttime in the Stroke ICU, quicker rehabilitation and recov-ery, the possibility of returning to independent living,lower hospitalisation and rehabilitation costs to the healthservice and hospital; our hospital has been receptive tothis argument by and large.

For example, we had a patient in a few weeks agowho had a massive stroke. Three years ago, if the pa-tient had survived the initial incident, they wouldprobably have spent six to nine months in hospitaland ended up in some sort of care facility. Certainly,there’s no way they would have ever gone back to in-dependent living. But literally within three weeks,that patient was treated, rehabilitated and out of hos-pital to resume an independent existence.

To provide this type of stroke service requires an invest-ment in resources up front, but the hospital and societyas a whole definitely make up for it in the long run, bothin terms of financial savings for the health service andimproved outcomes for the patients."

Dr. Ryan finishes with some advice to his fellow IRs:

“We liaised with our neurointerventional radiology col-leagues at the National Neurosurgical Unit at BeaumontHospital to ensure that the treatment we offer is withinnational standard protocol. By liaising with them, we feelvery comfortable with the service we provide, and I’d certainly encourage other interventionists to do that too.

IRs should definitely embrace the area of stroke throm-bolysis treatment because the vast majority of IRs al-ready have all of the technical skills necessary to do this;and as an interventionist, one can really make a huge im-pact on patient outcomes. It is incredibly rewarding as aphysician to see patients recover, often in front of yourvery eyes as the thrombus dissolves, from an acutestroke.”

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A Conference to Change LivesSuccessful stroke care requires a multidisciplinary ap-proach, with specialists from various medical fields allwor king together for the benefit of the patient. This oftenproves difficult in developing countries where medicalstructures are overburdened and emphasis is placed oncommunicable rather than non-communicable diseases.A conference is being held in Lagos, Nigeria to discussways of improving interdisciplinary cooperation in strokemanagement on the African continent. The conference,which is planned for December 2010, aims to provide var-ious medical specialists, including the continent’s few spe -cialists in minimally invasive treatments, with a platform forinterdisciplinary exchange and for sharing best practicerecommendations. Organised by the UK-based NGO, LifeChangers, the conference could very well lead to impor-tant changes in the lives of many African stroke patients. www.life-changers.org.uk

Liquid EmbolisationThe vast majority of strokes that occur are ischaemic innature with only few being haemorrhagic. The treatmentsfor the two forms of stroke vary greatly - ischaemic stroketreatments aim to increase blood flow to the affectedareas whereas haemorrhagic stroke treatments aim tostop it. While the current gold standard for haemorrhagicstrokes is the IR procedure known as Coil Embolisation,researchers at the Methodist Neurological Institute inHouston, Texas started using Liquid Embolisation earlierthis year. The first patient to be treated using the mini-mally invasive technique was a 68-year-old haemorrhagicstroke patient. The procedure was performed by interven-tional neuroradiologist Dr. Orlando Diaz, and involved in-jecting the embolising liquid, Onyx HD 500, directly intothe patient’s cerebral blood vessels. Once the liquidmakes contact with the blood inside the aneurysm, itthickens to a pudding-like consistency, disrupting bloodflow. www.methodisthealth.com

A Day for Combating StrokeWhen it comes to stroke, awareness can be life saving.Without knowledge of the avoidable causes, people canunknowingly put themselves at risk. Similarly, withoutawareness of the time restrictions for effective treatment,patients may not make it to the hospital on time. Brazil isrecorded as having the highest number of strokes inSouth America and stroke remains a leading cause ofdeath among the Brazilian population. Despite the recentadvances in stroke therapy, the number of patients in thecountry with access to reperfusion therapy remains lowand studies have shown that awareness surroundingstroke is also poor. To combat this lack of knowledge, theBrazilian Academy of Neurology along with the BrazilianSociety of Cerebrovascular Diseases and the BrazilianStroke Network organised a day of enlightenment for thenation. Their “World Stroke Day” programmes includedthe distribution of stroke awareness material as well asvarious workshops and interactive events. The pro-grammes proved so successful that it earned them theSilver World Stroke Day Award, after Sri Lanka, from theWorld Stroke Society.www.world-stroke.org

IR in First-ever Stroke CongressEvery seven seconds, a Canadian dies of heart diseaseor stroke and in 2000, stroke accounted for 7% of alldeaths in Canada. These figures are particularly disturb-ing considering the fact that approximately 80% of Canadians are thought to be exposed to at least one riskfactor for heart or cerebrovascular disease including dailysmoking, diabetes, and obesity. To combat this trend, thefirst-ever Canadian Stroke Congress was held this sum-mer in Quebec City, Canada. The congress brought to-gether stroke researchers and specialists from all overCanada and included special sessions on advances inand benefits of interventional neuroradiology in strokecare. www.strokecongress.ca

Worldview

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A Novel Use for an Established TechniqueMinimally invasive techniques are often discovered whenan established procedure is used in a new and innovativeway. This was the case when an Israeli-based medicalde vice company took an established procedure forepilepsy called neurostimulation and applied it to is-chaemic stroke patients. What they discovered was thatstimulating the Spheno-Palatine Ganglion (SPG) causedan interesting chain reaction - neurotransmitters were re-leased, which caused blood vessels in the affected areato dilate, increasing cerebral blood flow. In their experi-ments, they found that this led to more efficient recover-ies following stroke. The Ischaemic Stroke System (ISS),as it is known, consists of a staple-sized neurostimulatorwhich is implanted in the roof of the patient’s mouthunder local anaesthesia and a donut-shaped transmitterwhich is held to the patient’s cheek, near the neurostimu-lator. Clinical trials are currently underway to assess thebenefits and possible risks of the therapy.www.brainsgate.com

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Stroke DetectivesOur individual genetic codes form the guidelines that thebuilding blocks of our body must follow, and our genesform the individual rules within these guidelines. Research -ers, acting as genetic detectives, can use genes as cluesto unlocking the causes and nature of an array of diseas es.At the University of Edinburgh Centre for Cognitive Ageingand Cognitive Epidemiology (CCACE) in Scotland, re-searchers have discovered three genes which they be-lieve hold the key to the genetic causes of variousblood-clotting disorders including ischaemic stroke. Dur-ing their research, they found that the genes known as“F12”, “HRG” and “KNG1” were responsible for great differ -ences in the speed of blood clotting in healthy indi viduals.The scientists believe this discovery could help furtherour understanding of diseases such as stroke, thus aidingin the development of more effective forms of treatment.www.ccace.ed.ac.uk

With Nature’s HelpFor over two millennia, Traditional Chinese Medicine(TCM) has been used by people in China and other partsof eastern Asia to cure an array of illnesses includingstroke. Clinical studies confirming the benefits of a few ofthe ancient techniques and remedies are responsible forTCM’s ever increasing acceptance in the west. NeuroAidis a TCM remedy for stroke that was developed in Chinaand remarketed by the Singaporean biomedical company,Moleac. The complementary drug is a natural blend of 14 extracts including the antioxidant red sage plant andhas been shown to aid in post-stroke rehabilitation byhelping to repair and restore neuronal circuits. NeuroAid,already used by 0.5 million patients in China, is nowbeing used in over 25 countries around the world. Thebeneficial effects of the drug were published in the journal “Neuropharmacology" at the start of 2010.www.neuroaid.com/en

Support for a Speedy RecoveryThe period following a stroke is a time of reorientation andrecovery with many patients struggling to re-learn every-day activities. For these patients, support - whether phys-ical or emotional - is vitally important. Cerebrolysin is anatural neuroprotective drug that may offer pharmaceuti-cal support to both acute and chronic stroke patients. Developed in Russia, a country with one of the highestinci dences of stroke in the world, Cerebrolysin is derivedfrom extracts of swine cerebral tissue and was originallyused to treat infantile cerebral palsy; the drug has recent lybeen approved in America for the treatment of Alzhei mer’sDisease. Cerebrolysin’s use in stroke care is a more re-cent advancement and was the result of numerous pre-clinical trials which confirmed the drug’s ability to stimulatenerve growth, thus speeding up recovery times for strokepatients. With major studies planned for this year, anothermeans for supporting stroke patients may have been found. www.everpharma.com

Stroke Care on WheelsAccording to the German Stroke Society, of every100,000 patients who survive one year after a stroke,around 15% will have such severe disabilities that they willrequire round-the-clock care. A large number of stroke ca - ses occur in Germany’s smallest state, the Saarland, wherephysicians have found an answer to a common question -how can one lessen the time it takes to get a patient to thestroke unit? Led by Prof. Klaus Fassbender, the physi ciansat the Saarland University Hospital decid ed to take mattersinto their own hands by introducing the world’s first “mobilestroke unit”. The mobile unit is equipp ed with both anessent ial CT scanner as well as a miniature labor atory onboard. The team itself consists of a neu roradiolog ist, a neu-rologist, and an assistant. With studies currently beingcarried out on the cost-effectiveness of the mobile units,it could only be a matter of time before patients ac rossEurope will be able to benefit from stroke care on wheels. www.uniklinikum-saarland.de/en

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6-Hour WindowWhy Time is of the EssenceMy granddad had a stroke. In fact, he had several recurrent ones that left him with severe tunnel visionand a sense of betrayal, and eventually killed him. I never met him. Back then there was nothing thatmedicine could offer those who suffered strokes. A“wait and see” approach combined with prayers wasabout all any doctor could advise.

But this is no longer the case. In fact, quite the opposite -stroke is now classed as an emergency situation, and thead vice to anyone experiencing a stroke is clear: Get helpNOW.

This about-face might seem surprising, but it is the naturalresult of stellar advances in medicine, and the positive re ali-ty is that rather than stroke being untreatable, it is, in facthigh ly treatable - provided that one receives proper carein time.

New Trend in Stroke Treatment - Emergency Medicine

In the last few decades, doctors have discovered a medi-cine that can dissolve blood clots, which are a primecause of ischae mic stroke. The dissolving of blood clots inthis way is known as thrombolysis, or lysis. While a hugestep forward in stroke treatment, thrombolytic drugs arenonetheless limited by a time-window, after which theymay not work, or irreversible damage may already havebeen done to the patient’s brain from lack of oxygen.

Similarly, for patients suffering haemorrhagic stroke, timeis crucial. A stroke is essentially the brain starving frombeing deprived of oxygen, and whether this is caused bya blockage or a bleed, there is only so long that thebrain’s delicate cells can survive without it. When the pa-tient suffers bleeding in the brain, it is critical that this isstopped as soon as possible, either by interventional me -thods such as coil embolisation, or by surgical clamping.

The brain’s cells dying from a lack of oxygen has alwaysbeen the grim reality, but up until three decades ago, alldoctors could do was wait to see how many cells would die.Now they have treatment options, but they have to be quick.

When Stroke Strikes, Every Second Counts

Thrombolytic drugs can be given into the blood stream byinjection, and this is often how they are first administered.This systemic treatment must be given quickly though(most hospital guidelines are 3 hours, although someallow for 4.5 hours), and this is a very narrow timeframe.It is not merely a matter of giving a stroke patient a quickinjection - the type of stroke must first be establishedthrough diagnostic imaging, as a haemorrhagic strokewill be made much worse by giving these drugs. This willtake at least 30 minutes, and when you add this to thetime it took to report the patient and transfer them to hospital, you may be nearing the 3-hour mark already.

And this is assuming that the stroke was reportedstraight away - often stroke patients are found by relatives who are unsure when the episode began.

Interventional Radiology

Luckily, thrombolytic drugs can also be given directly atthe site of a clot. This local lysis is performed by interven -tional radiologists who use catheters to deliver the drugsto the clot itself. This method can buy the patient extratime, as it can be used effectively for up to 6 hours afterthe onset of the stroke. Ideally, the earlier this medicationcan be given, the better (within the first 60 minutes isconsidered optimal), but realistically, very few patientswill be attended to in that time frame. As such, local lysismeans that many more patients can be successfullytreated than would otherwise be possible. More recently,IRs have been using small devices, such as the MERCIdevice, to directly remove the clot blockage from thecerebral artery. In this way, minimal time is lost in gettingthe blood flowing to the brain again.

Stroke Units - Administration and Logistics

However, these 6 hours are a very short time whensomebody’s life or mobility hangs in the balance, andtherefore, it is very important that not a moment of thistime is wasted. Accordingly, many hospitals have set updedicated emergency stroke units, which are trained andequipped to treat stroke cases without delay. Many ofthese have also run awareness campaigns for their ambulance crews, instructing paramedics to rush anysuspected stroke cases to their units as fast as possible.Similar programmes are often run for local GPs. Strokesare given priority screening on arrival to the hospital, al-lowing appropriate treatment to be planned and deliveredwith minimal delay, which increases the patient’schances of recovery. It is not enough that these treat-ments merely exist - for them to be of any use, they mustbe accessed quickly, and having a solid logistical proto-col in place is the best way to ensure that.

Combating Stroke - A Team Effort

These stroke units usually consist of various experts whospecialise in different stroke conditions, such as neurolo-gists to administer systemic lysis and specialist interventio - nal radiologists to give local lysis, mechanical clot remo valor embolisation in case of haemorrhage. In this way, theentire hospital spectrum is trying to overhaul the treatmentof stroke. Awareness campaigns encourage the public toreport strokes without delays; training instructs parame dicsto rush the patient to the appropriate hospital department;giving priority to stroke patients means that diagnostic radiologists can ensure quick referral; and neurologistsand interventionists working together ensure that thebest treatment is available as quickly as possible.

Recently, there have been a huge number of strokeawareness campaigns, for the simple reason that manypeople still believe that stroke is an untreatable condition.

In milder instances of stroke, a patient or a patient’s com-panions may not recognise that something amiss has oc-curred at all. Some people may put their feeling dizzy orconfused down to “a funny turn”, and assume if they restor ignore the symptoms, they will go away. Numbness intheir leg may be dismissed as being due to “sitting funny”.Many people don’t want to make a fuss.

However, “not making a fuss” is the very worst thing thatthey can do. For this reason, awareness campaigns teachthe public to recognise possible signs of stroke as well asthe link between healthy living and lowered risk of stroke.

People are urged, when suspected stroke occurs, to gostraight to hospital without contacting their GP, as timereally is of the essence.

The British National Health Service ran a highly success-ful campaign, urging people to act FAST - an acronym forFace, Arm, Speech, Time. This informs people that whena patient has numbness or difficul ty moving their face orarms, or suffers slurred speech, it is time to get help. TheIrish Heart Foundation, a national charity fighting heartdisease and stroke, is currently running a similar cam-paign.

A FAST campaign run by the UK Department of Health hasbeen very successful at raising awareness in the UK, resul - ting in a 55% increase in stroke-related emergency calls.

Report by Ciara Madden

6-Hour Window - Why Time is of the Essence

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Creating awareness of the risks and symptoms - a highly effective way of cutting stroke fatalities

Stroke survivors at the launch of the FAST Campaign of the Irish HeartFoundation (www.stroke.ie). © Irish Heart Foundation

© The Stroke Association (www.stroke.org.uk)

© Heart and Stroke Foundation ofCanada (www.heartandstroke.ca)

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Report


Stroke ManagementSwedish StyleThere is good reason for Sweden’s position as globalleader in healthcare. Respectable healthcare spend-ing, modern, well-staffed facilities and short patientwaiting times are all characteristic of the country’sexemplary healthcare system. Sweden also holds theposition as a leading force in stroke care and re-search. The country was among the first to imple-ment specialised stroke units in its hospitals, and thevery first stroke registry was also Swedish.

Nestled in the capital of Stockholm lies one of the prod-ucts of the country's quality healthcare system, theKarolinska University Hospital (KUH). The hospital, aswell as its counterpart, the renowned Karolinska Institutet(KI), is well-known for its outstanding approach to strokemanagement.

With this in mind, IQ spoke to the KUH’s Head of Neu-rointervention, Dr. Tommy Andersson, to find out what les-sons could be learned from managing stroke theSwedish way.

IRs in Stroke UnitsAfter years of carrying out life-saving stroke interventions,Dr. Tommy Andersson is a firm believer in the benefits ofoffering IR procedures in stroke units as he believes it of-fers patients, “fast, safe and efficient therapy.” For thisreason, Dr. Andersson, along with his colleague Dr.Michael Söderman, introduced IR to the stroke unit of theKUH in 2005. The unit, which was established in the1990s by the neurologist Dr. Nils Wahlgren, currently hasthree neurointerventionists (IRs specialised in interven-tions dealing with the brain), with a fourth in training.

Having IRs in stroke units presents many advantagesand as Dr. Andersson described, in certain cases it canalso mean the difference between a life without disabilityand a life of severe disability, or even death. In casessuch as Björn’s (see Björn's story), Dr. Andersson ex-plained that, “Without active treatment, this patient wouldmost certainly have succumbed.” With the ability of neu-rointerventionists to actively administer drugs, they are avaluable asset to a successful stroke unit: “Endovasculartherapy has already revolutionised stroke treatment andwill do so even more in the future,” he pointed out.

Organised LogisticsAnother important element of stroke care in the KUH unitis down to its well-organised and clearly defined logistics.The logistical set-up of a hospital is central to ensuringthat patients get to the care they need without delay. Atthe KUH, patients who arrive without referrals are takento the emergency room, while referred patients are takento the Department of Neurology, where the stroke unit islocated. Following an obligatory initial CT examination, IVthrombolysis is administered to ischaemic stroke patients

and, “based on diagnostic investigations and the clinicalcondition of the patients, whether or not to perform athrombectomy is then decided.” In the unit, which ranksamong the best in Europe for thrombectomy procedures,much emphasis is placed on selecting only those pa-tients who are highly likely to benefit from thrombectomy,thus ensuring a safe risk/benefit ratio.

24/7 AvailabilityGood logistics also requires having relevant physicianson call; it is of utmost importance that enough expertsare available to fulfil demand. According to Dr. Anders-son, “In 2009, we treated 42 patients with thrombectomy.If the current flow of patients continues, this number willmore than double by the end of 2010.” With demand forinterventional treatments on the rise, neurointervention-ists in the unit are on call 24 hours a day, 7 days a week.This is particularly important for critical cases that requireactive treatment.

Raising AwarenessPublic understanding of stroke is also crucial in helpingpeople to recognise its signs and symptoms. Sweden haslaunched various national campaigns over the yearssuch as the recent HASTA campaign (Hyper Akut STrokeAlarm) which aims to reduce the amount of time betweenthe onset of a stroke and the administration of care. Dr.Andersson also felt that knowledge of IR’s role in strokemanagement has increased over recent years. This de-velopment, he found, “is partly due to the target-orientedefforts that centres like the KUH has engaged in.” Theseefforts include the numerous workshops and symposiathat the KUH runs to raise awareness of stroke and therole of neurointerventions. Dr. Andersson stressed theim portant role that IRs at the KUH play in these initia-tives: “As interventionists working with stroke, we activelytake part in all such activities which includes travelling tohospitals within the catchment area to hold educationalseminars with their physicians.”

Björn’s storyWhen Björn suddenly began experiencing strange sen-sory disturbances, dizziness, and nausea, he knew hehad to get to hospital. Mustering all his strength, he craw-led to the phone and made his life-saving call to the eme-rgency services. The previously healthy 35-year-old hadjust experienced a stroke and was quickly rushed to theEmergency Department of the Karolinska Hospital.Björn’s condition rapidly deteriorated and by the time hereached the angio-suite, he was in a critical state. Neuro -interventionists performed a thrombectomy which restor edthe blood flow to his brain just 15 minutes after the pro ce -dure. His condition improved so significantly that, la ter onthat evening, Björn, whose life had hung in the balanceonly moments before, asked if he could go home.

Stroke Management, Swedish Style

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Stroke ResearchThe fast pace of medical advances would not be possiblewithout the work of individuals who are dedicated to re-search. Their work is not only important to help improvethe procedures and techniques used to treat stroke pa-tients, it also plays a vital role in developing new ones.Sweden is also a world leader in the field of medical re-search, with the renowned Karolinska Institutet oftenbearing the torch. Established by Dr. Nils Wahlgren, theinternational ‘Safe Implementation of Treatments forStroke Network’ (SITS) is coordinated by the KarolinskaInstitutet and supports the development of groundbreak-ing research - research which its members hope willsomeday lead to a cure for stroke.

Interdisciplinary CareThe fact that patients who are treated in multidisciplinarystroke units have a greater chance of disability-free sur-vival is a well-documented phenomenon. This is no coin-cidence as patients benefit most from the synergy thatoccurs when specialists pool their knowledge and skills.

For this reason, Dr. Andersson revealed, “In the KUH, weaim for outstanding organisation, and are focussed on fa-cilitating cooperation among the specialists, the separatedepartments of the hospital as well as with the differenthospitals in the region.” With such interdisciplinary coop-eration at the KUH, stroke patients are certainly in verysafe hands.

So what is there to learn from the success of the KUHstroke unit? For one thing, its success is down to its in-clusion of neurointerventionists on the team. These neu-rointerventionists are available round-the-clock toadminister brain-saving active treatment when neededand they work in cooperation with other medical special-ists for the good of the patient. The neurointerventionistsand other specialists in the stroke unit are also activelyinvolved in raising awareness of stroke, taking part in thenumerous workshops and symposia organised by theKUH.

The KUH and the Karolinska Institutet are exemplary intheir dedication to stroke research and the well-organised logistical structures that are in place to ensure patientsreceive the care they need, when they need it. There is alot to learn from the success of the KUH stroke unit andfrom its distinctly Swedish way of managing stroke.

http://ki.se

Dr. Tommy AnderssonHead of NeurointerventionsKarolinska University Hospital, Stockholm, Sweden

Karolinska University Hospital (KUH)

KUH is one of Europe’s premier health institutions. Together with the renowned medical university, theKarolinska Institutet, both institutions account for the vastmajority of medical training and academic research inSweden.

The KUH in numbers:• 1,600 beds• 1.3 million patient visits per year• 14,500 employees• 20 million laboratory tests per year• Approx. 5,000 scientific articles published annually

24

New Horizons


Stopping Stroke Damage Cold Hypothermic Therapy

Most people must have thought him cruel or at bestsimply crazy when the renowned American neuro -surgeon, Dr. Temple Fay, described how he had in-tended to treat his young pain-ridden patient. Hewanted to place her, anaesthetised, on a pile ofcrushed ice, turn off the heating and open all the win-dows in her room to expose her to the bitter cold ofthe harsh winter. On November 28th 1938, despitefacing opposition, he did just that and contrary to thepredictions of most, the patient recovered not onlyfrom the novel form of treatment but also from herailments1. Fay had started his pioneering work intoan area that makes many of us shiver at the thought -Hypothermic Therapy (HT).

While cold has been used for millennia in the treatmentof various conditions, it was only following Fay’s work thatit was used in connection with damaged brain tissues.Fay went on to dedicate his research to how cold couldbe used to help protect the brain from damage caused byvarious neurological disorders. However, his work waseventually hijacked by the Nazis during World War II andbrutally applied without anaesthesia in concentrationcamp experiments. For years following the war, HT wassynonymous with atrocious Nazi war crimes and little tono investigation was made into its benefits. It was only asa new field of research emerged - neuroprotection - thatHT was re-explored in relation to acute ischaemic strokes.

What is Neuroprotection?The term neuroprotection refers to mechanisms and stra -tegies of the nervous system which protect neurons fromdeath or degeneration that can result from diseases of thecentral nervous system such as acute disorders (e.g.stroke or nervous system injury/trauma) or chronic neuro -degenerative diseases (e.g. Parkinson's, Alzheimer's,Multiple Sclerosis).

Mild hypothermia (34-36°C) has been shown to haveneuroprotective effects on the brain following acute ischaemic strokes.

Various neuroprotective agents and drugs are also beingdeveloped to mimic or encourage natural neuroprotectionand prevent damage to the brain following a range of disorders including stroke.

What is Hypothermic Therapy?HT is a form of therapy that involves the application ofmild, moderate or extreme cold in order to treat or palliate a medical condition.

It has been shown to have beneficial effects in both neurological and cardiological disorders.

The two methods that have been shown to be feasible forHT in stroke are:

· Surface cooling - cooling the whole body using icepacks, cooling blankets and cooling hoods.

· Intravascular cooling - cooling using Heat ExchangeCatheters or by infusing cold fluids. This method isconsidered more effective in acute stroke therapy.

The use of HT in stroke care is based on a principle thathas been proven time and again in various studies - hyperthermia or the over-heating of the patient can havedetrimental effects on the areas of their brain that havebeen damaged by a stroke. Mild hypothermia (droppingthe patient’s core temperature to no lower than 35°C) onthe other hand, has the opposite effect and reduces theadverse progression of stroke-related brain damage.

A patient wrapped in the cooling blanket and hood developed by Fay.

Reproduced with kind permission from Dr. William Olivero.

Stopping Stroke Damage Cold - Hypothermic Therapy

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ICTuS 2 - the largest clinical trial

Another major study into the benefits of HT followingacute ischaemic strokes is currently underway. Cedars-Sinai Medical Center, the University of California, SanDiego School of Medicine and University of Texas HealthMedical School are currently collaborating on the largestendovascular HT clinical trial to date - the endovascularcooling for acute stroke or ICTuS 2 Trial3. Cooling in therandomised, placebo-controlled trial will be achieved byinserting a special catheter into the inferior vena cavaand using a heat exchange catheter; heat will be trans-ferred out of the brain tissue.

HT is an exciting field of medical research that harboursgreat potential in ischaemic stroke care. With the ability to administer cooling solutions directly using minimally invasive catheterisation, the heights that this novel ther-apy can achieve have been raised. While much researchis still needed to better understand and improve HT, theICTuS 2 Trial and others that are also underway will helpshed light into future minimally invasive techniques tohelp stop ischaemic stroke-induced brain damage cold inits tracks.

The numerous benefits of HT instroke care include:· Reducing the loss of neurologic function following a

stroke· Reducing inflammation of brain tissue, thus

minimising intracranial pressure· Reducing exitotoxicity, a process that leads to nerve

cell damage · Reducing the oxygen demand· Maintaining the integrity of the blood brain barrier

Endovascular Hypothermic Therapy With the unconventional cooling methods that Fay usedin his first experiment, he soon found that few nurseswere willing to care for patients at his “refrigeration service” as it was known. This led him to develop thecooling hood and blanket in which the patient could bezipped up, which still remains in use today. Only a fewyears on, the modern interventional technique ofcatheterisation revolutionised the way cooling agentscould be administered to patients. Endovascular hypothermia involves either the infusion of cooling substances (typically saline solution) or the insertion of aheat exchange catheter to draw heat out of the tissue.Both methods provide instant, short-term, and selectivehypothermia.

Minimising Reperfusion InjuryIn a clinical pilot study published in the American Journalof Neuroradiology at the start of 20102, researchers re-ported that endovascular HT by means of intra-arterialinfusion of cold saline could be seen not only as safe butalso as an effective form of neuroprotection. A major out-come of the study showed that local HT could be used inminimising the risk of reperfusion injury due to intra-arterial thrombolysis (IAT). Reperfusion injury describesthe damage caused when blood returns to tissues thathave been temporarily deprived of blood, as happens instroke. When blood returns to the brain, as is the casefollowing IAT, it can result in inflammation and oxidativedamage. The adverse effects of perfusion injury could,therefore, be lessened as a result of intra-arterial HT,thus improving the results of the minimally invasive technique of IAT.

1 Wand et al.; History of Neurosurgery: Cold as a therapeutic agent;

Acta Neurochirurgica; 148:565-570, 2006

2 Choi et al.; Selective Brain Cooling with Endovascular Intracarotid

Infusion of Cold Saline: A Pilot Feasibility Study; American Journal of

Neuroradiology; 31: 928-934, May 2010

3 http://www.cedars-sinai.edu/About-Us/News/

News-Releases-2010/Multicenter-NIH-Clinical-Trial-Will-Study-

Potential-Benefits-of-Brain-Cooling-After-a-Stroke.aspx

Philips Accutrol™ Catheter

used for minimally invasive

HT.

Image courtesy of Philips

Healthcare.

26 I Q | I n t e r v e n t i o n a l Q u a r t e r

New Horizons

Making a World of DifferenceBrain Imaging Advances

Looking at an image of a brain, it is hard to fully com-prehend the complexity of its functions. How can acontorted mass of soft tissue control the way wethink, behave and feel? However difficult it may befor us to understand how the brain works, it is notdifficult to understand the devastation that can arisewhen parts of it stop working.

Ischaemic strokes can lead to large sections of the brainbeing killed off or irreversibly damaged, subsequentlyrobbing patients of certain functions they once foundeasy to perform. Once dead, these brain cells can neverregenerate, but cells that have been damaged may besalvageable. Acute IR interventions such as Intra-arterialThrombolysis (IAT) and Mechanical Thrombectomy (MT)can help save parts of the brain that are damaged butnot dead. However, with techniques as sophisticated asIAT and MT, patient selection is crucial to maintaining anacceptable risk/benefit ratio.

Two modern innovations in neuroimaging - DiffusionWeighted Imaging (DWI) and Perfusion Weighted Imaging(PWI) - are being combined to help interventional radiol -ogists better select candidates for IAT and MT by helpingto distinguish the areas of the brain that have been dam-aged irreversibly by a stroke from those which can berescued.

Interventional Radiologists“Treat” the DifferenceNumerous imaging modalities exist which IRs can use tohelp diagnose stroke and examine the extent of damagecaused by it. Examples include Computer Tomographywhich is widely available and is used to diagnose haem-orrhagic strokes, and Carotid Ultrasonography which canbe used to visualise narrowing of the carotid arteries.However, most imaging techniques are not sufficientlysensitive for appropriate IAT or MT patient selection. Insuch cases, IRs can turn to the cutting-edge techniquesof DWI and PWI to provide more accurate information.

What is Diffusion Weighted Imaging (DWI)?

DWI is used for detecting restrictions in the movement(diffusion) of water molecules in biological tissuescaused by damage or injury.

Certain medical conditions such as strokes can lead toareas of the brain with restricted diffusion. These areasshow up as very bright spots on the DW images.

DWI can also be used to distinguish between areas ofacute stroke and areas damaged by older strokes orother chronic changes in the brain.

When combined with MRI, DWI becomes by far the mostsensitive way to detect acute ischaemic stroke damageto the brain, as well as being highly effective in the earlydiagnosis of stroke. Diffusion Weighted MRI is also ableto clearly show ischaemic changes beginning within min-utes to a few hours after symptom onset.

What is Perfusion Weighted Imaging (PWI)?Perfusion Imaging is used for detecting dangerously lowcerebral blood flow and cerebral blood volume levels incerebral microvasculature.

Areas of the brain that have been affected by a strokeusually show signs of low levels of cerebral blood flow/volume.

Perfusion Imaging is usually coupled with MRI but CTPerfusion is also used in stroke imaging. Perfusion MR isperformed by injecting a contrast agent and then obtain-ing a rapid series of MRIs. The images obtained helptrack the passage of the contrast agent through thebrain.

Making a World of Di fference - Brain Imaging Advances

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Combined with what is known as multimodal imaging,DWI and PWI can help identify the areas of the brain thathave been damaged but not killed during an ischaemicstroke. The areas of a DW image that show up as havingrestricted diffusion are generally considered to be unsal-vageable (yellow, below). When the DW scan is placedon top of a PW scan, the area that overlaps (i.e. theareas with both restricted diffusion and cerebral bloodflow/volumes) forms what is seen as the core of the in-farction (red, below) and is often surrounded by an areathat has restricted blood flow/volume but no restrictionsin diffusion (green, below). This area which forms the dif-ference between the DW and PW images is known asthe “penumbra” or the “diffusion-perfusion mismatch” andrepresents the parts of the patient’s brain that can be salvaged using IAT or MT. The viability of the penumbra

can extend up to 48 hours after the onset of a stroke andmust be treated rapidly. Determining the diffusion-perfu-sion mismatch is a great asset in helping IRs determinethe patients that would benefit from IAT or MT.

For many patients, having as many brain cells restoredas possible means the difference between leading a lifeof painful disability and maintaining a good quality of life.Despite the increasing number of awareness campaigns,many patients simply do not or cannot make it to a hospital within the 3-hour window required for systemicthrombolytic therapy. With the help of these imagingmodalities, IAT and MT can provide these patients with a valuable second chance.

KEY:Area of restricted diffusion onDWI Area of restricted perfusion onPWI Penumbra/diffusion-perfusionmismatch are when DWI andPWI are overlapped

DWI

Overlapped images

PWI

© Szymon Rusinkiewicz, Doug DeCarlo, Adam Finkelstein, and Anothony Santella

28

News


The Evolution of TherapyAll Eyes on Minimally Invasive, Image-guided Therapy

Interventional radiology has been a forerunner in the pro-gression of modern medicine over the last few decades;progression which has shifted outlooks for stroke patientsfrom dire to surprisingly good.

The European Stroke Organisation (ESO) has supportedthe viability of IR’s therapies in both the prevention andmanagement of stroke by including interventional treat-ments such as carotid artery stenting in their “Guidelinesfor Management of Ischaemic Stroke 2008”. To reflect thisincreased call for minimally invasive procedures, moreand more hospitals are eager to make interventional op-tions available to their patients.

To further develop this, interventional circles have in-creased their attention to the field of stroke interventions.Select examples can be found as follows:

The XIX Symposium Neuroradiologicum of the WorldCongress of Neuroradiology will feature seminars andlectures on stroke-related neurointerventions. The con-gress will be held in Bologna, 4-9 October.

Interventional speakers and sessions also featured at the1st Canadian Stroke Congress in June 2010 in Quebec, aclear indication of how important it is to have intervention -al options available for those stroke patients who need it.

The reciprocal presence of interventional radiology atstroke conferences and stroke topics at interventionalconferences is a clear indicator of how the two disci-plines are collaborating to ensure that stroke patients re-ceive the best possible care.

CIRSE 2010, Europe’s biggest interventional radiol-ogy conference, will see the introduction of a newneurointerventions track. The programme will incor-porate a range of workshops, special sessions andhands-on workshops to give interventionists accessto the latest innovations, applications and trial re-sults in this field, and to encourage more interven-tionists to get involved in this crucial area. Thecongress will take place in Valencia, 2-6 October.

www.eso-stroke.orgwww.cirse.orgwww.symposiumneuroradiologicum.orgwww.strokecongress.ca

» THE ART OF INTERVENTION

Stroke PreventionDiagnostics

MRI Studies, MRIFlow Studies

Stroke

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Clinical Pathways for StrokeStandardising the Decision Tree for Consistent Care

Implementing Evidence-Based Medicine through Organisational Infrastructure

The aim of a care pathway is to enhance the quality of careby improving patient outcomes, promoting patient safety,achieving efficiencies by design, increasing both patient andphysician satisfaction, and optimising the use of resources.

Defining characteristics of care pathways include:

· An explicit statement of the goals and key elements ofcare based on evidence, best practice, and patient ex-pectations

· The facilitation of the communication, coordination ofroles, and sequencing the activities of the multidiscipli-nary care team, patients and their relatives

· The documentation, monitoring, and evaluation ofvariances and outcomes

· The identification of the appropriate resources

A clinical pathway is an “if/then” decision tree, or caremap for specific disease categories, allowing all care per-sonnel to follow a mutually agreed upon diagnostic andtreatment protocol for patients who enter the hospital.

Each inpatient care pathway represents one part of alarger whole that includes the full life cycle of stroke, in-cluding prevention, primary care, diagnostics, acutestroke care and rehabilitation (please see Table 1).

Input to the structure of clinical pathways comes from allcaregivers involved in a patient's hospital stay, includingnursing, physicians, physical therapy, administration, etc.They are designed to support clinical management, clinicaland non-clinical resource management, clinical audit andalso financial management. They provide detailed guid-ance for each stage in the management of a patient witha specific condition over a given time period, and includeprogress and outcomes details.

For example, input for a Stroke Care Pathway includes:Clinical care pathways are structured, multidisciplinaryplans of care. They are designed to support the reliableimplementation of evidence-based guidelines and proto-cols, representing best practices for achieving desiredoutcomes with optimal efficiency.

Prevention Managed Primary Care

TIA Clinic ImmediateTreatment

Diet, Smoking Ces sa -tion, Exercise, StrokeNewsletter, SupportGroups, Obesity

Atrial Fibrillation,Hypertension, Hy-perlipidimia, Aspirin

Neurologic careSOPs

Inpatient care path way,Thrombolysis, IR ther-apies, Ca rotid End art -erect omy, Stroke Unit

Stroke Care Clinical Pathway

· Nursing· Rehab· Admissions· Speech, Social, Swallow· Emergency Services

& Ambulance Crew· Radiology

· Laboratory· Physical Therapy· Discharge Planning· Physicians:

Neurology, Neuroradiology, Neurosurgery, EmergencyMedicine, Critical Care, Anaesthesia, Cardiac Services

Clinical pathways have four main components:· Timeline: admission, diagnostics, hospital course,

discharge, post-hospital care plan· Care map: “if/then” disease-specific decision algorithm· Outcome goals: intermediate and long-term· Variance record: deviations documented and analysed

Outline for admission/discharge and follow-up days for aclinical pathway:· Day 1-7: Assessment, Laboratory, Diagnostics, Inter-

vention, Medications, Consults, Nursing plan, Triageplan, Family counselling, Discharge prediction, Out-come, (Variance record)

· Day of Discharge: Assessment, Outcome, Dischargeplan, SNF/Rehab/Home, Medication schedule, Familypacket, Physician call, (Variance record)

· Follow-up Call Day: Assessment, Status/Satifactionevaluation, Medication review, Physical/Occupationaltherapy status, Family education review, Outcome assessment, (Variance record)

Each day of the clinical pathway consists of a set of “if/then” decisions that determine the specifics of the variousevents that follow after the initial assessment of the day.Variance recordings collected over time allow for re assess -ment and revision of a particular clinical pathway, so thatvariance events decrease over the life of a pathway.

The concept of clinical pathways was developed initially in Great Britainduring the early 1990s, and very soon there after was taken up by health-care facilities in the Uni ted States. The European Pathway Association wasformed in 2003. Since then, numerous EU countries have institut ed clinicalpathways, with Germany being the most frequent implementer of the con -cept. For those disease groups for which they are applicable, clinical carepathways have become the benchmark for “best practice” standards.

"Care pathways are a methodology for the mutual decision-ma king andorganisation of care for a well-defined group of patients during a well-defined period,” as defined by the European Pathway Association.

With thanks to Dr. John Mangiardi

Rehabilitation

Stroke Rehab Units,Community Services,Rehab Support,Groups

> > > > >

Table 1

30

Stroke


The Stroke RegistryFollowing the Data to Improve Stroke CareCreating a transparent window for stroke informationsharingWith local death rates from stroke approaching 250 per -sons per 100,000 in some areas, awareness of the impor-tance of maintaining stroke registries has significantlygrown over the past 10 years, aiming for a better under-standing, assessment and eventually improvement of pre-vention measures, treatment options, and past experiences.

Patients, clinicians, insurance companies, and health agen-cies all have a vested interest to understand stroke care inan open and transparent way, so that new strategies for re-designing and improving stroke care can be implemented.These include:· Prevention programmes· Community education such as “BRAIN ATTACK” aware-

ness campaigns· Notification and response of emergency medical serv-

ices· Comprehensive stroke centres enabling complicated

acute (e.g. IR) and subacute stroke treatment and sec-ondary prevention

· Rehabilitation· Continuous quality improvement (CQI) activities includ-

ing the use of stroke registries

Stroke RegistriesIn the past, stroke registries were set up to evaluate specificquestions, most often regarding treatment protocols or dis-ease types. However, with improvements in computers andinformation technologies such as data mining software, per-manent registries are being introduced.

In the United States, the American Congress has fundedthe National Institutes of Health’s Centers for Disease Con-trol (CDC) to sponsor the Paul Coverdell National AcuteStroke Registry in an attempt to bring together the manystroke registries within the country under a common um-brella for information sharing. This project began in 2001,with final consensus for shared data points having beenreached in 2004. The programme has been gradually rolledout to provide infrastructure grants to multiple state andlocal registries since that time.

In Europe, numerous mainly hospital-based, mono-centre,regional, national, European and intercontinental registriescovering all cerebrovascular diseases and their treatment incontrolled-randomised trials and observational studies wereinstalled. The first was the renowned Lausanne Stroke Reg-istry founded in 19821. Nearly 20 years later, the EuropeanUnion funded the largest thrombolysis registry, the Safe Im-plementation of Thrombolysis in Stroke-Monitoring Study(SITS-MOST) to assess the safety profile of alteplase inroutine clinical practice2. The largest registry in Switzerland,the Zurich Stroke Registry, was founded in 19973. It has sofar included more than 3,500 patients, and will be imple-mented in the Comprehensive Stroke Centre at the ClinicHirslanden in Zurich.

Designing Permanent Stroke RegistriesWith the gradual introduction of electronic medical recordsand distributed hospital information systems (HIS), it is nowpossible to collect data from every patient on a daily basis as part of the routine of clinical care. At hospitals such as UCLAin Los Angeles, bedside computers allow patient informationto be entered by nurses, doctors, and even dieticians intowhat are essentially organised database spreadsheets thatsave individual data point fields that can later be retrieved.Patient data can be recorded and retrieved across entirehospital groups that share similar HIS, presenting a quantumleap in our ability to evaluate patient care paradigms.

Following the DataThe value of permanent stroke registries grows as the num-ber of patients whose data is enrolled into the database in-creases. Treatment outcomes, costs, clinical pathwaysefficiencies, awareness and prevention programmes’ effec-tiveness, and even patient and physician satisfaction can befollowed to allow the many questions that will arise to be an-swered as the status of stroke care for a region evolves. Hardquestions that need to be asked and often are difficult to findthe answers for can be transparently answered as the strokeregistry grows. Examples include:· Which therapy protocols and clinical pathways provide

for the best patient outcomes?· How can we rapidly evaluate and implement new thera-

peutic options?· Are high-cost, high-tech comprehensive stroke centres

cost-effective?· Do stroke awareness and prevention programmes work in

your culture?· Does our approach to stroke rehabilitation have an impact?· Are our activities leading to a reduction in the number of

stroke in our country?

ConclusionThe current catchphrase for stroke care is “Time is Brain”.With the gradual rollout and implementation of stroke reg-istries throughout many countries, along with improvementsand homogenisation of information technologies, the catch-phrase might be “Data is Brain”. Accurate information gather-ing, a growing multiplicity of retrievable data points, and anincreasingly transparent method for seeing and learning fromthat information will further accelerate and improve the cur-rent revolution in modern stroke care and prevention.

With thanks to Prof. Ralf Baumgartner, Dr. John Mangiardi and Prof. Daniel

Rüfenacht

1 Bogousslavsky J, et al. The lausanne stroke registry: Analysis of 1'000

consecutive patients with first stroke. Stroke. 1988;19:1083-1092

2 Wahlgren N, et al., for the SITS-MOST investigators. Thrombolysis with

alteplase for acute ischaemic stroke in the safe implementation of

thrombolysis in stroke-monitoring study (sits-most): An observational

study. Lancet. 2007;369:275-382

3 Baumgartner RW, et al. Ischemic lacunar stroke in patients with and

without potential mechanism other than small-artery disease. Stroke.

2003;34:653-659

Stroke

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Stroke Interventions Trials and Registries

IQ takes no responsibility for the content of the individualtrials and registries; please refer to their source(www.clinicaltrials.gov) for further information.

Please note, this does not constitute an exhaustive overviewof Stroke Interventions trials and registries. If you are awareof a trial or registry which may be of interest to our readers,please feel free to contact us at [email protected].

Trial: a study carried out with the purpose of testinga new medical treatment on a defined group of peo-ple. The results are compared with a group that aretreated using another method and/or a control group.

Registry: a (retrospective) collection of data about acertain treatment or illness. Using the compiled data,conclusions can be drawn about effectiveness of aparticular treatment method.

www.intervention-iq.orgwww.clinicaltrials.govwww.who.int/trialsearch/default.aspxhttp://clinicaltrials.mayo.edu

✱

Stenting versus Best Medical Treatment of Asymptomatic High Grade Carotid Artery Stenosis

Contact Prof. Erich Minar, Vienna General Hospital, ATDate openedMarch 2004Status of trialRecruiting DescriptionThe aim of the present randomised controlled trial was toanalyse the neurological and cardiovascular outcome ofpatients treated with elective CAS plus best me dicaltreatment compared to best medical treatment only. ClinicalTrials.gov Identifier: NCT00497094

Swiss Intravenous and Intra-arterial Thrombolysis forTreatment of Acute Ischemic Stroke Registry (SWISS)

Contact Dr. Marcel Arnold, Bern University Hospital, CHDate openedDecember 2007Status of registryRecruitingDescriptionThe clinical and radiological data of patients with anacute ischaemic stroke treated with intravenous throm-bolysis (IVT) or intra-arterial thrombolysis (IAT) in a Swissstroke unit are assessed in a Swiss Multicenter Throm-bolysis Registry to compare the safety and efficacy of thetwo treatments. A clinical evaluation takes place at a 3-month follow-up and quality of life is assessed with astandardised questionnaire. The registry also helps to im-prove in-hospital management of stroke patients.ClinicalTrials.gov Identifier: NCT00811538

Carotid Endarterectomy versus Carotid Artery Stenting in Asymptomatic Patients (ACST-2)

Contact Dr. Alison Halliday, St. George's, University of London, UKDate openedJanuary 2008Status of trialRecruitingDescriptionThe trial randomises patients with asymptomatic carotid ar-tery narrowing in whom prompt physical intervention isthought to be needed, but there is still substantial uncer-tainty shared by patient and doctor about whether surgeryor stenting is the more appropriate choice. ClinicalTrials.gov Identifier: NCT00640770

Intra-arterial versus Systemic Thrombolysis for Acute Ischemic Stroke (SYNTHESIS EXP)

Contact Dr. Alfonso Ciccone, Niguarda Hospital, ITDate openedFebruary 2008Status of trialRecruitingDescriptionSYNTHESIS is a pragmatic multicentre, randomised con trol -led trial (RCT), open-label, with blinded follow-up aiming todetermine whether loco-regional intra-arterial (IA), with re -com binant tissue-plasminogen activator (rt-PA) and/or me - chanical devices, as compared with systemic intraven ous(I.V.) infusion of rt-PA within 3 hours of ischaemic stroke, in - crea ses the proportion of independent survivors at 3months.ClinicalTrials.gov Identifier: NCT00640367

Mechanical Retrieval and Recanalization of StrokeClots Using Embolectomy (MR RESCUE)

Contact Ms. Judy Guzy, University of California, Los Angeles, USDate openedMay 2004Status of studyRecruitingDescriptionThe purpose of this study is to compare the effectiveness oftreating acute ischaemic stroke with mechanical embo lec to myusing the MERCI Retriever or the Penumbra System with in 8hours of symptom onset to standard medical treat ment, andto identify people who might benefit frommecha nical em bolec -tomy by the appearance of stroke on multi modal com pu ter -ised tomography (CT) or magnetic resonance (MR) imaging.ClinicalTrials.gov Identifier: NCT00389467

Originally founded in 1733, St. George’s Hospital isone of the oldest hospitals in London. When was theIR department established and by whom? What, inyour opinion, is the greatest value that having an IRdepartment has brought to the hospital?

The IR department was originally started in the late1980s by Drs Tim Buckenham, Alan Grundy and DerekDundas. Currently, we are seven interventional radiolo-gists, all with slightly different areas of expertise.

With the explosion of IR techniques in the last two de -cades, interventional radiologists are now involved in thetreatment of patients in virtually every clinical departmentin the hospital. This has revolutionised the way patientswith many different conditions are treated, enabling themto undergo less invasive procedures with lower complica-tion rates and earlier discharge from hospital. The hospi-tal itself also benefits, as it experiences an increasedde mand from patients and the funding that goes with it,as well as cutting down on recuperation times, whichfrees up more beds for further patients in need of treat-ment. It’s a win-win situation and something any state-of-the-art hospital should include.

St. George’s Hospital was recently named among thetop five leading trusts in the UK in the area of patientsafety (in the Dr. Foster Intelligence “Hospital Guide”).From your experience, what is the best way to pro-mote patient safety?

The safety of patients and proper patient selection are always paramount. The minimally invasive nature of IRmeans that the techniques are delicate affairs, which re-quire a long learning curve. While it is important for everyIR to have experience of a wide range of basic IR proce-dures, most IRs focus on one specific aspect (vascular,oncology, etc.), as many of the more technically challeng-ing procedures require particular expertise.

This is one of the many reasons why it is not safe forother clinical specialties to perform often complex IR procedures on their patients unless they have undergonethe necessary training. IRs are at a natural advantage

32

Interview


when performing these procedures - as trained expertsin imaging and radioprotection, they can ensure properquality standards are met. With imaging forming a com-mon thread throughout their whole careers, they ensurea high standard of care for their patients.

We are aware that you have a good relationship withthe vascular surgeons in your hospital. The overlap in procedural responsibilities of IRs and vascularsur geons can sometimes put strain on their relation-ships. How did you forge your good relationship andhow do you maintain it? How does it benefit the pa-tients?

Mutual respect for each other’s abilities has resulted in aproven history of our working together, and a long friend-ship. We have learnt various techniques such as aorticendografting together, allowing us to take on patientswith ever more challenging anatomy and to treat themsafely and successfully. A collaborative relationship is es-sential if a unit is to develop fully to its maximum potentialfor the ultimate benefit of patients.

Our hospital facilitates this collaborative relationship byholding weekly meetings between IRs and their referringclinical colleagues to discuss patient cases. These meet-ings are essential for the interchange of ideas necessaryfor the safe management of patients.

The Greek fabulist, Aesop, once said: “In union thereis strength”. How important is it for IRs to take aninter nationally unified stance on training? As currentChair per son of the new, unified European IR quali -fication, the European Board of Interventional Radiology (EBIR), what impact do you feel the EBIRwill have on IR in Europe?

IR is a young speciality, and this is reflected in proce-dural and training discrepancies between countries.Some of the innovative IR techniques have now becomestandard treatments, creating both a possibility and aneed to ensure standard care across the board.Moreover, it is important that fully trained IRs have asymbol of their training that is recognised across nationaland international boundaries. It is intended that the newEBIR examination will be recognised as this symbol, bytheir peers, their clinical colleagues and current and fu-ture employers. The standardised EU-wide exam is a collaborative project between CIRSE, ESR and theUEMS.

IR procedures are complex, and require specific facilitiesto ensure good results - gaining visibility and recognitionwill help ensure that IRs get the proper support and resources necessary to carry out their procedures in themost efficient manner. EBIR will also help to define theskills needed to perform these procedures safely, whichwill facilitate better patient care.

Interventional radiologistsare now involved in the treatment of patients in virtually every clinical department in the hospital

5 minutes with…Dr. Robert Morgan

Dr. Robert Morgan, respected British IR,shares his experiences of training, patient safety and interdisciplinary cooperation.

5 minutes with …

33I Q | 2 | 2 0 1 0

You played a key role in the creation of the IR ClinicalPractice Guidelines released by the Cardiovascularand Interventional Radiological Society of Europe(CIRSE) which were intended to “help IRs promotethemselves directly to referring physicians”. What areyour top tips for IRs to help them improve their clinical practice?

Of primary importance is to look after patients the waythat other clinical specialties (e.g. general surgery) do.IRs should be clinically involved, and admit patients intotheir own beds and oversee their care before, during andafter their procedure, such as seeing patients in an initialconsultation and performing follow-up after dischargefrom hospital in a dedicated IR outpatient clinic.

This is, however, a wish-list that depends on hospitalmanagement and health authorities recognising thevalue of the speciality.

What is the status of IR curricula in the UK?

In the UK, IR curriculum is undergoing development at themoment. The RCR, under the leadership of Prof. AndyAdam and Dr. Tony Nicholson, has been working forsome years to establish IR as a subspecialty of Radiology.This process is working towards completion and will beof substantial benefit to IRs in the UK, and their patients.

The internet is increasingly forging a place for itselfas a key information source for medical trainees andprofessionals alike. How do you feel modern tech-nologies such as the internet and online CME willshape the future of medical training?

It’s a huge step forward, and professional societies suchas CIRSE have already embraced this opportunity: edu-cational websites such as www.esir.org have allowed ed-ucation to move from the printed page of a book onto thecomputer screen. As a result, educational materials canbe continually updated and improved, which can onlybenefit the trainee. This will also allow 24-hour access tosuch education materials as online lectures.

Similarly, internet technology now enables the trained IRto work at CME on their computer without the need to at-tend a multitude of CME courses, which again CIRSE isin the process of introducing.

Based on your experience as a lecturer in numerousinstitutions in the UK, what feedback have you hadfrom trainee doctors on their reasons behind pursu-ing, or not pursuing, a career in IR?

Due to existing training and qualification structures, theIR speciality is relatively unknown amongst undergradu-ates. This is problematic, as it leads to a shortage of IRsat national and EU level. An awareness initiative must belaunched so that students consider radiology and IR as asolid career opportunity.

IR is an attractive option for those doctors who enjoy per-forming clinical procedures, who are fascinated by imag-ing and who seek an option that can combine thesepassions. IR is in the unique position of offering this com-bination as a career choice.

As Deputy Editor of the peer-reviewed journal “CardioVascular and Interventional Radiology” (CVIR) and as someone who is actively involved in IRtraining and clinical practice, as well as medical so-cieties and publications, how do you balance allthese aspects of your professional life?

I would have to admit that fitting all of the work in to myschedule is sometimes problematic. My work at St.George’s NHS Trust is very demanding and as a result, a large proportion of the “extra work” must be done athome in the evenings or at weekends. One of my mostvaluable possessions is my laptop computer which goeseverywhere with me. You never know when you mightfind a spare moment to work on that document thatneeds to be submitted yesterday!

Most are familiar with the archetypical tale of thedragon being slain by the namesake of the hospitalin which you work, St. George. Many would arguethat IR has already slain many dragons in its path.What do you feel needs to be confronted next?

The main “dragon” facing IRs is the ever presentencroach ment by other clinical specialties on IR turf. We are now seeing amazing situations where gynaecologistsstate they should be carrying out fibroid embolisation, GIphysicians claim they should be carrying out hepaticchemoembolisation, neurologists say they should be coil-ing intracranial aneurysms, and the list goes on and on.

It is our duty as IRs to protect our patients from otherclinical specialities dabbling in procedures they are nottrained to do.

This is why adequate training of all IRs, the EBIR, clinicalpractice, and online CME are so important for our spe-ciality and for our patients. There is a lot of work ahead.However, I will continue to work towards these goals.

IR procedures are complex,and require specific facilitiesto ensure good results

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Dai ly Pract ice


When asked if he thinks it is necessary to have a dedicatedradiographer, Prof. Peregrin is very definite:

“I believe that every radiographer first has to be trained in basic skills, after which can come training in special proce -dures. IR should have a specialised team of radiographersand nurses. This does not mean that they should not partlyrotate within the hospital, but they should spend at least 50-70% of their time in the IR suite. I do not think that a radiog-rapher spending less than the abovementioned amount oftime can reach appropriate level of skills necessary.”

He continues:

“I really believe that radiographers are our natural allies and co-workers. To open a space for them at CIRSE meet ingscould help them to learn more about newest developmentsin IR and to establish better cooperation with interventionalradiologists. I am really convinced that giving more responsi-bility to well-trained radiographers will give us better chancesof working as a successful team.”

Developing Excellence: Dedicated Radiographers

They are an integral part ofthe interventional team andtheir work is very importantfor the final procedure outcome

Radiographers are often the unsung heroes of the radi-ology discipline - in many ways, the lack of understand-ing surrounding their vocation puts them in a similarposition to interventional radiologists. But this lack ofawareness is by no means a reflection of the qualityand necessity of their work. Radiographers are a crucialpart of the radiological team, and radiologists, interven-tional or diagnostic, depend heavily on the skills theybring to the imaging room.

There is a growing demand among radiology specialists fordedicated radiographers, and a growing tendency to regardthese specialist radiographers as part of the speciality theyserve. This is no less so in interventional circles, with theworld’s most comprehensive annual interventional radiologycongress, CIRSE (Cardiovascular and Interventional Radio-logical Society of Europe), this year dedicating specialistworkshops to radiographers. Indeed, many regular atten-dees of the congress have for some years been bringingtheir radiographers with them, in order to keep them abreastof developments in the field. We speak to some of thespeakers and advocates of this dedicated workshop se-ries to find out why they think dedicated radiographersare vital to the smooth-running of the interventional suite.

Prof. Jan Peregrin (IR at IKEM, Prague and CIRSEPresident) is one such advocate. When we asked himlast year about the role of dedicated staff1, he forward -ed the opinion that societies such as CIRSE shouldaim to be more inclusive of radiographers and nurses.The radiographer workshops to be held in CIRSE’sannual congress in Valencia this year are certainly amove in this direction, and he tells us why a radiogra-pher is so vital to the smooth-running of the IR team:

“The radiographer is the first contact for the patient on arrivalin the angio-room. Their demeanour and behaviour canstrongly influence the patient’s feelings and acceptance ofthe procedure, and sometimes communicating with the radi-ographer is easier for the patient than communicating withthe doctor. It is their job to explain the procedure to the pa-tient, and to position them on the examination table. Workingwith the nurse, they prepare the patient and the puncturesite. As such, it is essential that the radiographer is knowl-edgeable about the procedure, and can reassure the patient.

During the procedure, they are responsible for radiation pro-tection for both the patient and the staff members, and theymonitor dose levels and observe the patient throughout.They monitor our equipment regularly. They are also essen-tial to improving the quality of the image, and look after boththe archiving of records and documents, and preparation ofthe procedure data for insurance companies. Following theprocedure, they often look after the puncture site. They arean integral part of the interventional team and their work isvery important for the final procedure outcome.”

1 “Non-Dedicated Staff: may cause serious side-effects” IQ Issue 0,

Dec 2009

Professor Jan Peregrin, IRHead of Department of Radiology, IKEM Prague,Czech Republic

Developing Excel lence: Dedicated Radiographers

35I Q | 2 | 2 0 1 0

Mr. Cestmír David is a radiographer who will be presen -ting some of the CIRSE workshops later this year. Heworks alongside Prof. Peregrin at the Institute for Clinical and Experimental Medicine (IKEM) in Prague.He is also Editor-in-Chief of “Praktická radiologie”, theofficial periodic journal of the Society for Radiographersof the Czech Republic.

We ask him what he thinks radiographers bring to interven-tional procedures.

“Radiographers study a great many subjects in the course oftheir training, and they use this knowledge to bring many ad-vantages to the IR team. A good radiographer can use theirtechnical knowledge to protect both staff and patient fromharmful radiation, ensuring adherence to the ALARA guide-lines (As Low As Reasonably Achievable), and ensure betterquality images, which means better outcomes and shorterprocedures. They take care of the patient, ensuring theirsafety and comfort at all times, and by enabling the safe useof angio-machines and monitoring them regularly, they canhelp the hospital save money on repairs, and guarantee theirgood reputation of patient safety. Furthermore, two radiogra-phers remain in the hospital overnight to ensure round-the-clock care for emergency patients.

Teamwork is very important in IR - good collaboration is thebasic requirement for optimal results.”

He explains how training and work practices are structur ed in the Czech Republic:

“Currently, radiographer training in the Czech Republic isachieved by a three-year bachelor degree, finished by astate examination. In our hospital, radiographers are as -signed to the IR team - we may send them to work inother sections of our radiology department (CT, MR,Ultra sound) when we have a critical personnel situation, butonly as long as the crisis lasts. However, in some hospitalsin the Czech Republic, all radiographers rotate for allmodalities.”

When it comes to having dedicated, specialist radio graphers, he can see two sides to the debate:

“For IR teams, for the patient and for ensuring the best qual-ity IR procedures, it is better to have specialist radio graphers. For the sake of variety, some radiographers might prefer tospend a fraction of their time in other departments. How-ever, they understand that the deciding factor must alwaysbe the patient’s benefit. Besides, the profession of radio -graphers is so branched and encyclo paedic that it is notpossible to be perfect in every aspect of the profession.

He believes that it is important that radiographers who workin IR should train alongside their interventional colleagues.The workshops he will host at CIRSE 2010 should be ofbenefit to all parties:

“Education in radiation protection (RP) and imaging is veryuseful for nurses and radiologists too. Only radiographersare educated in pregradual training in RP and imaging, andthis knowledge is very important for IR. The radiographerprofits from this workshop, because he gets to refresh hisknowledge of RP and imaging, and the IR profits, becausehe learns about lowering radiation stress of patients andstaff, higher quality of imaging during procedures and imagedocumentation after procedures.

For radiographers, continuing (lifelong) education isessential. The massive progress that is constantly beingmade in radiology, IR and technologies requires per -manent education.”

For radiographers, continu-ing (lifelong) education is essential. The massiveprogress that is constantlybeing made in radiology, IR and technologies requirespermanent education

www.cirse.orgwww.efrs.euwww.ikem.czwww.laiko.gr

Mr. Cestmír David Senior RadiographerIKEM Prague, Czech Republic

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Dai ly Pract ice


Greek radiographers are also highly involved in thisyear’s workshops. Mr. Euthimios Agadakos from LaikoGeneral Hospital, Athens is President of the Greek Scientific Society of Radiologic Technologists and willbe presenting some of the sessions.

Although the role of radiographers can vary from country tocountry, Greek radiographers have a similar role to theirCzech counterparts, and are central to quality controlwithin their hospitals.

He tells us that in Greece, most radiographers are as -signed to particular teams, such as interventional radiol-ogy teams. In some hospitals, this is not the case, but Mr. Agadakos believes that it is to everyone’s ad vantageto have specialist radiographers:

“I strongly support specialisation within radiography, throughadditional training following their initial qualification. Theskills and competencies obtained during such specialisationwould permit for immediate and effective inclusion in the IRteam. Being a key member of the team is in itself an ad-vantage. The radiographer is a central figure, as the teamwill not function without their physical presence. The ded-icated radiographer is assigned with a more personal andresponsible role, building up a strong rapport with theother team members and colleagues. This dedication offersprofessional self-esteem and enhanced job satisfaction.In numerous medical imaging departments, the ra diogra -phers in IR are considered highly skilled when comparedwith radiographers working in general radiography.”

“Greek radiographers are officially called “radiologic tech no l -ogists” and obtain tertiary qualification upon completion of4.5 years at the Department of Medical Radio logical Tech -nologists of the Faculty of Health and Caring Professions ofthe Technological Educational Institute of Athens (TEI). How-ever at present, radiographers are not formally train ed in IR. I see this as being a disadvantage, as it can make daily prac-tice in this high-risk field difficult and less effective. However,continuing professional development (CPD) is mandatoryaccording to Greek law and EURATOM.”

For this reason, he believes that continuing education, par-ticularly specific interventional education alongside interven-tional colleagues, can be highly advantageous:

“Medical imaging technology is evolving rapidly, new stand - ards in imaging practice are set, the radiographer's role iscontinuously expanding: all these changes demand con tinu -ing education. I feel that synchronous training alongsidenon-radiographer colleagues obviously provides strongerbonds between the members of the team. This will benefitthe radiographer since one will be aware of the tasks thenon-radiographers are responsible for and vice versa. Fun -damentally, IR will benefit in terms of direct teamwork: es-sential when providing quality healthcare services.”

This obvious lean towards specialisation within radiographyis understandable when one considers the role of the radio -grapher. Although training, and indeed role, may vary fromcountry to country, most radiographers in Europe complete3-5 years university training. This education co vers a broadrange of subjects, including human anato my, physiology, bi-ology, pathology, genetics, nursing procedur es, emergen cymedical procedures, biostatistics, mathema tics, gener al, nu-clear and radiation physics, electro magnetism, trigo no metry,radiopharmacology, psycho logy, philosophy, medical ethics,logic, computer program ming, chemistry, as well as a wholehost of imaging subjects.

This reflects the highly responsible position they are given -they are responsible for the maintenance and efficiency of the imaging machines; they ensure high quality imageswhile simultaneously keeping the dosage low; they look afterradiation protection for both staff and patient, archive patientdata and images, and monitor the patient during the proce-dure. But crucially, they are also often tasked with patientpreparation, which includes informing the patient aboutthe procedure they are about to undergo.

Given the wide range of radiology specialties that functionwithin the average hospital, it is asking a lot for one radiogra -pher to be able to perform all of these tasks in all of theseareas to the highest standards possible. Allowing radiogra -phers to specialise in certain areas allows them to develophigher levels of competence in those fields, which can onlybe of benefit to the performing clinician, the patient, and theradiographer himself.

A radiographer who accurately applies the latesttechniques … leads tohigher cost-effectiveness forthe hospital due to improvedhuman resource management

>

Skilled radiographers are an essential ally for hospital man-agers and department heads:

“In general, ensuring accurate functioning of the equipmentmust be performed by the radiographer on a daily basis ac-cording to quality standards. A radiographer who accuratelyapplies the latest techniques, with less examination time andreduced hospitalisation, leads to higher cost-effectiveness forthe hospital due to improved human resource management,i.e. a reduced number of staff per shift. To ensure 24-hourcare for the patient, a few hospitals have overcome staffshortage problems by employing an on-call radiographerservice.”

He points out, however, that although most Greek radiogra-phers specialise in their work placement, the training doesnot yet reflect this:

Mr. Euthimios AgadakosSenior RadiographerLaiko General Hospital,Athens, Greece

Featured Tria ls

37I Q | 2 | 2 0 1 0

CRESTCarotid Revascularization Endarterectomy versus StentingCarotid artery surgery and carotid artery stenting aretreatments for carotid artery blockages, an importantcause of stroke. To compare the safety and effective-ness of these 2 procedures in patients with or with-out a pre -vious stroke, the NIH-funded CarotidRevascularization Endarterectomy versus StentingTrial (CREST) randomly assigned 2,502 participantsat 117 medical centres in the U.S. and Canada to sur-gery or stenting. From 2000-2008, participants (aver-age age 69) were followed up to 4 years (2.5 yearsaverage follow-up).

Trial ResultsResults were announced on February 26, 2010 at theAmerican Heart Association International Stroke Confer-ence and published online on May 26, 2010 by The NewEngland Journal of Medicine. CREST found that the 2treatments have similar safety and long-term outcomes:· In the weeks following the procedures, the risk for

stroke was slightly higher after stenting and the risk forheart attack was slightly higher after surgery.

· Both procedures appear to have low complications -the lowest yet reported from a large stroke preventionresearch trial.

· There were no differences in results between men andwomen, those with or without a previous stroke, or instroke outcomes up to 4 years.

· Patients over 70 fared better with surgery; thoseyounger had better outcomes with stenting.

As more long-term data are needed, CREST plans to mo nitor participants for up to 10 years. Cost-effectiveanalysis based upon hospitalisations, medical proced -ures, long-term care, and outpatient care during 1 yearwill be published in the following months.

Trial results show they are 2 safe and effective methodsfor treating carotid artery disease. CREST provides doc-tors and patients with risk/benefit information to choose aprocedure based on an individual’s health history and riskprofile. Carotid stenting may offer an alternative to carotidsurgery for those preferring a less invasive procedure,and for younger patients.

For further information, please contact:Alice Sheffet, PhDCREST Project DirectorAssistant Professor, Department of SurgeryUniversity of Medicine and Dentistry of New JerseyNew Jersey Medical School, Newark, NJ, USA

ClinicalTrials.gov Identifier: NCT00004732

www.umdnj.edu/crestweb

SAPPHIREStenting and Angioplasty with Protection in Patients at High Riskfor EndarterectomyCarotid Artery Stenting (CAS) is often used as an al-ternative treatment for patients who are not eligiblefor surgical Carotid Endarterectomy (CEA). Whilestudies exist that examine the efficacy of both proce-dures, few have examined the quality of life that re-sults from them.

A team of investigators, led by Dr. David J. Cohen ofSaint Luke’s Mid America Heart Institute, launched astudy comparing CAS and CEA patient quality of life.Their findings, published in the May 2010 issue of JACC:Cardiovascular Interventions, were based on the SAP-PHIRE trial. SAPPHIRE was a randomised trial whichcompared CAS and CEA in 334 high-risk patients withcarotid stenosis. Their health status was assessed di-rectly after and then at 2 weeks and at 1, 6, and 12months following revascularisation.

Study ResultsThe study found that patients who are treated with mini-mally invasive CAS experienced fewer adverse symp-toms during the first 2 weeks of recovery compared to

those who underwent surgical CEA. Thus, CAS helpedpatients achieve a higher quality of life than CEA pa-tients, in the period closely following the procedure.

CAS patients· experienced less pain,· had fewer neck problems,· had less difficulty eating and swallowing, and· had less difficulty driving.

However, after 1 month, no differences between the twogroups were recorded.The study not only highlights the equal efficacy of CASand CEA but also sheds light on the benefits that CASbrings to high-risk patients that CEA does not.

For further information, please contact:Dr. David CohenSaint Luke's Mid America Heart InstituteKansas City, MO, USA

ClinicalTrials.gov Identifier: NCT00231270

38

Trials and Registries


Comparing Angioplasty and DES in the Treatment of Subjects with Ischemic Infrapopliteal Arterial Disease (ACHILLES)

Contact personDr. Dierk Scheinert, Universität Leipzig, Herzzentrum, DEDate openedMarch 2008Status of trialActive, not recruiting

DescriptionThe primary objective of this study is to compare the performance of the CYPHER SELECTTM + Sirolimus-eluting Balloon-expandable Coronary and InfrapoplitealStent over balloon angioplasty in de novo and restenoticnative below the knee tibioperoneal, anterior and/or posterior tibial and/or peroneal arterial lesions in aprospective, multicentre, randomised clinical study.ClinicalTrials.gov Identifier: NCT00640770

Drug Coated Balloons for Prevention of Restenosis(Piccolo)

Contact personDr. Gunnar Tepe, University of Tuebingen, DEDate openedApril 2008Status of trialRecruiting

DescriptionA randomised, double-blind trial (in respect of the pri-mary end point) in which stenotic lesions are treatedusing uncoated PTA-catheters as control group.ClinicalTrials.gov Identifier: NCT00696956

Effects of Carotid Stent Design on Cerebral Embolization

Contact personDr. Carlos H. Timaran, Dallas VA Medical Center, USDate openedDecember 2008Status of studyRecruiting

DescriptionThe goal of the proposed study is to contrast the relativeefficacy of closed-cell stents versus open-cell stents inpreventing periprocedural cerebral embolisation in high-riskpatients with symptomatic and asymptomatic extra cranialcarotid stenosis undergoing carotid artery stenting (CAS).ClinicalTrials.gov Identifier: NCT00830232

Stent vs. Angioplasty for Treatment of ThrombosedAV Grafts: Long-term Outcomes

Contact personDr. Ivan D. Maya, University of Alabama Hospitals, USDate openedOctober 2006Status of trialRecruiting

DescriptionThis is a single-centre, randomised clinical trial, in whichpatients with a clotted graft with underlying stenosis at thevenous anastomosis of the graft will be allocated to throm -bectomy plus angioplasty (control group) or to thrombec-tomy plus stent placement (study group). The primaryendpoint will be primary (unassisted) graft patency.ClinicalTrials.gov Identifier: NCT00496639

Trials and RegistriesTrial: a study carried out with the purpose of testinga new medical treatment on a defined group of peo-ple. The results are compared with a group that aretreated using another method and/or a control group.

Registry: a (retrospective) collection of data about acertain treatment or illness. Using the compiled data,conclusions can be drawn about effectiveness of aparticular treatment method.

Angioplasty

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www.intervention-iq.orgwww.clinicaltrials.govwww.who.int/trialsearch/default.aspxhttp://clinicaltrials.mayo.edu

Embolisation

Cryoablation Therapy in Treating Patients with Invasive Ductal Breast Cancer

Contact personDr. Rache M. Simmons, Weill Medical College of CornellUniversity, USDate openedSeptember 2008Status of studyRecruiting

DescriptionThis phase II trial is studying how well cryoablation therapy works in treating patients with invasive ductalbreast cancer.ClinicalTrials.gov Identifier: NCT00723294

Oncology

Trials and Registries

39I Q | 2 | 2 0 1 0

Percutaneous Renal Tumor Cryoablation Followed by Biopsy

Contact personDr. Stephen Solomon, Memorial Sloan Kettering CancerCenter, USDate openedNovember 2009Status of studyRecruiting

DescriptionA study examining the effectiveness of cryoablation inkilling cancer cells in the kidney.ClinicalTrials.gov Identifier: NCT01012427

Radiofrequency Ablation in Resectable ColorectalLung Metastasis

Contact personDr. Haruyuki Takaki, Mie University School of Medicine,JPDate openedOctober 2008Status of studyRecruiting

DescriptionIn this phase II trial, clinical utility of lung RF ablation willbe evaluated in patients with resectable colorectal lungmetastases.ClinicalTrials.gov Identifier: NCT00776399

Uterine Fibroid Treatment: Magnetic Resonance Imaging-guided Ultrasound Surgery (MRgFUS) versus Uterine Artery Embolization (UAE)

Contact personMs. Lisa G. Peterson, Mayo Clinic, Minnesota, USDate openedOctober 2009Status of studyRecruiting

DescriptionThe main goal of this study is to compare the safety andeffectiveness of two standard fibroid treatments: MRI-guided ultrasound surgery (MRgFUS) and uterine arteryembolisation (UAE). Both treatments are approved by theFood and Drug Administration (FDA) for women who donot plan to become pregnant.ClinicalTrials.gov Identifier: NCT00995878

UFE / UAEFertility after Uterine Artery Embolisation for theTreatment of Leiomyomas (EFU)

Contact personDr. Jean-Pierre Pelage, Assistance Publique, Hopitaux deParis, FRDate openedFebruary 2009Status of studyRecruiting

DescriptionThe main goal of this study is to evaluate spontaneousfertility after uterine leiomyomas embolisation, in womenbetween 18 and 40 years old.ClinicalTrials.gov Identifier: NCT00839722

IQ takes no responsibility for the content of the individualtrials and registries; please refer to their source(www.clinicaltrials.gov) for further information.

Please note, this does not constitute an exhaustive overview of trials and registries. If you are aware of a trial orregistry which may be of interest to our readers, pleasefeel free to contact us at [email protected].

Quality of Life after Vertebroplasty versus Conservative Treatment in Patients with Painful Osteoporotic Vertebral Fractures

Contact personDr. Jordi Blasco, Hospital Clinic of Barcelona, ESDate openedMarch 2006Status of studyActive, not recruiting

DescriptionThe purpose of this study is to determine whether percu-taneous vertebroplasty is able to improve long-term qual-ity of life in patients with pain secondary to osteoporoticvertebral fractures, compared to conventional medicaltreatment.ClinicalTrials.gov Identifier: NCT00994032

Vertebroplasty

40

The Early Days of IR


Interventional radiology was born in 1963, but itwould not have been possible without the early inno-vations of pioneer radiologists.

Largely credited as being the single most important inno-vation to enable interventional radiology, the SeldingerTechnique has been used for almost 60 years. Thestraight-forwardness of the technique belies the difficul-ties faced by innovators to find a safe and practical wayto insert a catheter into a blood vessel. But finally, in1952, a young Swedish radiologist named Sven-IvarSeldinger came up with the answer.

The quest to find the solution began in 1940. A Cuban ra-diologist, Fariñas, managed to introduce a catheter intothe aorta by means of a surgical incision in the femoralartery. While a highly commended breakthrough, mostdoctors, including Fariñas himself, had their reservations.It was a start, but there were still too many hazards asso-ciated with it - and besides, accessing the aorta was notenough. A way to allow access to more vessels wasneeded.

So the odyssey continued, with doctors such as Lundand Jönsson in Sweden, Cournand, Richards, Miller,Freeman and Pierce in the USA, Euler in Germany andPonsdomenech and Beato-Nuñez in Cuba putting alltheir efforts into finding the answer.

Problems were manifold. Surgical openings increased therisk of infection and haemorrhage, so a hollow needlewas devised through which the catheters could be fed.But the catheters were too flexible - once inside the ar-tery, it was impossible to advance or steer them properly.So the idea of a guidewire was born - but how to ad-vance it without injuring the delicate walls of the bloodvessels? It was a tricky one.

However, in 1952, our hero (at the time a young residentat the soon-to-be-famous Karolinska Institute in Sweden)stood in a lab, unsuccessfully attempting to practice in-serting a catheter through a hollow needle, and then in-troducing a guidewire to support it. To no avail. It justwould not work. But the darkest hour comes right beforethe dawn, and in lightning-bolt eureka moment, he sud-denly realised how to crack the puzzle.

The materials (hollow needle, catheter and guidewire)were the right instruments, but he, and everyone beforehim, had been using them in the wrong order. Instead ofneedle-catheter-wire, the logical and workable order ofdoing things was:· needle in, wire in· needle out, catheter placed over wire· insert catheter, remove wire

Seldinger had, in a split second’s inspiration, devised asafe and easy way to gain catheter access to virtually

The Early Days of IRThe Seldinger Technique

The Seldinger Technique

a) The artery punctured. The needle pushed upwards. b) The leader in-

serted. c) The needle withdrawn and the artery compressed. d) The

catheter threaded on to the leader. e) The catheter inserted into the artery.

f) The leader withdrawn.

Taken from the original manuscript by Seldinger, Sven Ivar (1953)

'Catheter Replacement of the Needle in Percutaneous Arteriography: A

new technique', Acta Radiologica [Old Series], 39:5, 368-376

(http://informahealthcare.com/loi/ard)

Sven-Ivar Seldinger 1921-1998“Founder of Seldinger Technique”

• Qualified as Docent of Radiology, 1967• Presented with the Valentine Award by

the New York Academy of Medicine, 1975• Awarded honorary membership to both the

Swedish Association of Medical Radiologyand the German Roentgen Association

Portrait taken from the article by Greitz,T, Sven-Ivar Seldinger, AmericanJournal of Neuroradiology20:1180-1181, 6, 1999, © by American Society of Neuroradiology.

every vessel and organ in the body. His first publishedpaper appeared in Acta Radiologica in 1953, bringing hisnew method to the radiologists of the world. In time, thisdiscovery was to win him both fame and acclaim in med-ical circles, but bizarrely, his chief at the Department ofRadiology at the Karolinska Institute did not think thatthis discovery was enough to form the basis for a doc-toral thesis. So Seldinger began to research another proj -ect, investigating percutaneous transhepaticcholangiography and defended his thesis in 1966.

Despite his ingenious discovery, Seldinger never lookedfor acclaim, never became a professor, and worked qui-etly and diligently as Chief of Radiology in the hospital ofhis hometown of Mora, a small town in northern Sweden,from 1967 until his retirement.

Seldinger’s breakthrough, effectively the igniting spark toa collaborative project that had taken over a decade, al-lowed for diagnostic angiography to come into its own,and 11 years later, was to lead to yet another eureka mo-ment of medical discovery - the first percutaneous angio-plasty.

With thanks to Professors Lars Lönn and Ulf Nymen for their insights

IQWhat's in store

We have brought you the theory behind theprocedures, now we show you the results.

Cancer is one word for over 200 types of diseasethat can occur in over 60 organs of the humanbody. It is just as unlikely for one word to appro-priately define the range of diseases as it is forone course of treatment to successfully treat it.We show how Interventional Oncology can pro-vide palliative and lifesaving solutions to debilitat-ing and life threatening conditions.

The next issue of IQ completes the 2010 cancerseries with an in-depth look at the discipline, featuring unbiased accounts from the interven-tional oncologists, referring physicians and patients. Current as well as future methods of Interventional Oncology will be presented clearlyand openly.

Interventional OncologyImage-guided, minimally invasivetherapy for cancer

Also featured:

- Global IR Statement

- Recycling, the IR way

- IR in Veterinary Medicine

If you are interested in contributing to IQ, please contact [email protected]

Coming up in Issue 3, November 2010

... The Quarter’s Focus

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Recycling, the IR way

IR in Veterinary Medicine

The Oncologists

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The Minimally

Invasive Knife

ISSUE 3 - November 2010

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IQI n t e r v e n t i o n

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october 2009 interventional quarter issue 2 - july 2010 iq€¦ · has established the efficacy of...

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