Neurosurgeon Nick Hopkins Calls for Cardiologists to Adapt Technology and Skills to Battle Stroke

September 23, 2010—In a presentation at the Transcatheter Cardiovascular Therapeutics scientific symposium in Washington, DC, neurointerventionist L. Nelson "Nick" Hopkins, MD, FACS, discussed the need for cardiologists to play a role in the future of stroke care. Dr. Hopkins urged cardiologists and neurointerventionists to join forces to take on the increasing number of strokes that occur in the United States, reported the TCT Daily.

“[Stroke] has to be a focus for all of us because it is the number one cause of disability, one of the most expensive diseases we face, and the number three cause of death,” Dr. Hopkins said. Dr. Hopkins is Professor and Chairman of Neurosurgery, Professor of Radiology, and Director of the Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York in Buffalo, New York; and Chairman, Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health in Buffalo, New York.

According to Dr. Hopkins, the manpower needed to treat the approximately 800,000 strokes that will occur in the United States in the next year must come from interventional cardiology—a field with experts whose goal of timely treatment is aligned with those currently treating stroke. He noted that the infrastructure for the provision of emergency service already exists in interventional cardiology and cardiologists are familiar with many stroke interventions, such as clot removal and stenting.

Dr. Hopkins noted that the goal of performing stroke interventions is to restore blood flow in the occluded cerebral artery to preserve the brain territory it supplies and return the patient to normal function. Current treatment options include both medical (eg, lytics, antiplatelet therapy, anticoagulants, blood pressure regulation, and electrolyte control) and endovascular (eg, intra-arterial injections, mechanical thrombolysis, and clot retrieval) methods.

All of the current options are effective, Dr. Hopkins said, but they each have caveats. Intravenous tissue-type plasminogen activator is not approved for patients older than 80 years, those taking oral anticoagulants, those with an National Institutes of Health Stroke Scale of > 25, or those with a history of stroke or diabetes. In addition, there is a limited time window and limited benefit. For intra-arterial methods, data from studies of such as PROACT II showed superiority versus placebo but an increased risk for hemorrhage and no difference in the rate of mortality, according to Hopkins.

Cerebral perfusion is a new tool that provides quantitative data on blood flow, blood volume, and mean transit time, a useful guide during intervention that Dr. Hopkins and investigators relied upon heavily during the SARIS trial. SARIS was a small safety study that examined the use of the self-expanding Wingspan stent (Boston Scientific Corporation, Natick, MA) for stroke intervention. Recanalization results from the trial were favorable (100% of patients improved to TIMI flow ≥ 2), Dr. Hopkins said. However, data on the use of stents in stroke intervention are lacking, and this method is not currently approved by the US Food and Drug Administration.

“Stenting for salvage of ischemia works,” stated Dr. Hopkins. “It is a principle that was developed by cardiology, and it needs to be applied to acute stroke.”

Dr. Hopkins said that there is a need for more manpower in the battle against stroke and that cardiologists are the key. Training programs designed for cardiologists to learn neuroanatomy and neurotechniques are critical to the success of stroke intervention.