"There is an increase in ictus due to our ageing population"
Doctor and UAB lecturer in Medicine Antoni Dávalos has been working for years on the research into ictus, which affects 12,000 people in Catalonia alone. In this interview, he explains risk factors, medical treatments, and current and future research issues.
Antoni Dávalos is a doctor specialised in Neurology. For 18 years, he has been at the head of the Neurology Section and Stroke Unit of the Hospital Josep Trueta in Girona, where he was also scientific director. He is head of the Neurology Unit and Clinical Director of the Neurosciences Area of the Germans Trias i Pujol Hospital since October 2004, and lecturer of the UAB Department of Medicine.
Lecturer Dávalos leads the Basic and Translational Research Group in Neurosciences, accredited and funded by the Government of Catalonia's AGAUR agency, and member of the RETICS-INVICTUS network belonging to the Institute of Health Carlos III of the Spanish Government. He has contributed to implementing very important cutting-edge treatments for ictus, for which he has received international recognition and awards.
1.- What is an ICTUS?
-The concept before included the words apoplexy, embolism, stroke, haemorrhage, etc. It is a sudden interruption of the blood supply to the brain. This can be caused by two reasons: it is most frequently due to the obstruction of an artery, which is when a person suffers a stroke (80% of ictus); and secondly, an artery can burst, causing a haemorrhage in the brain (20% of ictus).
2.- How can one detect the first symptoms and remain alert?
-The most frequent symptoms fit into an acronym we use, which is FAST: F for Face (those who have suffered an ictus may experience a facial drooping, with a crooked smile); A, for Arm (weakness in the arm and paralysis of half of the body); S, for Speech (difficulty in speaking or understanding what they are being told); and T, for Time (if any of the above symptoms appear, the person must be rushed to the hospital). The symptoms are the same for both types of ictus. The person may only show one of the signs, but if the ictus is severe, all symptoms will appear together.
3- Who is most vulnerable? What are the risk factors?
The main risk is hypertension (it is extremely important to control one's blood pressure); diabetes, obesity, hypercholesterolemia, a sedentary lifestyle, and another very important factor is atrial fibrillation (an abnormal hearth rhythm), which is when the heart, instead of contracting, shakes, and blood clots can form which can block one of the cerebral arteries. This factor is becoming increasingly important because it is closely linked to age; people over 80 years old have a high chance of this happening to them. Since we now live longer, this is becoming more frequent. And this is one of the reasons why the cases of ictus are not decreasing; they are actually increasing. However, even young people must remain alert because 5% of patients are not even 50 years old.
4.- Is it the main cause of death in women?
Yes. It is probably so because more men die of heart attacks and more women die of strokes. Research says that women recover less from strokes than men do, due to a hormonal factor... But basically it is because more men die of heart attacks.
5.- In what direction are the research studies headed?
The research line of each team is different. What is most important is to improve interventions in arteries. If we bear in mind that 80% of ictus are caused by the blockage of an artery, the first we need to consider is opening the artery. With each minute that passes, more brain cells die and the stroke expands and grows in volume. That is why it is important to act quickly and open up the artery again so that the blood can flow. There are two ways of opening arteries, and this is the research I have been working on: the first, which has been used for some years now, is with the tPA treatment, which is administered intravenously and has the advantage of being available at any hospital.
The problem is when the obstruction is located in a large cerebral artery, this treatment only dissolves the clot some 20-30%, and when it is in the largest cerebral artery it only works in 10% of the cases. Therefore, it's easy to use but not very effective. I participated in one of the studies for the drug, many hospitals were participating. But once the treatment was applied, we began to think that extraordinary measures may be more effective, and that is when we began researching into thrombectomy.
6.- What is the thrombectomy technique which you have developed?
- It consists in removing the clot not with a drug but with a catheter. We introduce the catheter and travel to where the cerebral artery is clogged. As if it were a tree, we travel up the branches and when we reach the place where we need to work, we unfold a net which seizes the clot and then we vacuum it out. This technique helps open up the arteries in 80% of the cases. It has been done for eight years now, but its effectiveness was only demonstrated one and a half years ago (we do many things in medicine, but can only fully demonstrate that they work after trying them).
7.- How does it fare when compared to the tPA treatment?
The technique has doubled, and almost tripled the chances of a patient being independent and not needing anybody else. This is the study entitled REVICAT, which I directed and which has been published in scientific journals. A total of five studies were conducted worldwide and in two or three months we all published similar results. We are not the only ones, but we are one of the five who were able to demonstrate it. This technique has changed how we treat ictus.
8.- And what challenges are you now facing?
The challenge is to make this technique available to everyone, regardless of where they live. At the moment this is not so. It is a very complex technique and currently only five large hospitals in the Barcelona area offer it.
We are now working on making it possible for all patients to reach one of these hospitals as quickly as possible. I live in Girona, for example, and it would not be the same if I were to suffer an ictus in Girona or here, in Badalona. That is why we are now studying whether it is more effective to take a patient immediately to one of the big hospitals, or first to the nearest local hospital to perform a tPA and later transfer them to one of the five with a thrombectomy technique. We do not know what could be best for a patient in cases in which each minute is precious. It is still unknown to us, but we will have answers in three years. We are at the same time working to train professionals. There will be a moment in which local hospitals will be forced to provide this treatment, but first professionals must be trained so that in two or three years this can be possible.
9.- How many patients are treated with thrombectomy?
In Catalonia, 500 patients are being treated, of a total of 12,000 affected. As you can see, we are far below the number of patients who should be receiving this treatment. It must be highlighted that many are not treated because they do not recognise the symptoms, or they go to hospitals where they cannot be treated, or they arrive too late, etc. We should at least double the number of patients we treat.
10.- How important is research for a patient who has suffered an ictus?
- Progress has been made mostly in prevention, which is the best treatment there is (not smoking, abandoning a sedentary life, maintaining a normal blood pressure, etc.) and people are becoming increasingly aware of that. Secondly, fibrillation treatments (new medications which are more expensive, but also more effective than those known until now, such as the drug Sintrom®).
In contrast, in the case of ictus caused by haemorrhages we have made little progress. Operating is adequate in some cases, but not all. To try to stabilise a person's blood pressure in the first few hours is the best option we have for now.
11.- And once the ictus has occurred, what must we do?
This is the one huge problem we have. Techniques and treatments are being studied with the aim of regenerating brain cells, but up until today we have not been able to find anything that works. Rehabilitation is very important, of both motor and neuropsychological skills, but we are still in the stage in which more research is needed. It is possible that large portions of the donations to the TV3 Marathon will go towards improving the sequels of an ictus. There are formulas to help stimulate the brain which could contribute to recovering motor skills, but it is all still in the initial stages.
12.- What is the right amount of time in which to reach the hospital?
The less time it takes, the better. All the techniques I've explained have reduced effects the longer it takes to apply them. Most patients do not benefit from a surgery if more than seven hours have passed. Seven or eight hours maximum for the thrombocytosis and 4.5 hours for the thrombolysis. Past those 4.5 hours of thrombolysis it is very difficult to recover anything. But if the hospital is reached in the first hour and the doctors can unclog the artery, most patients recover. We call it the "golden hour"!
13.- Is Catalonia a pioneering country in the treatments for ICTUS?
Yes, definitely. The potential we have here and the research which has been conducted is crucial. We have cutting-edge treatments for ictus.