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Advanced treatment for stroke is not an elegantly designed drug or gene therapy, but a device that works like a pipe cleaner. It is a thin metal catheter that rises from the patient's thigh, into his heart and into the blood vessels of the brain, where he cleans the obstruction that caused the stroke.
Technology, called "mechanical thrombectomy" or "endovascular treatment", has become the treatment of choice for certain types of ischemic stroke, not because it is simple or inexpensive – it is neither 'other') – but because the pharmaceutical industry does have medicine that works as well.
The only currently available drug, tPA, sold under the brand names Activase and Actilyse, can be fatal in certain types of stroke (which means that patients must be examined with a CT scan before the drug can be administered) and elicit doubts about their effectiveness. his security. According to a study conducted in 2011, it was therefore used in less than 5% of American patients with stroke.
The 50-year quest to develop drugs that protect the brain after a stroke is one of the most enduring failures of the pharmaceutical industry.
Why a Canadian surgeon could succeed where Big Pharma has failed: https://qz.com/1583965/
Other health system actors have stepped in to fill the void, inventing devices, techniques and systems to treat stroke, and to preserve brain cells by narrowing the gap between the moment stroke and that of treatment. As a result, combined with improvements in stroke prevention, the number of stroke deaths has dropped dramatically in the United States and in other rich countries that can afford these advances.
Some developments have been as prosaic as new protocols for identifying stroke victims in ambulances and emergency rooms, and directing them to specialized units. Many deaths from a stroke are not caused by a clot or bleeding in the brain, but by complications such as pneumonia, which could be avoided with good care.
The adoption of new technologies has also helped. For example, telemedicine allows neurologists at large hospitals to remotely diagnose patients with stroke in small rural settings. Mobile stroke treatment units (ambulances equipped with scanning devices, sometimes accompanied by a neurologist on board) can speed up the critical diagnosis determining the tPA of a patient. .
The most dramatic change however has been the rapid adoption of mechanical thrombectomy.
The first device for recovering blood clots in the brain was approved in 2004 by the US Food and Drug Administration. But the real value of the procedure was only revealed when advances in scanning technology allowed doctors to identify the candidates most likely to benefit. Because devices can only work in large cerebral blood vessels, they will not work for obstructed patients in smaller vessels.
For patients with large vessel blockages, however, the benefits of the procedure are considerable. According to the British Medical Journal, a series of nine clinical trials conducted between 2010 and 2015 established the "consistent superiority" of mechanical thrombectomy over tPA. In a meta-badysis of the first five studies, the procedure resulted in a good outcome (defined as the patient having only a slight disability or better) in 46% of stroke patients, compared with 27 % who received tPA or other medical treatment.
This is a powerful procedure that fuels a lucrative business with strong growth. Sales of thrombectomy devices are expected to increase from $ 502 million in 2017 to $ 750 million in 2025.
But from now on, it is still rarely used. In 2017, US neurosurgeons performed 27,000 mechanical thrombectomies, out of approximately 50,000 and 70,000 eligible stroke victims, said Italo Linfante, a neurosurgeon in Miami and president of the Society of Vascular and Interventional Neurology. (Overall, it's still a small part of the 795,000 strokes suffered in the United States each year.)
The procedure requires extensive training and adequate facilities. It can cost $ 17,000, in addition to the already costly emergency care of all stroke patients. In many parts of the world, the procedure is inaccessible except for the very rich. A clot retrieval device is for single use and can cost more than $ 5,000.
But given the cost of stroke, this is a good deal, according to its champions. A thrombectomy device is always cheaper than a typical tPA dose and stroke care costs an average of $ 140,000 over a patient's life.
Regardless of the direct costs, the advent of mechanical thrombectomy is causing waves of confusion in the world of emergency medicine. Hospitals are striving to improve their stroke treatment capabilities so that they are not left behind. Ambulance teams are now being asked to comment on the severity of the stroke in order to know where to transport patients.
Everything is complicated by the for-profit American health care system. Unlike hospitals in countries like Canada, where stroke care is centrally planned, US institutions are encouraged to compete with one another. "Patients are at the heart of an arms race," said Peter Panagos, a stroke specialist who led the emergency medical services boards.
Mechanical thrombectomy is reminiscent of other disruptive technologies, as existing systems are shaken and there are winners and losers. In this case, a selected population of stroke patients is very clearly a winner. The challenge will be to ensure that progress is shared by all who can benefit.
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