An 'Incredible' New Wave in Neurology Care

Andrew N. Wilner, MD


June 01, 2018

Andrew N. Wilner, MD: Welcome to Medscape. I am Dr Andrew Wilner, and I am at the 2018 American Academy of Neurology (AAN) meeting in Los Angeles. I have the pleasure to be joined by Dr Terry Detrich. Dr Detrich has been a frequent attendee at the AAN meetings and is still in practice.

Thanks for joining me, Terry. I would like to talk with you about the AAN meetings and have you share your insights on how the meeting has changed over the years, in particular with respect to its value to neurologists.

Terry P. Detrich, MD: Thank you for having me.

Wilner: When we spoke last night, I could see how very excited you are about the meeting.

Detrich: Every time I attend an AAN meeting, there is new information that changes my practice. I am very patient-oriented, and when I attend these meetings, I look for information that will enhance the care of my patients.

I see myself as a buffer between unrealistic and realistic [patient] expectations and reality. When things change—and they are changing rapidly—I want to be part of these changes, incorporate them into my practice, and deliver the latest care recommendations to my patients as soon as possible.

I have been very active in the management and treatment of stroke, and I just recently retired as medical director of a stroke center at a small rural hospital. Following the approval of tissue plasminogen activator (tPA), my colleagues and I have been very successful in treating stroke patients. I was actually with Michael Walker, MD, at the 1995 AAN meeting in San Francisco when he and his colleagues presented the tPA data. This [treatment] changed my life and the lives of my patients; it also changed our hospital's healthcare delivery system.

For a primary hospital, my institution has been incredibly successful in its care of stroke patients. Our hospital system sees approximately 225 stroke patients a year. This past year, we won the American Heart Association/American Stroke Association Get With The Guidelines-Stroke Gold-Plus Quality Achievement Award for stroke care, and our use of tPA has gone up substantially owing to the support of our emergency physicians. My institution is affiliated with the University of Maryland, which helped us with [stroke care] coverage.

The MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands)[1] was the beginning of the changes in stroke care. Yesterday, the data that were presented from the DAWN (Diffusion Weighted Imaging [DWI] or Computerized Tomography Perfusion [CTP] Assessment With Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention)[2] and the DEFUSE 3 (Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 3)[3] trials provided a new perspective on stroke care delivery.

Wilner: These trials suggest that thrombectomy now can be performed up to 24 hours after an ischemic stroke—a new wave of ways to help patients.

Detrich: It is an incredible new wave of care. There will be a lot of growing pains in implementing these new changes to stroke care, and we have already begun to address some potential problems in this regard at my institution.

For example, we cannot send all stroke patients to a tertiary facility—there are not enough beds to do so. At our institution, located in a small town in Maryland, we are going to select our patients, prestudy them, and move the transfer through the use of telemedicine. We have a great transport system, in part based on our shock-trauma unit, which I believe was the first in the country. We have an extensive medical evacuation system already in place, and are ultimately looking at a telemedicine program. We have not been able to expand in the way that I would like in regard to telemedicine, but I have the whole medical team on board, thanks in part to the great coordinators with whom I work.

We also will need advanced imaging modalities to assess perfusion or perfusion/diffusion mismatches to determine which patients require transport to a tertiary center.

As I mentioned, we are very big on administering tPA to stroke patients and have had outstanding treatment successes. This past year, I believe all of our stroke patients received tPA within 60 minutes We are thrilled with and proud of our achievements.

For 20 years, there were no changes in stroke care. I did not even bother to go to any of the stroke sessions at the AAN meeting. My perspective changed when the tPA data were presented. Now I always attend the stroke sessions to keep up with the latest trial data, the direction care is heading, and the latest standard of care.

I am overwhelmed by the data [from DAWN and DEFUSE 3] and the impact these will have on our patients over the next few years. I do have concerns about the increasing cost, an issue that also was raised by others yesterday. Providing 24/7 care for patients is a big deal. We do not have enough stroke doctors or stroke trainees to offer this type of coverage. Another concern related to cost is specifically who is going to pay for this care.

Although the selected group of patients in each of the two trials was small, the outcomes were spectacular.[2,3] These outcomes may be compared with studies showing the effectiveness of catheterization in preventing myocardial infarction (MI). It took 22 patients to get a catheter study to prevent an MI to have dramatic improvement in stroke in this selected group.

With respect to the DAWN and DEFUSE 3 trials, we have to keep in mind that the results were seen in a selected group of patients. It was between two and three patients to get outstanding results. These outstanding results were that the patients were alive and had a modified Rankin scale score of 2 or less, indicating at least self-care or even the ability to return to work and function normally. That is pretty outstanding.

Wilner: What other information from the AAN meeting are you going to share with your patients?

Detrich: I was blown away by the results of some of the gene-modifying trials that were reported. I had an off-label, anecdotal conversation with some of my colleagues in the genetics field about their experiences with gene modification for Huntington disease and amyloid beta modification. I have patients with amyloid disease and patients with Huntington disease, so [I was excited] to hear these anecdotal reports on the possibility of genetic modification in Friedreich ataxia.

I thought these research findings would take 20 years, which was a realistic expectation when I started in practice. Now things are happening so quickly. With all the basic science, with all the technical advances, with all the experience, this has come about in a matter of 2-3 years from what was postulated.

It is great to have this type of data to share with patients. In fact, I have an informal discussion scheduled in May to talk with staff, patients, and caregivers about what is new in neurology. I am thrilled to talk about this with them.

Wilner: With your level of interest and enthusiasm, I do not see retirement in your near future.

Detrich: Well, I retired from private practice, but am working full-time. In my practice, I focused more on what I will call "geriatric neurology," though more on movement disorders and dementias.

In addition to the changes that are taking place in diagnoses [of neurologic diseases], new therapies are not that far away. We are finally at a point where we are sorting through all these conditions.

I am an old man who has been in practice for a long time. Now, after all of the information presented at the AAN meeting, I am rethinking Parkinson disease. For example, I no longer view Parkinson disease as a dopamine deficiency disease, but rather as an alpha-synucleinopathy. This perspective explains a lot of my clinical observations. I am both thrilled and excited to share some of this new information with my staff and my patients and their caregivers.

Wilner: Dr Detrich, I share your enthusiasm, and that is also why I attend the AAN meetings. Now that we have tools to help our patients, I think more and more physicians are going to stay in practice longer. We finally have the ability to help patients and change the ill-deserved reputation that neurologists had a long time ago.

Detrich: I can talk about that too, because I was there a long time ago and remember the "diagnose and adios" reputation we had. As you know, the decade of the brain in the 1990s changed neurology from being a diagnostic specialty to a therapeutic specialty. I was very enthusiastic and excited about this. The big thing then, when we look at the long term, was disease-modifying therapies in multiple sclerosis.

I was very hopeful in the 2000s, but became a little frustrated in early years of the 2010s. Now, with all this new information, technology, and potential new treatments over the past couple of years, I am rejuvenated, anticipating that next step at the bedside. There are actually ongoing clinical trials for tau and for alpha-synuclein. I want to be part of that, which is why I want to continue to practice.

Wilner: I want to thank Dr Detrich for joining me here at the annual AAN meeting in Los Angeles. I am Dr Andrew Wilner, reporting for Medscape.


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