Designing the Future of Stroke Care
Aug 27, 2021 Cedars-Sinai Staff
For the better part of the last decade, Nestor Gonzalez, MD, has focused his research on revolutionizing the future of stroke care. At Cedars-Sinai, he leads the investigation of a pioneering new treatment option for patients suffering from intracranial atherosclerotic disease (ICAD). Evaluating encephaloduroarteriosynangiosis (EDAS) to prevent secondary stroke, it’s one of the few national surgical clinical trials currently seeking to address neurovascular problems.
“ICAD is an extremely significant problem,” Gonzalez said. “At least 20% of the population that suffers strokes will have a better alternative of treatment.” With Black, Asian, and Hispanic populations disproportionately impacted by ICAD, the trial holds the potential to advance health equity.
"This reduction would have a significant impact in years of function, cost of healthcare, secondary hospitalization, rehabilitation, job loss, etc., related to secondary stroke."
Existing surgical and nonsurgical therapies—medical management, cranial bypass, stenting with angioplasty—have not been effective at reducing the risk of secondary stroke or death in randomized clinical trials of patients with ICAD.
Gonzalez, director of the Neurovascular Laboratory at Cedars-Sinai, is excited for the future of stroke care given the advancement of acute treatments like EDAS, exciting research to advance endovascular treatment methods, and continuing education on stroke recognition for families and providers. With the lowest mortality rates for ischemic stroke in the nation, Cedars-Sinai is at the forefront of stroke care.
Spotlight on Encephaloduroarteriosynangiosis (EDAS)
Encephaloduroarteriosynangiosis (EDAS) is a procedure currently used to achieve revascularization in pediatric patients with restricted blood flow to the brain caused by Moyamoya disease. Surgeons reroute arteries from the scalp, placing them in close proximity with arteries of the brain. The procedure is much lower risk compared to the direct bypasses tested in other trials.
“Leaving the arteries intact, not cutting any vessels nor doing a direct bypass, we reposition the arteries of the scalp and wait for the body to respond,” Gonzalez said.
As early as three to four weeks following surgery, vessels form between the arteries of the scalp and the brain, increasing blood flow to the brain. Symptoms begin to subside and patients can start resuming normal activities.
At Cedars-Sinai, Gonzalez served as principal investigator on trials focused on expanding this revascularization technique to stroke patients. The first trial established the feasibility of the procedure to achieve revascularization for patients with ICAD, and the second successfully demonstrated lower secondary stroke rates in ICAD patients following EDAS revascularization than what was anticipated with medical management alone.
“We have shown that our rates of stroke and death are significantly less than they were with just medical management,” Gonzalez said.
The data shows that the rates of secondary stroke or death for patients are less than 10% at two years, a significant improvement over the current rate of 20-30% in medical management.
“This reduction would have a significant impact in years of function, cost of healthcare, secondary hospitalization, rehabilitation, job loss, etc., related to secondary stroke,” Gonzalez said.
For that reason, in collaboration with the National Institutes of Health and The Stroke Network, Gonzalez is preparing to expand the application of this technique to a multicenter clinical trial with more than 40 institutions to test EDAS as compared to standard medical management in a definitive randomized clinical trial.
If approved, the EDAS trial would be the first neurosurgery clinical trial for a surgical technique since the early 2000s.
"We have shown that our rates of stroke and death are significantly less than they were with just medical management"
Three trends shaping the future of stroke care
Beyond his game-changing EDAS research, Gonzalez is passionate about shaping the future of stroke care more broadly and serves as head of the Cedars-Sinai Neurovascular Laboratory and the official representative for the American Heart Association to the Academy of Neurology Guidelines Committee.
He said he sees three critical areas where stroke care is evolving in significant ways.
The first is high-impact research for stroke patients with chronic conditions causing high risk of additional strokes. The groundbreaking EDAS study is a prime example.
“Even with the best medical management, the recurrency rate of stroke is very high—as high as one in three patients with high-risk characteristics,” Gonzalez said.
The second piece of the puzzle, Gonzalez said, is the exciting expansion of endovascular therapy to respond to acute ischemic stroke.
“These endovascular techniques allow us to very rapidly get into the arteries and remove the clots causing the stroke, and they have been extensively validated in clinical trials,” he said.
In endovascular therapy, surgeons use catheters to insert wires and cylindrical metal stents that trap and remove the clot while the artery is aspirated.
Previously, these devices were successful in treating clots located in larger proximal vessels.
“Now we have smaller devices and better ways to navigate that allow us to go further up into arteries. We can treat strokes in smaller distal vessels that, before, may have been considered inaccessible,” Gonzalez said.
Additional new research shows that the treatment window for responding to ischemic stroke with endovascular therapy can be safely expanded. Further, these endovascular techniques are safe and effective in treating strokes in pediatric patients.
Gonzalez encourages fellow neurosurgeons and neurologists to participate in systematic studies using these treatments and to collect and publish the data to establish their effectiveness and advance the field.
Finally, Gonzalez considers bolstering stroke recognition among both physicians and community members to be a critical frontier in the future of stroke care, particularly in populations in which stroke is often misdiagnosed, like young adults and pediatric patients.
“Education for doctors and nurses can shift to prioritize stroke recognition,” Gonzalez said. Any new focal deficit, or an infant with a change in mental status or seizure, should be treated as a possible stroke.
“Sometimes we consider possible patient diagnoses from most common to less common,” he said. “Instead we should evaluate from most to least dangerous. Because stroke is the most dangerous, we should think about stroke first, rule it out, then look at other possibilities.”
This shift could be particularly impactful in pediatric settings, where strokes are not very common, but can be devastating.
Reaching the best patient outcomes
Gonzalez cautioned that trying to remove a clot alone does not guarantee a good patient outcome all the time. It is essential to recognize stroke promptly and intervene as soon as possible to save these patients and their function. The Stroke Program at Cedars-Sinai is committed to fast intervention and coordinated rapid response, and regularly monitors and reports on outcomes and quality measures.
The program was the first in Los Angeles County to reach Comprehensive Stroke Center certification from The Joint Commission and the American Heart Association/American Stroke Association. Designated a certified Approved Stroke Center by the L.A. County Emergency Stroke System, Cedars-Sinai is a preferred location for first responders to take suspected stroke patients.
With stroke care, Gonzalez said, “time is essential.”