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Did you know that strokes are the leading cause of death and disability in Portugal?

Every hour, three Portuguese people suffer a stroke and it can be ischemic (blockage of arteries, that prevents oxygenation of the brain), or haemorrhagic (a vessel that breaks and causes a haemorrhage in the brain, or between the brain and the skull). Of these three patients, one ends up dying and those who manage to survive have sequelae.

The 31st of March recalls this statistic as it is the day of the Stroke Patient, and conveys the crucial message that it is enough to have one of 3 symptoms (loss of Strength, change in Speech or a fallen Face) to call 112 immediately.

While the scenario may seem rather scary, statistically speaking, the two aspects that follow will alleviate the initial shock. The first one is that it is possible to prevent a stroke, by having healthy food habits, treating risk factors, playing sports and not smoking. The second aspect is that, at present, there are multidisciplinary teams committed to treating patients with this pathology and strongly motivated to improve the pre-existing national Green Route for Strokes network.

Lia Neto, in addition to being a Professor, is a Neuroradiologist and member of the Santa Maria Hospital (HSM) team responsible for the endovascular treatment of acute strokes.

She studied at the Faculty of Medicine of the University of Lisbon, her first choice. From an early age she had an interest in Anatomy, the "scariest" subject that many students speak of with some fear. "It's a complicated subject because we have a lot to study, but it soon shows that there is a correlation with what we are going to do in the future, and that excited me. Voluntarily, I began to collaborate in the classes early on, as well as in research projects that were underway at the time". She started in the 2nd year, and in the 5th she was recruited to be a Monitor in Neuroanatomy classes. It was precisely because of Neuroanatomy that she realised that she wanted to pursue something connected to the nervous system, and for some time considered the possibility of being a Neurosurgeon; she went on to do internships and attend surgeries, but felt as if it was a speciality with a dynamic that did not match her personality. Although Neuroradiology wasn't yet a very well-known speciality during her course, it gained greater relevance and this connection between anatomy, rapidly evolving complementary diagnostic tests, and the possibility of therapeutic intervention in a less invasive way enthralled her.

Her connection to teaching at the Faculty remained constant throughout the course. After finishing her degree, she was invited to be an Assistant Professor of Neuroanatomy. This was followed by her Master's thesis on Neurosciences and the start of her complementary Internship in Neuroradiology at the HSM. Later, she developed her PhD in Medicine (Anatomy), in an area of translation between basic science and medical science. She says that things happened as life went by "and they came together naturally". Today, she is an Assistant Professor at the Institute of Anatomy and Co-Director of the Disciplinary Area of Neuroanatomy.

In addition to teaching, she coordinates research projects developed by students and mentors the younger ones who, as she did in the past, show an interest in contributing during class. Parallel to her academic career and within Neuroradiology, she pursued the sub-area of Neurointervention which includes, among others, endovascular intervention in acute strokes.

Endovascular therapy of acute strokes is reserved for a selection of patients with certain characteristics and, therefore, it is only one of the stages of the treatment process in a very wide universe, and is under the coordination of Neurology at this hospital.

Early in 2016, the HSM created the so-called Lisbon Metropolitan Emergency Service for acute strokes, in a rotational system, together with the S. José, São Francisco Xavier/Egas Moniz and Garcia de Orta Hospitals. In the country there are only 5 other facilities that prioritise endovascular intervention in acute strokes: Braga, Gaia, Porto (2 hospitals) and one in Coimbra.

She is a member of the HSM prevention team, which is composed of two endovascular intervention physicians, an anaesthesiologist, two nurses and one assistant. Tuesdays, Wednesdays and one weekend a month they must all be available, and from the moment that the procedure is triggered by Neurology, they have half an hour to reach the hospital.

I met her at a presentation at the Junior Doctors Meeting, where she gave an enlightening lecture on what the Green Route for Strokes is, and I did not rest until we spoke in person.

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One of the things that struck me the most about her contribution was learning that a hospital like Santa Maria can have a severe shortage of beds when there is a stroke-related emergency.

This hospital has always received and still receives stroke patients, but the metropolitan emergency service was created 2 years ago, meaning that there are specific days on which the Santa Maria hospital receives candidates for endovascular therapy. The metropolitan emergency service was organised together with three other hospitals: The São José, Centro Hospitalar Ocidental (Egas Moniz and São Francisco Xavier) and Garcia de Orta hospitals, in a rotation system, receive patients who will receive that therapy based on appropriate criteria. On our days (Tuesdays, Wednesdays and one weekend a month) we cannot refuse any patient who meets these criteria, because it is our day, we have to treat them, so sometimes it is difficult to allocate them to the most appropriate services once they have been treated. This is because the stroke unit may be full, or because the Intensive Care units receive other patients, and are also full; Thus there is no other way, if the hospital is full and we are part of the metropolitan emergency service we should find a solution to prepare ourselves for these days. Of course, we always end up arranging a suitable place, even if it's temporary. However, sometimes the procedures finish, and the patients stay in the room where the operation took place, waiting for a vacancy. We have to bear in mind that we may need a respirator for example.

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Clinically, how does the endovascular process take place?

Neuroradiology is an area focused on the nervous system and is integrated into the complementary diagnostic tests and therapy. It uses some imaging methods to observe and analyse the nervous system, such as CT (Computerised Tomography), magnetic resonance and Angiography. In the case of ischemic strokes, there is a clot that forms and blocks the artery, stopping the flow of blood into the brain cells. Lacking the oxygen and glucose that they need, they die in a very short period of time. And this ischemia determines the signs and symptoms of the stroke, such as a change in speech or mobility, depending on the area that is affected. When this type of stroke occurs, with the formation of a clot, what Neuroradiology does is try to remove it and restore the blood flow so that these cells, which are at risk, can be restored back to functionality. This procedure is done with the help of very thin catheters that attempt to aspirate or wrap the clot, with the indispensable help of X-ray visualisation. It has to be a quick process, because time is of the essence.

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Do you want to tell me about that time?

Time is very important, and we should start by talking about transportation. It's really necessary to optimise transport between hospitals, because sometimes the means are not readily available, which wastes a lot of time. The same applies to the helicopter, which should be faster in the first place. For example, a person that has an acute stroke in the Algarve doesn't have anyone in the south to perform endovascular treatments. The patient, who is far away, may receive the first part of the treatment - the administration of an endovascular drug which attempts to dissolve the clot - but has to be transferred for endovascular treatment. It is also important to say, however, that the quickness of transport has been improving over time, everything is now faster than when we started.



From the moment a stroke happens, you have to recognise the signs to be able to act. Just one of the three symptoms mentioned above is enough for the affected person or family member to call 112. Those who answer recognise these signs, and trigger the Green Route call. From here on out, everything has to be faster, giving all priority to the emergency room. Medical therapy, at least here at Santa Maria, is always performed with the cooperation of the Neurologists, who define guidelines for the patient. The patient may be administered an endovenous, thrombolytic drug but, as with endovascular operation, he/she is also subject to criteria and performance times that, if unmet, may increase the risk of haemorrhage. This endovenous treatment was the only one approved for acute strokes for many years.

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So, endovascular treatment didn't exist until now?



It existed, and was found to be beneficial in some cases, but its effectiveness wasn't proven by randomised clinical trials. These trials are considered the most rigorous forms of scientific evidence. It was at the end of 2015 when four or five trials emerged, all at once, proving that this treatment, in selected cases, reduced patient mortality and disability. The trials were stopped prematurely, as people started to notice that the benefit was so great that they were wasting treatment opportunities. That led the American and European guidelines to be amended and in 2016 the Lisbon metropolitan emergency service was organised. I should mentioned that this endovascular treatment is only provided in a set time, as we have a therapeutic window of up to six hours from the first incidence of the symptoms, although recently new clinical trials have emerged that show that the window of the treatment's benefits can be extended to up to 24 hours, provided that the imaging tests (CT/MRI) reveal favourable conditions. Little by little, the guidelines are expanding and allowing more patients to be operated on.

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Is there anyone who can't be treated via the endovascular approach?

There are defined criteria that we always try to follow. Those who don't entirely fit the criteria are cases to consider as a team. For example, a patient with a very extensive cerebral ischemia is likely to gain little from a re-canalisation of the artery, because the cells will no longer regain their function, and there may even be a risk of haemorrhage.

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I know that this is a very basic question, but where and how do you train to perfect such a delicate technique?

In truth, there are endovascular therapies even more delicate than stroke therapy. An aneurysm, for example, is much more meticulous. But I can tell you about my training. When I was doing my specialisation I practised on animals, I did some practical courses, but also on computerised models. The companies that market materials for the treatment sponsor the organisation of courses and promote them so that we can train.

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But there is a moment when it becomes real. And that is the first time. Do you remember it?

Before we are independent, we spend hours watching and helping senior colleagues. This is very important, and you learn a lot. The difficult part of the technique isn't limited to the hand, nor the delicacy of your movements, it's having the sense of how to decide in that moment what is the best material to use, its dimensions and, once again, whether we should proceed with the treatment in that particular case or not. I think that the first time that I removed a thrombus was during another procedure. We were treating an aneurysm and a clot formed unexpectedly. It was all so quick and effective that there were no sequelae.

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Does the physician feel the time pressure too?

Yes, one of the most commonly used phrases in stroke initiatives is "Time is Brain" and, according to this logic, everything always seems to take too much time. The patient has to arrive, be laid down, prepared, anaesthetised and the entire process seems to be very slow.

Then there are patients who have straight arteries, and others who have winding arteries, which means it takes more time to get to the exact place where the clot has formed. Then, there are thrombi that can be removed quickly, and others that take longer to get out. Time depends not only on our quickness, but also on the anatomy of the patient, the type of blood clot and the material used. Sometimes, the same material and the same brand that was used successfully in one patient may not be effective in another, and we can't explain that.

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What happens to the patient if an endovascular procedure doesn't go well?

They may maintain their initial state, show no improvements. If there is too much ischemia and cerebral oedema they may need a surgical procedure, a craniectomy. Neurology and Neurosurgery are always aware of these stroke situations, where it isn't possible to reverse ischemia. And, from then on, there is a long process of rehabilitation, physiotherapy, speech therapy, etc., etc., to try to alleviate the disability and dependence in daily activities.

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Lia Neto, as any physician in her area of intervention, has a fleeting contact with the patients that she treats, since she doesn't follow them after treatment, as they are referred to Neurology. Sometimes she speaks with the family at the end of the procedure. After the first 24 hours, you can analyse your patient's CT scan, but in fact it is usually only after a few months that the actual results of the treatments are evaluated. Each case with a less than ideal outcome, however, only gives us experience and lessons to deal with the next patient who comes in, helping us to remember the best decision to make.

The coordination of all the means, to ensure that the functioning of the Green Route becomes more and more effective, depends on an enormous combination of factors that are out of your hands. There are still many physicians who don't know which hospitals are part of the Lisbon Metropolitan Emergency Service or when it is working. Providing information and raising awareness within the medical community, but also within the civil community, may help to consolidate routines so that these procedures become increasingly agile and swift.

Professor and physician Lia Neto was born in Faro, and her parents continue to live in south Portugal. If, by chance, they have a stroke, she knows that they will certainly not be treated as her patients in Lisbon.

Maybe that's why she considers the possibility of one day performing her procedures in the south. But the south must activate them.

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Joana Sousa

Editorial Team