- Email: [email protected]
Stephen Davis: realising the potential of imaging in stroke care
In Context
Profile Stephen Davis: realising the potential of imaging in stroke care
For the EPITHET trial see Articles Lancet Neurol 2008; 7: 299–309
30
The multitude of choices that stretch before a young mind can often lead to difficulties in choosing a career. Not so for Stephen Davis—Director of Neurology and the recently opened Melbourne Brain Centre at the Royal Melbourne Hospital and inaugural Professor of Translational Neuroscience at the University of Melbourne, Australia—who aimed for a medical career from his early teens. “I had always been interested in medicine and medical research”, Davis told The Lancet Neurology. “In particular, the brain fascinated me. The brain is what makes us different, intriguing, and individual.” Although now a Melbournian, Davis was born in London, and has maintained strong links to the UK. He graduated in medicine at the University of Melbourne, and then worked at Melbourne’s Alfred Hospital with neurologist Bernard Gilligan, who strongly encouraged him to train in neurology. During this rotation, he decided to abandon his earlier aspiration to be a psychiatrist and subsequently spent 2 years as a neurology trainee at the Royal Melbourne Hospital with Peter Ebeling before completing “neurology finishing school”—namely, 18 months at the National Hospital of Neurology and Neurosurgery in London. He then spent 2 years doing research at the Massachusetts General Hospital (MGH), Boston, and Harvard University, USA, experience that piqued his interest in cerebral blood flow and stroke. In these early years (1980s), he was fortunate to work under the neurologist and neuroradiologist Robert Ackerman. It was the beginning of an exciting era in stroke research with the advent of PET scanning, enabling detailed analysis of the ischaemic penumbra for the first time. Davis’ career, which spans four decades, has seen the landscape of stroke care change radically, with the focus today very much on imaging and evidence-based treatments. “The most dramatic development in stroke care in my career has been the proof of the benefits of thrombolysis using tPA (alteplase)”, says Davis. “This completely changed the paradigm of stroke therapy. When I first started, stroke patients mostly had rather poor care on general medical wards and indeed most clinicians had a rather nihilistic view about treatment. Today, there are vastly improved outcomes after stroke, based on a range of important advances in stroke organisation and acute therapies.” The recent focus of Davis and his colleagues, including long-time collaborator Geoffrey Donnan (Director of the Florey Neuroscience Institutes in Melbourne) is to realise the potential of modern neuroimaging to individualise stroke care in the selection of acute therapies. The ongoing EXTEND trial, led by Davis, Donnan, and colleagues, is using multimodal MRI and multimodal CT to image salvageable tissue in the ischaemic penumbra as a selection criteria for intravenous
tPA beyond the present 4·5 h window. Davis and Donnan also co-chaired the EPITHET trial, a prelude to EXTEND published in The Lancet Neurology. This study indicated that alteplase had potential therapeutic benefits beyond the established 3 h window, with increased reperfusion and reduced infarct growth. The potential for individualised treatment selection, based on advanced neuroimaging rather than a rigid time window, has now emerged. Davis hopes EXTEND will identify which patients with acute stroke could be treated with alteplase beyond the currently recommended 4·5 h window. “Each stroke patient has their own tissue clock, and these techniques could help identify many tPA-responders currently thought untreatable under the existing guidelines, which were based on non-contrast CT scanning and clinical criteria”, says Davis. Asian countries will be involved to improve generalisability of the findings. He and Donnan are also closely collaborating with Werner Hacke (University of Heidelberg, Germany), heading a similar trial in Europe. Davis’ other specialist interest lies in intracerebral haemorrhage (ICH), accounting for 15–30% of all stroke cases. He helped show that haematoma growth was an important independent predictor of both mortality and functional outcome after ICH, and that recombinant factor VIIa showed promise for reducing haematoma expansion. But while his research interests are intensely focused, his leisure time shows greater variety. One might reasonably ask: with a life as busy as this, how can this neurologist possibly relax his brain? But Davis enjoys various hobbies including skiing, jogging, Australian rules football, and musical tastes that run from the Rolling Stones to Verdi, as well as dinner and a glass of wine with his family. Donnan says one of Davis’ great strengths is getting people to work together. “His collaborative skills have made him a major contributor to clinical trials in stroke worldwide, and he has been one of the main drivers behind the introduction of thrombolytic therapy for acute ischaemic stroke”, adds Donnan. “He has been a real pioneer in the field of MR imaging in acute ischaemic stroke, particularly in establishing the role of mismatch as a marker of viable penumbral brain tissue.“ “A dozen or so persons have been key for the transition of ‘stone age’ acute stroke care some 30 years ago to where we stand today with reperfusion therapies in clinical routine— one of them is clearly Steve”, says Bo Norrving, Professor of Neurology at Lund University, Sweden, and President of the World Stroke Organisation (WSO). “He also serves WSO eminently well as a board member with a wealth of ideas and visions.”
Tony Kirby www.thelancet.com/neurology Vol 11 January 2012
Profile Stephen Davis: realising the potential of imaging in stroke care
For the EPITHET trial see Articles Lancet Neurol 2008; 7: 299–309
30
The multitude of choices that stretch before a young mind can often lead to difficulties in choosing a career. Not so for Stephen Davis—Director of Neurology and the recently opened Melbourne Brain Centre at the Royal Melbourne Hospital and inaugural Professor of Translational Neuroscience at the University of Melbourne, Australia—who aimed for a medical career from his early teens. “I had always been interested in medicine and medical research”, Davis told The Lancet Neurology. “In particular, the brain fascinated me. The brain is what makes us different, intriguing, and individual.” Although now a Melbournian, Davis was born in London, and has maintained strong links to the UK. He graduated in medicine at the University of Melbourne, and then worked at Melbourne’s Alfred Hospital with neurologist Bernard Gilligan, who strongly encouraged him to train in neurology. During this rotation, he decided to abandon his earlier aspiration to be a psychiatrist and subsequently spent 2 years as a neurology trainee at the Royal Melbourne Hospital with Peter Ebeling before completing “neurology finishing school”—namely, 18 months at the National Hospital of Neurology and Neurosurgery in London. He then spent 2 years doing research at the Massachusetts General Hospital (MGH), Boston, and Harvard University, USA, experience that piqued his interest in cerebral blood flow and stroke. In these early years (1980s), he was fortunate to work under the neurologist and neuroradiologist Robert Ackerman. It was the beginning of an exciting era in stroke research with the advent of PET scanning, enabling detailed analysis of the ischaemic penumbra for the first time. Davis’ career, which spans four decades, has seen the landscape of stroke care change radically, with the focus today very much on imaging and evidence-based treatments. “The most dramatic development in stroke care in my career has been the proof of the benefits of thrombolysis using tPA (alteplase)”, says Davis. “This completely changed the paradigm of stroke therapy. When I first started, stroke patients mostly had rather poor care on general medical wards and indeed most clinicians had a rather nihilistic view about treatment. Today, there are vastly improved outcomes after stroke, based on a range of important advances in stroke organisation and acute therapies.” The recent focus of Davis and his colleagues, including long-time collaborator Geoffrey Donnan (Director of the Florey Neuroscience Institutes in Melbourne) is to realise the potential of modern neuroimaging to individualise stroke care in the selection of acute therapies. The ongoing EXTEND trial, led by Davis, Donnan, and colleagues, is using multimodal MRI and multimodal CT to image salvageable tissue in the ischaemic penumbra as a selection criteria for intravenous
tPA beyond the present 4·5 h window. Davis and Donnan also co-chaired the EPITHET trial, a prelude to EXTEND published in The Lancet Neurology. This study indicated that alteplase had potential therapeutic benefits beyond the established 3 h window, with increased reperfusion and reduced infarct growth. The potential for individualised treatment selection, based on advanced neuroimaging rather than a rigid time window, has now emerged. Davis hopes EXTEND will identify which patients with acute stroke could be treated with alteplase beyond the currently recommended 4·5 h window. “Each stroke patient has their own tissue clock, and these techniques could help identify many tPA-responders currently thought untreatable under the existing guidelines, which were based on non-contrast CT scanning and clinical criteria”, says Davis. Asian countries will be involved to improve generalisability of the findings. He and Donnan are also closely collaborating with Werner Hacke (University of Heidelberg, Germany), heading a similar trial in Europe. Davis’ other specialist interest lies in intracerebral haemorrhage (ICH), accounting for 15–30% of all stroke cases. He helped show that haematoma growth was an important independent predictor of both mortality and functional outcome after ICH, and that recombinant factor VIIa showed promise for reducing haematoma expansion. But while his research interests are intensely focused, his leisure time shows greater variety. One might reasonably ask: with a life as busy as this, how can this neurologist possibly relax his brain? But Davis enjoys various hobbies including skiing, jogging, Australian rules football, and musical tastes that run from the Rolling Stones to Verdi, as well as dinner and a glass of wine with his family. Donnan says one of Davis’ great strengths is getting people to work together. “His collaborative skills have made him a major contributor to clinical trials in stroke worldwide, and he has been one of the main drivers behind the introduction of thrombolytic therapy for acute ischaemic stroke”, adds Donnan. “He has been a real pioneer in the field of MR imaging in acute ischaemic stroke, particularly in establishing the role of mismatch as a marker of viable penumbral brain tissue.“ “A dozen or so persons have been key for the transition of ‘stone age’ acute stroke care some 30 years ago to where we stand today with reperfusion therapies in clinical routine— one of them is clearly Steve”, says Bo Norrving, Professor of Neurology at Lund University, Sweden, and President of the World Stroke Organisation (WSO). “He also serves WSO eminently well as a board member with a wealth of ideas and visions.”
Tony Kirby www.thelancet.com/neurology Vol 11 January 2012