Hans-Christoph Diener, MD, PhD
Dear colleagues, I am Christoph Diener, a neurologist from the University of Essen in Germany. In this video, I would like to summarize the important studies in stroke that came out in 2016.
We had two remarkable publications on primary prevention this year. One was a burden-of-disease study published in The Lancet, and the other was the case-control INTERSTROKE study with more than 27,000 patients. Both studies clearly show that 90% of the risk for stroke is due to treatable risk factors. I sometimes think that we have the priorities wrong;(You do have your priorities wrong, survivor needs are much more important than what doctors and researchers think is important) we should contemplate much more on the primary prevention of stroke rather than on treating and secondary stroke prevention.(Wrong, wrong, wrong you fucking idiot)
We had results from one randomized trial (ACT 1) and a 10-year follow-up study from the CREST trial comparing stenting and curative surgery with asymptomatic aortic stenosis. It is no surprise that there was no difference between stenting and surgery. Unfortunately, the most important question—whether best medical treatment would be as effective as surgery or stenting—was not answered.
Next we come to the acute treatment of ischemic stroke. The IST-3 study published a subgroup analysis comparing tissue plasminogen activator alteplase (tPA) and no treatment in the time window of up to 6 hours. What the study showed, which is extremely important, is that people above the age of 80 also benefit from tPA, as did those with severe strokes and who had high blood pressure at admission. They also showed that there is an increased risk for intracerebral bleeding if people who receive tPA are pretreated with antiplatelet drugs.
The ENCHANTED trial compared two doses of alteplase—the standard dose of 0.9 mg/kg body weight and the reduced dose of 0.6 mg/kg body weight. There was no major difference, but I think that one subgroup is important: The study showed that people who are pretreated with antiplatelet therapy obviously have a benefit from the low dose of tPA in terms of preventing bleeding.
The results of the DIAS-4 trial were also published. Desmoteplase was used in a time window of 4.5-9 hours and compared with placebo. The study was negative.
There [was also research] that looked at predictors of intracranial or intracerebral bleed after tPA. The results showed that a known high load of microbleeds or severe white matter lesions increases the risk of bleeding.
We had multiple trials[9,10] that showed thrombectomy to be highly effective. The numbers needed to treat to achieve a good outcome are between 2.6 and 4. The major challenge now is to implement thrombectomy on a wide basis. There was a randomized study from Heidelberg showing that the outcome is identical, regardless of whether people receive thrombectomy with sedation or global anesthesia.
When it comes to secondary stroke prevention, there was a meta-analysis of the early efficacy of aspirin. It is amazing how effective aspirin is compared with no treatment or placebo in the first 2 weeks after an ischemic stroke. The risk reduction is 55%. We should start aspirin as quickly as possible.
The SOCRATES trial compared ticagrelor and aspirin in people with high-risk transient ischemic attack or mild strokes. There was no benefit of ticagrelor over aspirin for the combined endpoint of stroke or myocardial infarction.
At the moment, we have two ongoing [unpublished] studies in embolic stroke of indeterminate source. These studies compare dabigatran or rivaroxaban with aspirin in this important subgroup of patients.
There was a meta-analysis on the treatment of hypertension in secondary stroke prevention with 39,000 patients, which showed that the best efficacy is achieved with angiotensin-converting enzyme (ACE) inhibitors and diuretics. Unfortunately, in all of the trials, which look at the treatment of diabetes in secondary stroke prevention, there was no positive outcome.
The last area is intracerebral bleeding. We now have data on aggressive lowering of blood pressure in people who have an intracerebral bleed and high blood pressure. Unfortunately, findings did not show a benefit of aggressive lowering of blood pressure.
The good news is that we now have reversal agents for the new oral anticoagulants, and this has implications. There are now 12 cases reported from Germany who had an intracerebral bleed on dabigatran, who were all treated with the reversal agent idarucizumab. In only one patient there was a growth of the hematoma and the patient died. The mortality in this group went down to 9% compared with the usual 50% that we see in anticoagulation-induced bleeding.
Ladies and gentlemen, 2016 was an exciting year for stroke. We learned a lot about how to manage our patients.
I am Christoph Diener from the department of neurology at the University of Essen in Germany. Thank you very much for listening.
- Feigin VL, Roth GA, Naghavi M, et al. Global burden of stroke and risk factors in 188 countries, during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet Neurol. 2016;15:913-924. Abstract
- O'Donnell MJ, Chin SL, Rangarajan S, et al. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet. 2016;388:761-775. Abstract
- Rosenfield K, Matsumura JS, Chaturvedi S, et al. Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med. 2016;374:1011-1020. Abstract
- Brott TG, Howard G, Roubin GS, et al. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med. 2016;374:1021-1031. Abstract
- Berge E, Cohen G, Roaldsen MB, et al. Effects of alteplase on survival after ischaemic stroke (IST-3): 3 year follow-up of a randomised, controlled, open-label trial. Lancet Neurol. 2016;15:1028-1034. Abstract
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- von Kummer R, Mori E, Truelsen T, et al. Desmoteplase 3 to 9 hours after major artery occlusion stroke: the DIAS-4 trial (efficacy and safety study of desmoteplase to treat acute ischemic stroke). Stroke. 2016;47:2880-2887. Abstract
- Lin Q, Li Z, Wei R, Lei Q, Liu Y, Cai X. Increased risk of post-thrombolysis intracranial hemorrhage in acute ischemic stroke patients with leukoaraiosis: a meta-analysis. PLoS One. 2016;11:e0153486. doi: 10.1371/journal.pone.0153486. eCollection 2016.
- Saver JL, Goyal M, van der Lugt A, et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA. 2016;316:1279-1288. Abstract
- Goyal M, Menon BK, Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723-1731. Abstract
- Schönenberger S, Uhlmann L, Hacke W, et al. Effect of conscious sedation vs general anesthesia on early neurological improvement among patients with ischemic stroke undergoing endovascular thrombectomy: a randomized clinical trial. JAMA. 2016;316:1986-1996. Abstract
- Rothwell PM, Algra A, Chen Z, Diener HC, Norrving B, Mehta Z. Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials. Lancet. 2016;388:365-375. Abstract
- Johnston SC, Amarenco P, Albers GW, et al. Ticagrelor versus aspirin in acute stroke or transient ischemic attack. N Engl J Med. 2016;375:35-43. Abstract
- Katsanos AH, Filippatou A, Manios E, et al. Blood pressure reduction and secondary stroke prevention: a systematic review and metaregression analysis of randomized clinical trials. Hypertension. 2016 Oct 31. [Epub ahead of print]
- Qureshi AI, Palesch YY, Barsan WG, et al; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016;375:1033-1043. Abstract