Both trials are using the tyranny of low expectations to declare they are effective. modified Rankin Score of 0–3 is not effective, mRS of zero is effective. Survivors effectiveness rating is 100% recovery. Hope you're OK with this ineffective intervention when you're the 1 in 4 per WHO that has a stroke.)
The return of in-person stroke conferences, thrombectomy for basilar occlusion, and advances in intracerebral hemorrhage
It was a great pleasure to attend my first in-person international conference since the COVID-19 pandemic, the European Stroke Organization conference (ESOC 2022) in Lyon. Apart from meeting in-person many old friends and colleagues, a highlight of the conference was two late breaking trials demonstrating the effectiveness of thrombectomy for acute basilar artery occlusion. Both had previously published protocols in the International Journal of Stroke (IJS).1,2 While convincing clinical trial data have shown that thrombectomy is highly effective for anterior circulation stroke, trials in basilar thrombosis have been less convincing.3 Both the ATTENTION1 and Basilar Artery Occlusion CHinese Endovascular trial (BAOCHE)2 presented convincing data showing its effectiveness. ATTENTION recruited patients within 0–12 h from estimated time of stroke onset from 36 comprehensive stroke centers in China. Patients were randomly assigned to thrombectomy or best medical management in a 2:1 ratio. There was a highly significant improvement in the primary endpoint of modified Rankin score 0–3 at 90 days which was achieved in 104/226 (46%) of the endovascular therapy group and 26/114 (22.8%) of the best medical management group; adjusted risk ratio of 2.1 (95% confidence interval (CI): 1.5–3.0), p ⩽ 0.001). BAOCHE differed in that it recruited patients within 6–24 h of symptom onset where the patient was ineligible for intravenous (IV) thrombolysis or had received IV thrombolysis without recanalisation. The planned sample size was 318, but after a planned interim analysis after 212 patients, the data and safety monitoring committee recommended early termination of the trial due to high significance between the two treatments. Fifty-one of 110 (46.4%) patients randomized to thrombectomy achieved mRS 0–3 at 90 days, compared with 26/107 (24.3%) receiving best medical therapy, giving an adjusted odds ratio of improved outcome of 2.92 (95% CI 1.56–5.47), p = 0.001). Together, these trials present convincing data that thrombectomy improves outcome in basilar artery occlusion up to 24 h after symptom onset. It was exciting to hear the results presented live to an audience of more than 2000 with both trials being greeted by a round of applause. The next large international stroke conference will be the World Stroke Congress (https://worldstrokecongress.org/) to be held in Singapore from 26 to 29 October 2022, which already has almost 1000 abstracts submitted. I look forward to similarly exciting findings being presented to an in person and hybrid audience, and hope you will be able to join the World Stroke Organization’s now annual conference.
The effects of the COVID pandemic on delivering stroke care4 have led to increasing interest on telehealth approaches. Many patients have lost out on badly needed rehabilitation services over this period, and telehealth could make major contributions to delivering such services, but first we need to be sure that the quality of services provided is sufficient despite its remote administration. An important review in this issue of IJS by English and colleagues, reviews the current state of telehealth for stroke rehabilitation.5 It concludes that while it shows promise, much of the data evaluating its effectiveness is from smaller phase-2 trials, and much larger initiatives are required to determine how best it can be provided and how effective it is.
A number of papers in this issue address acute intracerebral hemorrhage (ICH). We know acute hemorrhage extends over the first few hours in many patients, but how this extension can be reduced remains uncertain. The role of blood pressure lowering has been controversial.6 A pooled analysis of the INTERACT2 and ATTACH-II individual participant data by Wang et al.7 looked at the association between degree of early blood pressure reduction and outcomes in ICH. The analysis included 3796 patients. Compared to those patients with no systolic blood pressure reduction within 1 h which was used as the reference, improved outcome (defined by a shift in the mRS score) was found for systolic blood pressure (SBP) reductions up to 60 mmHg, but worse outcome was seen for SBP reductions greater than 70 mmHg. The results suggested a J-shaped relationship with improved functional outcome with moderate blood pressure but larger reductions being associated with loss or reversal of any such benefits. A related paper by Toyoda et al.8 also in this issue studied the effects of intensive blood pressure lowering with nicardipine following acute ICH. They performed a systematic review and individual participant data analysis in 1265 patients from three studies. Rapid lowering of SBP during the initial 24 h was associated with lower risks of haematoma expansion and of 90-day death and disability.
Secondary ICH following ischaemic infarction is a concern in acute stroke patients treated with anticoagulation for atrial fibrillation. Whether we should restart anticoagulation early, or wait for a couple of weeks until the risk of haemorrhagic transformation has receded, has been hotly debated. This question can only be answered by clinical trials, and the protocol for a pivotal trial in this area is published in this month’s issue. The optimal timing of anticoagulation after acute ischaemic stroke with atrial fibrillation (OPTIMAS) trial is a multicentre randomized controlled trial with blinded outcome adjudication, in which patients with acute ischaemic stroke and atrial fibrillation eligible for anticoagulation are randomized to early versus delayed initiation of a direct acting oral anticoagulant (DOAC).9 A total of 3478 participants will be randomized, assuming event rates of 11.5% in the control arm and 8% in the intervention arm. Randomization is already well underway, and the study will provide us with definitive data on this difficult clinical dilemma.
OPTIMAS only uses DOACs, rather than warfarin. Randomized controlled trials have shown they are as effective as warfarin in the prevention of stroke in atrial fibrillation and may have lower bleeding risks.10 However, there has been concern as to whether these trial data apply to the general population in standard clinical practice. A paper by Nielsen et al.11 in this month’s issue provides reassuring data on this. They used the Danish nationwide registry and compared outcome in 1772 patients treated with edoxaban 60 or 30 mg, and 4142 treated with warfarin. The thromboembolic rate for edoxaban 60 mg and for warfarin showed equivalence; 0.95 and 1.0, respectively. Edoxaban 60 mg was associated with lower rates of all-cause mortality with a hazard ratio of 0.64 (95% CI: 0.47–0.88). Their results confirm that edoxaban is as effective as warfarin in stroke prevention in routine clinical practice and appeared to also have lower all-cause mortality. On a related issue, a study in just over 1000 individuals with aneurysmal subarachnoid hemorrhage by Sebök et al.,12 also in this issue, found that pre-hemorrhage aspirin use was associated with poor clinical outcome at 6 months with an odds ratio of 1.8.
Finally we are delighted to publish the new Japan stroke guidelines which are now available online at IJS.13 These represent an enormous amount of effort by many physicians across Japan. The original guidelines are published in Japanese, but a summary of the key points are published in IJS, with the full guidelines in English available as Supplementary Material.
University of Cambridge, Cambridge, UK
Email: hsm32@medschl.cam.ac.uk
References
| 1. |
Tao, C, Li, R, Zhu, Y, et al Endovascular treatment for acute basilar artery occlusion: a multicenter randomized controlled trial (ATTENTION). Int J Stroke. Epub ahead of print 22 February 2022. DOI: 10.1177/17474930221077164. Google Scholar | SAGE Journals |
| 2. |
Li, C, Wu, C, Wu, L, et al. Basilar Artery Occlusion Chinese Endovascular Trial: protocol for a prospective randomized controlled study. Int J Stroke. Epub ahead of print 28 August 2021. DOI: 10.1177/17474930211040923. Google Scholar | SAGE Journals |
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