Notice that NOTHING HERE IS ABOUT GETTING SURVIVORS 100% RECOVERED! That is how fucking useless the WSO is! Thrombolysis is only the first step in stroke treatment, they seem to have no clue that by not stopping the 5 causes of the neuronal cascade of death in the first week thus letting hundreds of millions to billions of neurons die. That just proves the complete incompetence of the WSO!
Send me hate mail on this: oc1dean@gmail.com. I'll print your complete statement with your name and my response in my blog. Or are you afraid to engage with my stroke-addled mind? I would like to know what your definition of competence in stroke is.
World Stroke Congress 2024 Session Report: “Borderline Indications in Stroke Thrombolysis”
World Stroke Congress
October 23–26, 2024
Session: Borderline Indications in Stroke Thrombolysis
The session was chaired by Ana Catarina Fonseca (Lisbon, Portugal) and Sven Poli (Tübingen, Germany).
Michael D. Hill (Calgary, Canada), co-PI of the TEMPO-2 trial, kicked off the session with a talk about “Thrombolysis in Minor and/or Non-Disabling Stroke.” The TEMPO-2 trial, which was recently published in The Lancet, included patients with minor acute ischemic stroke (defined as NIHSS 0-5) and intracranial occlusion and randomized 1:1 to thrombolysis with tenecteplase (TNK) or non-thrombolytic standard of care. The trial was stopped early due to futility and showed an increased risk for symptomatic intracerebral hemorrhage and more deaths in the thrombolysis group. Dr. Hill highlighted that patients in the non-thrombolytic group did better than expected with a recanalization rate that was clearly higher than other trials have previously shown for patients receiving antiplatelet monotherapy. This suggests that dual antiplatelet treatment is a very active treatment that should not be underestimated in terms of both benefit and harm. The findings from TEMPO-2 and ARAMIS changed practice in Calgary such that minor strokes are not treated by thrombolysis anymore.
David Seiffge (Bern, Switzerland) followed with a talk on “Thrombolysis and NOAC-Pretreatment.” There is a significant burden of “breakthrough strokes” in patients who are already on anticoagulants. Forty percent of Swiss patients with atrial fibrillation are already on anticoagulation at stroke onset. The most frequent reason to withhold thrombolysis in patients within the treatment window are anticoagulants because international guidelines mention that they “may be harmful.” However, Dr. Seiffge pointed out that, to date, there is some observational data that show no increase in bleeding risk of thrombolysis in patients with anticoagulants compared with patients without. Following the current guidelines thus leads to ethically questionable exclusion of patients who could potentially benefit from thrombolysis. DO-IT, a randomized controlled superiority trial to determine safety and efficacy of thrombolysis in patients with recent DOAC intake (<48h), is currently being conducted in Switzerland and Canada. However, based on current observational data and in face of increasing numbers of stroke patients on anticoagulation, the Swiss team under Prof. Urs Fischer suggests changing the guidelines before conclusion of DO-IT. Consistently, they have already changed their local guidelines.
Bruce Campbell (Melbourne, Australia) talked about “Thrombolysis After 4.5h of Symptom Onset.” The relevance of the topic is illustrated by the fact that over 75% of stroke patients present beyond 4.5 hours. Prof. Campbell led through a variety of studies concluding that there was no definite benefit of alteplase or TNK >4.5 hours using standard CT selection. He then elucidated treatment selection with perfusion imaging (penumbral imaging) and DWI-FLAIR mismatch, which inform us of two entirely different things, but both enable a patient selection that likely benefits from thrombolysis beyond 4.5 hours. He highlighted the importance of NCCT for safety as extensive hypodensities indicate increased risk of hemorrhage.
Ashkan Shoamanesh (Hamilton, Canada) elaborated on “Thrombolysis in Patients With Cortical Microbleeds,” a concern that arises because cortical microbleeds indicate small vessel diseases that are more prone to bleeding. The two underlying pathologies of cortical microbleeds are atherosclerosis and cerebral amyloid angiopathy (CAA). As 20% of stroke patients have cortical microbleeds, the topic is highly relevant. However, there is good data indicating no increased bleeding risk of thrombolysis in patients with cortical microbleeds, with the possible exception of patients with >10 microbleeds. It is important to note that cortical microbleeds are associated with poor functional outcome after stroke, even if without receiving thrombolysis. We have yet to understand the incremental risk of thrombolysis. Additionally, it has been shown in several case reports that patients with cortical microbleeds develop new microbleeds in the first week after stroke whether or not they received thrombolysis.
European and North American guidelines agree that there is insufficient data to screen stroke patients for microbleeds before thrombolysis and that it may even harm patients due to treatment delay. The only discrepancy in guidelines is for patients with >10 microbleeds for whom Europeans advise against and North Americans in favor of thrombolysis, both acknowledging the weak evidence on this patient subgroup.
Andrew Lee (Adelaide, Australia) challenged the audience to turn its eyes to “Thrombolysis in Central Retinal Artery Occlusion.” In preclinical models, it was shown that the retina shows almost full recovery after 97min of ischemia but can still potentially recover up to 240mins of ischemia. Intra-arterial application of tPA into the ophthalmic artery shows a benefit of treatment within 12 hours. Unfortunately, intravenous tPA within the same time window led to severe adverse events, including intracerebral hemorrhages, and the trial had to be stopped. However, it showed that patients with central retinal artery occlusion benefit if lysed intravenously within 6 hours.
Chairwoman Ana Catarina Fonseca (Lisbon, Portugal) closed the session with “Off-Label Use of IV Thrombolysis: What We Know From The Real-World Data.” Off-label use of thrombolysis is very common and has increased over the years from 30 to 75%. After giving an overview of indications for thrombolysis in the United States and Europe, Prof. Fonseca explained that FDA approvement is commonly based on exclusion criteria of trials published before the time of FDA approval and are rarely updated despite high-level evidence. Several off-label indications have been shown to not be associated with poorer outcome or higher symptomatic intracerebral hemorrhage rates. Data from off-label use has been progressively incorporated into scientific society guidelines. Therefore, many indications in the guidelines are off-label. There is an association between use of older drugs and off-label use indicating that industry and regulators show little interest in paying for adjustment of regulations for old drugs.
