This is ABSOLUTELY APPALLING! 'Management' NOT RECOVERY! I don't think there is a stroke association in the world that has any clue on what survivors want(100% recovery) and are working towards that!
ESOC 2024 Session Report: “Hyperacute Management”
European Stroke Organisation Conference
May 15–17, 2024
Session: Hyperacute Management
The session on hyperacute management was chaired by Else Charlotte Sandset (Oslo, Norway) and Marc Ribo (Barcelona, Spain).
Yijun Zhang (Beijing, China) kicked off the session with “Edaravone Dexborneol In Treatment Of Large Artery Atherosclerosis Stroke.” Edavarone, a free radical scavenger of reactive oxygen species and reactive nitrogen species which penetrates the blood brain barrier, holds promise as a potential neuroprotective agent and has been widely used in Japan, China, and India. Dr. Zhang emphasized the importance of large artery atherosclerosis, which is the most frequent etiology of ischemic stroke in the Chinese population. This study was a post hoc analysis of the TASTE trial and the TASTE-SL trial and assessed the effects of edaravone dexborneol in 658 patients with large artery atherosclerosis-etiology stroke with treatment <48 hours of onset and a duration of 2 weeks. Treatment significantly increased rates of excellent functional outcome on the mRS scale with no difference in safety outcomes after 90 days. These results have to be validated in the future.
Next, Yufei Wei (Beijing, China) presented “Timing Of Antihypertensive Treatment Initiation In Anterior Versus Posterior Circulation Acute Ischemic Stroke.” This post hoc analysis of the CATIS-2 trial analyzed outcomes of anterior and posterior circulation strokes. The rate of death and major disability (mRS³3) was 12.4% in anterior circulation stroke and 8.3% in posterior circulation stroke regarding early antihypertensive treatment. Wei concluded that anterior circulation stroke patients are more susceptible to blood pressure fluctuations, which lead to a passive decrease in cerebral perfusion. This may exacerbate secondary neuronal damage in the ischemic penumbra. Further studies are needed to explore the underlying mechanisms of these findings.
Davide Carone from Oxford, United Kingdom, presented “Patients Randomized To Glenzocimab Suffered Less Hemorrhagic Transformation With Greater Benefit In Larger Baseline Infarct Core.” The ACTISAVE trial did not result in better outcomes when using glenocizumab, which was presented in the main session. Carone showed data which support the hypothesis that mechanical thrombectomy-related ICH is moderated by glenocizumab (frequency and size). Additionally, glenocizumab reduced the risk of hemorrhagic transformation associated with larger infarcts at admission. Also, the influence of hemorrhage on functional outcome is moderated by glenocizumab. Carone concluded that, despite a moderate imbalance of baseline characteristics of the two groups, glenocizumab-treated patients had a trend for smaller lesion volumes at 24 hours after treatment compared to placebo. The smaller follow-up infarct volumes are likely due to both having less hemorrhagic transformation (frequency and volume) and ischemic injury. These data suggest a more pronounced effect in patients with larger infarct cores. Finally, Carone concluded that a reduction in hemorrhagic transformation volume can drive safer clinical outcomes.
Greg Albers from Stanford, United States, presented “Secondary Analyses From The Timeless Trial” where tenecteplase was investigated against placebo in the late time window of intravenous thrombolysis. In the subgroup of M1 occlusions only, use of tenecteplase resulted in a higher proportion of favorable functional outcome (mRS 0-2) at 3. On the contrary, in the M2 occlusion subgroup, there was no difference in achievement of favorable functional outcome. In wake-up stroke patients, final infarct volume growth showed a trend in favor for tenecteplase not reaching statistical significance. Three-month mRS ordinal shift and functional independence were numerically higher and infarct growth was less in patients with M1 occlusion treated with tenecteplase compared to placebo.
“Intravenous Thrombolytic Is Associated With Increased First Pass Effect In Thrombectomy” was presented by Steven Bush from Parkville, Australia. This sub study from the IRIS collaboration investigated if bridging thrombolysis increased the likelihood of angiographic first pass effect (FPE), which is considered to have beneficial effects on outcomes and safety. Bridging thrombolysis increased the likelihood of FPE by 27% translating to a Number Needed to Treat from 4 to move 1 patient into the FPE group. The odds of a patient having a favorable functional outcome at 3 months increased by 170% with FPE when compared to non-FPE thrombectomy. For patients that achieved eTICI2c or 3 revascularization, the odds of experiencing a favorable functional outcome increased by 40% when FPE was achieved. In these patients, the risk for developing an ICH or procedural complications decreased by 45% with FPE, but FPE had no impact on death or symptomatic ICH. Bush concluded that bridging thrombolysis significantly increases the chance of achieving a first pass effect, and the benefit of it on functional outcomes and safety was confirmed, even after adjusting for TICI score and procedural times of endovascular treatment.
João Pedro Marto from Lisbon, Portugal, presented results from the ETIICA Study – “Endovascular Treatment For Isolated Cervical Internal Carotid Artery Occlusion.” In 998 included patients from multiple international centers, no difference in 3-month mRS, 3-month favorable outcome (mRS 0-2), or 3-month mortality was observed in patients treated with endovascular treatment and thrombolysis compared to best medical treatment alone. Furthermore, the risk of intracerebral hemorrhage was higher in the group treated with thrombectomy. Marto concluded that in patients with isolated cervical internal artery occlusion, endovascular treatment was associated with similar chance of disability and mortality but resulted in a potentially higher risk of ICH. Further RCTs are warranted to find the optimal treatment for isolated cervical internal artery occlusion patients.
Nabila Wali from Amsterdam, the Netherlands, presented “Admission Systolic Blood Pressure And Outcomes After Endovascular Treatment In Acute Ischemic Stroke: A Cohort Study From The Eva-Trisp Collaboration.” This study found that both lower and higher admission systolic blood pressure was associated with poor functional outcome (mRS >2) with the threshold ~ 150 mmHg. The same applied to diastolic blood pressure ~ 80 mmHg. Lower systolic blood pressure was associated with higher mortality, and higher systolic blood pressure was associated with higher NIHSS after 24 hours and increased sICH-risk. Each 10-mmHg decrease, or increase showed a significant effect on 3-month poor functional outcome (mRS >2). Wali concluded that EVT was most effective in patients with a systolic blood pressure ~ 150 mmHg.
Davide Strambo from Lausanne, Switzerland, completed the session with “Influence Of Stroke Severity And Occlusion Site On Endovascular Therapy Effect For Posterior Cerebral Artery Occlusion Strokes,” a secondary analysis of the PLATO study. This study investigated if in acute ischemic stroke from isolated posterior cerebral artery occlusion, the association of endovascular treatment plus medical management is modified by baseline stroke severity and the segment of arterial occlusion within PCA (P1 or P2-segment). Of 1059 patients, 35% received EVT; IVT was administered in 40% of each study group. In patients with a moderate to severe baseline stroke severity (NIHSS >6), EVT was associated with a higher odds for functional independence at 3 months, whereas in patients with milder strokes (NIHSS <7), EVT was associated with a worse outcome, compared to those with medical management. There were no differences in ordinal mRS shift, excellent outcome, independence, sICH, or mortality when comparing P1 and P2-segment occlusions. Strambo concluded that in isolated posterior cerebral artery occlusion, baseline NIHSS appears to be an important modifier of the association of EVT and outcomes. EVT was associated with more favorable disability outcomes than medical management only in moderate-to-severe strokes. The risk of symptomatic intracerebral hemorrhage was increased with EVT irrespective of baseline stroke severity. Mortality was higher with EVT compared to medical management in both minor and severe stroke, but to a greater extent in the latter group. These results might be important for hypothesis generating and clinical trial design in future randomized trials of EVT in isolated posterior cerebral artery occlusions. The reasons why sICH risk was increased are subject to further investigation. In my opinion, the lower sensitivity of non-contrast CT in the posterior circulation might underestimate early ischemic lesions, and, therefore, sICH risk might be increased in patients with a longer onset-to-recanalization time. Secondly, differences in autoregulation properties and lower sympathetic nervous activity of the posterior circulation arteries compared to anterior circulation arteries might play a role in higher sICH risk after reperfusion in posterior circulation stroke.
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