After a wonderful three days of first-rate science, gathering of the stroke community, and an energetic ESOC party at the Finlandia hall last evening, we rounded out our scientific program with an interesting plenary session this morning. After the presentation of awards to the emerging leaders programme and the prize winners, we kicked off with some evidence for pre-hospital stroke management.
Performed in Australia, the MSU-TELEMED trial demonstrated the safety and efficacy of telemedicine in mobile stroke units. Based on these results the team plan to deploy two mobile stroke units with one neurologist who will be aboard in one vehicle and communicating with the other via telemedicine. This will both enhance the productivity of the units and be cost-saving.
Next, the MAP-STROKE study. This is a pre-hospital triage tool developed using a Bayesian predictive modelling algorithm which can advise the EMS whether they should bypass the local centre and instead transfer the patient to a comprehensive stroke centre. The researchers sampled data from Get With The Guidelines in the USA and simulated an impact study estimating the use of the MAP STROKE tool in these data. The results suggested that use of MAP-STROKE would be associated with a 2.1% increase in the likelihood of achieving a mRS of 0-2 when compared to transporting the patient to the nearest hospital. The improvement was driven by a reduced time to reperfusion in those eligible for thrombectomy. However, this approach also caused a delay of on average 14 minutes in time to thrombolysis in those eligible for tPA. A geographical subgroup analysis suggested that the benefit was more marked in rural areas. As these results are derived from simulated data and may be optimistic, the team are now planning to integrate MAP STROKE into an online application and conduct an RCT testing its use. We will watch this space.
Moving to secondary prevention and anti-inflammatory therapies, the results of two studies featuring colchicine, a repurposed gout anti-inflammatory medication, were presented. Firstly, in a secondary analysis of the CONVINCE trial, participants with non-severe non-cardioembolic stroke, randomised to 0.5mg colchicine daily or usual care, had CRP levels measured in blood at baseline, 28 days and annually at their local hospital. This pre-specified secondary analysis stratified patients by their achieved CRP level on treatment: ‘low’ <2mg/L or ‘high’ ≥2mg/L and compared the rates of MACE events across these categories. Those with low CRP levels < 2mg/L on colchicine had a significantly lower rate of MACE compared to those with CRP >2mg/l and the control arm, suggesting that lower is better for CRP in secondary prevention.
Then, the results of the Co-VASC-ICH feasibility phase-2 trial performed in Canada were presented. This study aimed to assess if a trial investigating colchicine to reduce MACE in patients intracranial haemorrhage (ICH) was feasible. The investigators achieved their aim, recruiting 100 participants presenting with ICH within 24 hours. They now plan to continue with phase-3 trial CoVASC-ICH-2. Colchicine appeared to be well tolerated in this study, an extended release preparation of colchicine was used, and was sometimes administered via NG tube. There were no differences in MACE, death or dependency between treatment arms, but this was a feasibility study and not powered to estimate differences between these outcomes. We wish our colleagues well with the phase 3 trial and look forward to the results of CoVASC-ICH-2 with interest.
The STATICH trial is the most recent trial to investigate an important question, to which we still do not have a definitive answer. Should we restart antithrombotic treatment in patients after intracranial haemorrhage? Participants in this study were stratified into two trials- one for those with an indication for antiplatelet and another for those with indication for anticoagulation. Recruitment to this trial was slow and there were a low number of events. Unfortunately these results are underpowered. The primary outcome was recurrent spontaneous ICH within 2 years. A similar number of events occurred irrespective of treatment assigned. The investigators plan to collaborate on an individual participant data meta-analyses with similar trials and we hope these analyses provide some more information on this important unanswered question.
Next the results of the TENCRAOS trial. Patients presenting with central retinal artery occlusion were randomised to receive tenecteplase 0.25mg (within 4.5 hours of symptom onset) or ASA 300mg. The primary outcome was measured using logMAR at 30 days (and was approximately equivalent to being able to read an extra 3 lines on the Snellen chart). Participants were on average 71 years old, and the trial workflow relied on an ophthalmologist making the diagnosis of CRAO, then referring the patient to the stroke team for randomisation and treatment. Impressively, most of the patients in this trial were recruited and treated within 3 hours, highlighting the coordination and strong team work by recruiting sites. However, the results showed no difference in the primary outcome and importantly, there were numerically more adverse events and one fatal ICH in the TNK group.
Next, we move to the theme of neuroprotection. We listened to the results of an interesting study examining the effect of edaravone, a neuroprotectant that is already used in stroke care in China and Japan, which is thought to reduce oxidative stress. Investigators randomized 614 patients to treatment with edaravone for 28 days or placebo. More patients treated with edaravone (65%) achieved the primary outcome (a favourable mRS of 0-2) compared to control (47%), which was a significant difference. Paradoxically, the NIHSS score was similar in both treatment groups. There were also numerically more deaths and adverse events in the edaravone treatment arm. We look forward with interest to see if these results can be replicated, as effective neuroprotection strategies would be a powerful addition to our battery of stroke treatments.
We lack robust randomised trial data to guide us on the best approach to treatment of patients with tandem occlusions in the anterior circulation. The CERES-TANDEM Study is an important observational study which collated global real-world data and reported the functional outcomes of patients who received emergent stenting at time of EVT, compared to no stenting. The results demonstrated that there was a higher odds of an excellent functional outcome (defined as mRS 0-1) with emergent stenting and this was not associated with an increased risk of haemorrhage.
After that, we moved to blood pressure control during EVT. Patients in this trial were randomized between two different approaches to control BP during EVT: either standard care (no intervention if SBP remained between 140-180 during EVT) compared with an individualized targeted titration of BP every 2.5 minutes to achieve a MAP of ±10% of the patients baseline BP. This intervention required the support of anaesthesiology, but most EVT procedures were done under conscious sedation. The primary outcome was a favourable mRS 0-2 at 90 days. Of 433 randomized patients, the mean age was 69, baseline NIHSS 15, and ASPECTS 8. There was no difference in the mRS at 90 days with intensive BP management during EVT.
Finally, pivoting back to neuroprotection, the results of the IRIS trial were presented. This study sought to investigate the efficacy of IL-6 inhibitor tocilizumab as a neuroprotectant when given at the same time as EVT. Patients were recruited from 6 comprehensive stroke centres in China, were on average 69 years old, had a baseline NIHSS of 16 and ASPECTS of 8-9. The baseline infarct core volume measured by DWI was 15ml. The primary outcome was ischaemic core growth in millilitres measured from baseline to 72 hours. The results showed that the change in infarct volume was 8.8ml in the treatment group compared with 27ml in the placebo group, which was a statistically significant difference. More studies with a clinical endpoint are needed to investigate this promising strategy further.
And that concludes the science presented at this year’s ESOC. Now, we look towards Maastricht 2026. The organising committee aim to make 2026 the most sustainable ESO conference yet, and to that end, we will all be given the use of a bicycle throughout our time there. This was met with enthusiastic applause by the delegates! So, Moi Moi to Helsinki, thank you to ESO and the organising committees for an energising and collaborative few days, and see you all next year!
