ESOC 2018 – Acute Non Reperfusion Trials

Chairs: Thompson Robinson (UK) and Mikael Mazighi (France). The session covered a broad spectrum of different topics on prehospital and intrahospital stroke management.

Maria Berndt reported on thrombus permeability imaging using non-contrast CT and CT-angiography and correlated their findings with histological evaluation of thrombi. They found a positive association between thrombus permeability and fibrin-platelet-agglomerates, which were also associated with stroke of cardioembolic origin. Thrombus permeability is a new imaging biomarker, which might help to identify cardioembolic strokes (etiology), and which might help to guide acute stroke treatment in the future.

Carlos Laredo presented a post-hoc analysis of the URICO-ICTUS trial assessing the impact of collaterals on the effect of uric acid administration in patients receiving intravenous tPA. They showed that the addition of uric acid in thrombolyzed patients improved functional outcome in patients with excellent collaterals but not in those lacking good collaterals. Better drug delivery through collaterals to the area beyond the vessel occlusion might serve to explain the neuroprotective effect and collateral status should be considered in the design of new trials with neuroprotective agents.

Timo Kahles showed a new triage score for the identification of patients with acute ischemic stroke due to large vessel occlusion (LVO). The new FALCON score derived from selected baseline characteristics and single NIHSS items. It comprises the 4-binary items abnormal Fixation (gaze), Aphasia/dysathria, any Limb paresis and Level of CONnsciousness. FALCON ≥2 demonstrated a strong association with LVO with a sensitivity of 76%, specificity of 81% and accuracy of 0.79. The new FALCON score is a very simple and powerful triage tool to predict LVO in acute ischemic stroke and might facilitate prompt and appropriate triage of patients with LVO in the anterior or posterior circulation to dedicated stroke centers within an extended time window up to 24 hours after stroke onset.

Jong Kim summarized a Korean double blind randomized placebo controlled phase II study on the effect of the antioxidant Otaplimast (SP-8203) in thrombolyzed patients. Patients received SP-8203 either at a dose of 80mg bid, 40mg bid or placebo every 12 hours for 6 times. The administration of SP-8203 in acute stroke patients receiving tPA was feasible and safe, and improved functional neurological outcome in this phase IIa study.

Dr. Malik presented the results of a new systematic review and meta-analysis on cooling in acute ischemic stroke. He pointed out that the term cooling is not used uniformly and comprises “inducing hypothermia” and “maintaining normothermia”. The methods used are physical cooling by wearing a cap or by i.v. infusion of cold fluids, or pharmacologically by the administration of paracetamol or ibuprofen. They identified 11 appropriate studies: Five with physical cooling (n=193 patients) and six studies using a pharmacological approach (n=1889). They did not find any evidence to support cooling for the reduction of morbidity or mortality. In contrast, complications were more common.

Craig Smith reported on a post-hoc analysis of the VISTA-Acute study. They hypothesized that the antibiotic class used to treat clinically identified/suspected infections during the first two weeks after stroke would influence outcome in acute ischemic stroke. They found that in 2909 participants with more than 3000 infections – mostly pneumonia and urogenital – the use of macrolides for pneumonia and any infection was associated with a favorable neurological outcome, whereas the application of cephalosporins or aminoglycosides in any infection was associated with unfavorable outcome.

An interesting Indian work compared continuous labetalol infusion (n=38) vs repeated labetalol boli (n=38) in patients with first ever ICH <6h symptom onset, and a baseline ICH volume <90ml. Hematoma volume increase (>33% from baseline to 24h by ABC/2 method) and variability of the systolic blood pressure was similar in both groups. The absolute dose of labetalol was higher in patients with continuous infusion compared to those with labetalol boli.

Skye Coote showed data on the recent implementation of Australia`s first mobile stroke unit, the Melbourne MSU. Its catchment area comprises 1.7million people and it operates within a 20km radius of The Royal Melbourne Hospital, delivering patients to 8 stroke centers across the city. They substantially reduced the number of interhospital transfers and increased the proportion of patients, thrombolyzed in the golden hour, from 3 to 17%.

Sven Poli focused on the utility of point-of-care coagulation test (POCT) for DOAC patients in the emergency setting and provided new data for its use in patients treated with edoxaban. They already demonstrated that CoaguChek® is suitable for the assessment of anticoagulatory activity in patients receiving rivaroxaban and that the Hemochron® works for patients on rivaroxaban or dabigatran. The current study represents the first systematic evaluation of coagulation POCT in edoxaban-treated patients and suggests that available POCT devices may be able to reliably detect clinically relevant edoxaban concentrations in blood samples of stroke patients.