ESOC 2018 – Controversies in Stroke

By Giuseppe Reale

Although the evidence-based medicine and the “cult” of p value have made medical decision-making simpler than before, the all-day real-world is often a grey zone where literature interpretation and personal experience can lead clinicians to different choices. This is particularly true in Stroke care. At ESOC 2018 you may see stroke physicians spending time together and pleasantly talking during pauses, but, when the time comes, they can split up into fierce factions. At the Controversies session of this morning, these factions faced each other about some hot-topics of stroke care. Six champions where chosen and the match started, with striking twists.

Round 1. Should patients with suspicion of large vessel occlusion be transferred to the stroke center bypassing the next stroke unit?

Contenders: Prof. Gary Ford (YES) vs. Prof. Marc Ribó (NO).

Pre-match factions: YES 63% – NO 37%

Deciding which is the best pre-hospital stroke protocol between “drip and ship” and “direct to mothership” is very arduous. Different factors must be considered: health system organization, hospital services efficiency, geographical features and so on.

The pre-match polls were clear and Prof. Ford seemed to be the favorite. Time is brain and, in the best scenario, the “direct to mothership” brings the patient with a large vessel occlusion to endovascular treatment in about 170 minutes, with a slight delay (about 25 minutes) of intravenous thrombolysis. In addition, this model seems to achieve better clinical outcomes (Holodinsky et al, Stroke 2017). Of course, “direct to mothership” protocol requires ambulance paramedics training, rapid door-to-needle times and door-to-groin time, collaboration between stroke teams across a region.

Although the initial disadvantage, Prof. Ribó accepted the challenge. In the real-world, the “direct to mothership” model does not fit all situations (being areas served by hub and spoke hospitals different in terms of population density, extension…). In addition, at the best of LVO predicting tools, not all patients transported to central stroke centers are suitable for mechanical thrombectomy: what about other patients (e.g. hemorrhagic strokes, stroke mimics)?

Prof. Ribó’s pragmatic approach seemed to be very persuasive, as the final score revealed.

Final score: YES 34% – NO 65%


Round 2. Patients with mild symptoms and occlusion of a proximal intracranial artery should have intra-arterial thrombectomy?

Contenders: Prof. Jan Gralla (YES) vs Prof. Angel Chamorro (NO).

Pre-match factions: YES 83% – NO 17%

The Shakespearian question “to treat or not to treat” often echoes in stroke physicians’ minds when they face a patient with mild symptoms and a documented large vessel occlusion.  Data are still not conclusive and the risk of achieve just an angiographic success is always around the corner. Nevertheless, at the beginning of the match, the factions lined up fiercely.

Prof. Gralla started his match casting doubt about the mainstream idea that minor strokes associated to large vessel occlusion have good outcomes anyway. In fact, if untreated, these patients can present a later NIHSS increase in 22% of cases, clinical deterioration in 33% of cases at discharge and 41% of cases at 3 months (Heldner et al, Journal of Neurology Neurosurgery and Psychiatry, 2015). Considering the aforementioned data, endovascular treatment appears a reasonable and even safe therapeutic choice.

The minority’s champion, Prof. Chamorro, argued that, in previous studies assessing functional outcomes in patients with minor stroke and large vessel occlusion, only few of the considered patients had received intravenous thrombolysis, being this a potential bias. In addition, a recent multicenter study by Urra et al (Cerebrovascular Diseases, 2014), comparing medical vs endovascular treatment of patients with minor stroke (NIHSS<5) and large vessel occlusion, has showed no difference in functional outcomes between intravenous thrombolysis and endovascular treatment groups, being the latter associated to a major risk of intracranial hemorrhage. According to Prof. Chamorro, further randomized controlled trials are needed, but endovascular treatment could be reasonable as a rescue therapy when symptoms worsen.

This match gifted us with another exciting plot twist, as you can see in the following.

Final score: YES 35% – NO 65%


Round 3. PFO closure in cryptogenic stroke: should become routine for secondary stroke prevention?

Contenders: Prof. Marie Luise Mono (YES), Prof. Peter Rothwell (NO)

Pre-match factions: YES 27% – CON 73%

Last but not least, another nowadays apple of discord among stroke physicians: PFO closure in cryptogenic stroke. In this case, the Yes faction was very small and Prof. Mono did her best to persuade the audience. Starting from the metanalysis by Overell et al (Neurology, 2000) that showed a strong association between cryptogenic stroke and PFO in young patients, Prof. Mono made an elegant review of the recent milestone trials about PFO closure. She highlighted the relative low number needed to treat in preventing recurrent stroke and the cost-effectiveness feasibility of a routine use of PFO closure as secondary stroke prevention.

On the other hand, Prof. Rothwell pointed out that, if you consider the prevention of disabling strokes, the number needed to treat of the aforementioned trials increases dramatically (included complications, such as atrial fibrillation). In addition, there are no randomized controlled trial comparing PFO closure vs oral anticoagulants, that seemed efficacious in subgroup analysis of the previous trials.  Moreover, according to Prof. Rothwell, no data are available regarding the long-term safety of the implantable devices used for PFO closure.

No plot twist in this case.

Final score: YES 15% – NO 85%.

 The session is finished, peace is back. At least until next ESOC 2019 in Milan.