ESOC 2023: Highlights from the conference

By Märit Jensen & Vojtech Novotny

The last European Stroke Organization Conference (ESOC) took place in Munich, Germany, and it was packed with many exciting studies presented on this occasion, including numerous randomized clinical trials (RCTs). Finally, fully onsite after the COVID-19 regime, over 4000 participants gathered in the biggest forum on stroke to exchange and expand their knowledge within this rapidly evolving field.

Among many important RCTs, the long-anticipated ELAN trial, presented by Prof. Urs Fischer from Basel, Switzerland, answered the question that stroke physicians face daily: when to start oral anticoagulation after atrial fibrillation-associated ischemic stroke. The trial showed that early initiation of anticoagulation was safe. Moreover, patients in whom anticoagulation was started early experienced fewer recurrent events than those with later start of anticoagulation. This RCT represented another milestone in improving stroke care and decision-making, as early treatment probably provides a benefit to the patients if relevant contraindications are ruled out.1

Another RCT that stood out was the American TIMELESS study. At a time when the stroke society is slowly shifting from alteplase to obviously more convenient tenecteplase, further investigation of this thrombolytic is paramount. TIMELESS, led and presented by Prof. Gregory Albers, compared Tenecteplase 0.25 mg/kg with placebo in the late time window 4.5-24 hours and presence of salvageable tissue on perfusion imaging with large vessel occlusion, of whom the majority also received endovascular thrombectomy. The RCT showed a good safety profile in patients receiving tenecteplase; however, no difference in clinical outcome was observed.2

The next RCT worth mentioning was the PRECIOUS trial, presented by Dr. Jeroen de Jonge from Utrecht, the Netherlands, where the authors tested the effect of preventive treatment of complications in elderly patients with moderate to moderately severe stroke. The pharmacological approach included prevention of fever, aspiration, and infection by prophylactic use of paracetamol, metoclopramide, and ceftriaxone in any combination. Even though the study was terminated prematurely, there seemed to be no evidence that such an approach may have benefits, and instead, established close follow-up of complications in a modern stroke unit seems to be the way to go.3

The Scottish LACI-2 phase 2 trial led by Prof. Joanna Wardlaw, examined whether isosorbide mononitrate, cilostazol, and their combination may improve cognitive function in patients with small vessel diseases and lacunar stroke. The cognitive testing during a one-year follow-up indicated potential improvement of cognitive functions in the intervention arms. The results set the course for the initiation of phase 3 trial – LACI-3 with a similar methodological setting.4

Regarding intracerebral hemorrhage treatment, The ENRICH trial, presented by Dr. Jonathan Ratcliff and Alex Hall from Atlanta in the USA, evaluated if a very early minimally invasive evacuation of intracerebral hemorrhage improves functional outcome. Not delving into the details of the trial itself, the results indicate the superiority of minimally invasive surgical evacuation over standard medical care. The results appeared to be driven by the benefit for lobar hemorrhage, while no benefit was observed in basal ganglia hemorrhages. This promising treatment approach warrants further investigation and possibly a soon implementation in clinical practice.5

Finally, the Canadian SECRET trial tested direct anticoagulants in cerebral venous thrombosis (CVT). This was, a phase two trial, testing a 20mg dose of rivaroxaban versus standard anticoagulation with either a vitamin-K antagonist or low molecular weight heparin in CVT. As the study was underpowered and the trial favored the control arm, it may be difficult to draw any firm conclusions. The phase three trial will surely be more clarifying.6

As tradition continued, some of our colleagues were awarded for outstanding contributions to the stroke society. The ESO Presidential Award went to Prof. Philip Bath from the University of Nottingham in the UK. The European Stroke Organisation appreciated his activity in the stroke field both nationally in the UK and internationally. He represents a key figure within the British Stroke Society and has been a principal investigator in several international randomized controlled trials, such as TAIST (Lancet 2001), ENOS (Lancet 2015), TARDIS (Lancet 2018), and RIGHT-2 (Lancet 2019), as well as the ongoing PhEAST trial. The Scientific Excellence Award went to an up-and-coming researcher and stroke physician, Dr. Jonathan Countinho from Amsterdam University Medical Centers in the Netherlands. He is known for his interest in cerebral venous thrombosis. Besides his active presence in the consortium on cerebral venous thrombosis, he is also involved in several well-known projects such as the DOAC-CVT trial and many others.7

ESOC 2023 proved again to be an immensely enriching experience for most participants last year. Alongside international collaboration and networking, the conference again delivered high-quality research, as we are used to at ESO events.


  1. Fischer, Urs, et al. “Early versus later anticoagulation for stroke with atrial fibrillation.” New England Journal of Medicine 388.26 (2023): 2411-2421
  2. Albers, Gregory W., et al. “Tenecteplase for Stroke at 4.5 to 24 Hours with Perfusion-Imaging Selection.” New England Journal of Medicine (2024).
  3. de Jonge, Jeroen C., et al. “Prevention of infections and fever to improve outcome in older patients with acute stroke (PRECIOUS): a randomised, open, phase III, multifactorial, clinical trial with blinded outcome assessment.” The Lancet Regional Health–Europe 36 (2024).
  4. Wardlaw, Joanna M., et al. “Isosorbide mononitrate and cilostazol treatment in patients with symptomatic cerebral small vessel disease: the lacunar intervention trial-2 (LACI-2) randomized clinical trial.” JAMA neurology 80.7 (2023): 682-692.
  5. Pradilla, Gustavo, et al. “Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage.” New England Journal of Medicine 390.14 (2024): 1277-1289.
  6. Field, Thalia S., et al. “Study of rivaroxaban for cerebral venous thrombosis: a randomized controlled feasibility trial comparing anticoagulation with rivaroxaban to standard-of-care in symptomatic cerebral venous thrombosis.” Stroke 54.11 (2023): 2724-2736.