By Dr Christian Boehme
Department of Neurology, Medical University of Innsbruck, Austria
It was fun and exciting to meet up again with colleagues from all around the world for this year’s ESOC 2023 in Munich, Germany. We enjoyed amazing talks and high-quality posters in all different fields of stroke research. I got the opportunity to share some of the posters that caught my eye during the session on Thursday (Conference Day 2).
Among the posters on RISK FACTORS AND PREVENTION, I would like to highlight COMBINED INFLAMMATORY BIOMARKERS PREDICT RECURRENT IPSILATERAL ISCHAEMIC STROKE IN PATIENTS WITH CAROTID ATHEROSCLEROSIS by Sarah Gorey et al. from Ireland. They hypothesized that a combination of elevated hsCRP and IL-6 levels would be associated with recurrent ipsilateral ischaemic stroke in individuals who suffered a stroke/TIA with concomitant ipsilateral internal carotid stenosis. Over a median 4-year follow-up, they showed that in 267 patients from three prospective cohort studies, a combination of high hsCRP and IL-6 levels predicted recurrent ischemic stroke at a high sensitivity and specificity while solely elevated IL-6 levels did not. Of note, patients with combined high inflammatory biomarker levels (hsCRP ≥ 2 mg/l and IL-6 ≥ 7 pg/ml) showed a recurrence rate of 11% for ipsilateral ischemic stroke. In this cohort, roughly 56% of patients received carotid revascularization and 50% had a ³70% carotid stenosis. This concept could guide patient-tailored treatment decisions (surgical/interventional and anti-inflammatory) in the future.
Marie H Kristiansen et al. from Denmark contributed the poster THE JAK2V617F MUTATION IS COMMON IN ISCHEMIC STROKE. They analyzed the prevalence of JAK2V617F mutation in 591 consecutive patients with ischemic stroke and TIA. 3% of the general population acquire the mutation, however, whether the mutation is a risk factor for thrombosis in the absence of myeloproliferative neoplasms is unknown. An increased prevalence of the JAK2V617F mutation in a stroke population would suggest this link. The study revealed that 1 in 10 stroke/TIA patients carry the JAK2V617F mutation, leading to an OR of 2.4 compared to matched controls, whereupon the prevalence was a lot higher in stroke rather than TIA and only 8 out of 63 patients were diagnosed with MPN. This research could contribute to a better understanding of possible pathophysiological links between arterial and venous thrombosis in a subgroup of patients. As a matter of fact, future trials could possibly target JAK2V617F positive stroke patients for anticoagulation or JAK2 inhibitors in secondary prevention, perhaps in ESUS patients.
From the topic SERVICE ORGANISATION, I would like to highlight a poster for all morning persons and early birds out there, like me. The poster TIME OF DAY OF ENDOVASCULAR TREATMENT MODULATES CLINICAL OUTCOME AFTER STROKE by Vanessa Granja Burbano and colleagues tackled the question if the time of day of EVT is associated with clinical outcome and a benefit of successful recanalization. Patients from the German Stroke Registry were analyzed in 6-hour intervals starting at 5am regarding times of groin-puncture. In analyses adjusted for age, IVT-administration, NIHSS and time to treatment, morning EVT was associated with lower mRS scores and higher probability of functional independence at 90 days after stroke. Also, the association of successful recanalization and functional independence after 90 days was stronger in morning EVT compared to evening EVT. Finally, the benefit from successful recanalization persisted until 24 hours after onset for morning treated patients while it was lost after roughly 12 hours for evening-treated patients. This study supports the hypothesis that time of day effects (i.e. intrinsic circadian biology) influence stroke progression and outcomes as well as treatment benefits rather than EVT-procedural metrics. Nevertheless, neurologists and interventionalists will always be keen to bring their A-game, regardless of the time of day J
Among the LATE BREAKING ABSTRACTS, I want to emphasize results from the APRIL study. Maria Hernandez Perez et al. aimed to assess safety and efficacy of a novel TLR4-binding DNA aptamer (ApTOLL) in combination with EVT in acute ischemic stroke patients. In this phase Ib/IIa trial, anterior LVO moderate to severe stroke patients with an ASPECTS score of 6-10 were randomized to EVT±IVT plus ApTOLL in different dosages compared to EVT±IVT alone to assess differences in DWI lesion volume and grade of cerebral edema. The study demonstrated a significant reduction in DWI lesion volume and cerebral edema after 72 hours in the group receiving ApTOLL 0.2 mg/kg compared to placebo. Moreover, in patients receiving ApTOLL, the DWI lesion volume was significantly lower in patients with lower mTICI scores compared to placebo and also, the extent of white matter damage was lower. The effects seem to be dose-dependent as the other trial arm using a dosage of ApTOLL 0.05 mg/kg showed no benefits. Concerning these results, ApTOLL seems like a promising neuroprotective agent in combination with established reperfusion therapies and could be especially relevant for patients with futile recanalization and those with higher infarct core size at arrival. Also, ApTOLL seems to especially protect the white matter. We are looking forward to upcoming phase III trials and it will be interesting to see if there might be a benefit in patients who receive IVT alone.
I hope my brief summaries inspire you and that you keep your fingers crossed for the final publications of the studies.
It was exceptional to see so many Ukrainian colleagues participating in ESOC this year. We must encourage our Ukrainian friends to keep up the good work in the stroke network and avail them to restore stroke care in their country. Nevertheless, we must not forget all other countries affected by conflicts around the world. Our uttermost shared goal is to reduce the global burden of stroke and we can only do this together.
“Mankind must put an end to war before war puts an end to mankind.” – John F. Kennedy