by Dr Kailash Krishnan
Given trials including DAWN and DEFUSE-3 heralding a new era in acute ischaemic stroke, the updated guideline session this morning generated huge interest. Although assessed as moderate level of evidence, experts strongly recommend mechanical thrombectomy and best medical therapy in acute ischaemic stroke patients with large artery occlusion presenting within 6 hours. The experts found no reason to exclude patients over aged 80 within 6 hours and even consider treating those presenting between 6-24 hours. It was highlighted that both interventions should be offered as soon as possible and neither should delay the other. The experts also recommended mechanical thrombectomy and best medical therapy in those patients with high ASPECTS score and absence of extensive infarct core and the quality of evidence as high. In older patients with AF after TIA or acute stroke, DOACS are recommended over warfarin and the evidence extends to those with mild to moderate renal impairment.
The much-anticipated session also included anticoagulation early screening and impact of dysphagia after stroke, and reversal of haemorrhage related to anticoagulant use and recommendations on whether to use the ‘mother-ship’ model over transferring to a primary stroke centre. Although no RCT’s exist comparing early screening and no screening after stroke, early screening is shown to reduce mortality, pneumonia and length of stay and therefore strongly recommended. No recommendation is made when to start anticoagulation, small vessel disease and after intracerebral haemorrhage and ongoing trials will hopefully provide answers. We heard latest evidence that the use of DOAC’s is increasing and in ICH related to their use, neither PCC or FFP was favoured but in anticoagulation related to warfarin, vitamin K in addition to PCC is recommended. Idarucizimab is recommended in ICH from dabigatran and the quality of evidence to use Andexanat alpha in bleeding from apixaban or rivoroxaban was assessed to be low. The panel found no evidence to support the use of r-VIIa or tranexamic acid in ICH related to anticoagulation.
The session identified an unmet need in managing patients with unruptured intracranial aneurysms. The prevelance was reported to affect about15 million patients in the EU and it is anticipated that about 50,000 will suffer a subarachnoid haemorrhage. Whether endovascular closure compared to none, lifestyle modification or medications might help are pressing questions of future research and more trials in this area are warranted. All the new guidelines will be published in the European Stroke Journal!