By: Anke Wouters, Rustam Al-Shahi Salman
ESO European Stroke Science Workshop 2023
Session 7: Far Horizons
Heavy snow disrupted the exit out of Garmisch, but despite this distraction, a lively debate followed.
Keynote debate: There are no limits to mechanical thrombectomy for acute ischaemic stroke due to medium and large vessel occlusion.
Prof. Mikael Mazighi: PRO
Prof. Mazighi started with a picture of his opponent swimming in the ice-cold Eibsee. Debating against superwoman Else Sandset is not an easy task, but everyone knows the indications for thrombectomy are increasing. Prof. Mazighi started with showing the data about patients with large core ischaemic stroke. In the TENSION trial, using mostly only CT for patient selection, 20% of the patients ended up being functionally independent. Also, the most recent trial, IN EXTREMIS LASTE, showed similar results with a reduction of mortality and an increased functional independence, however at the cost of an increased intracranial hemorrhage risk. The distal medial vessel occlusions (DMVOS) are another important new thrombectomy target with 4 RCTs currently including patients. DMVOS are very common (25-40%), but a higher bleeding risk is associated with a worse outcome. Therefore, we need other strategies to reduce the bleeding risk, with for example new antiplatelet strategies (ACTIMIS trial) or neuroprotective agents (TLR4 antagonists). Prof. Mazighi concluded by stating that there are no limits for mechanical thrombectomy, but that we do need a combined approach: good level of evidence (waiting for results of RCTs), optimisation of reperfusion, prevention of bleeding and adjunctive therapies.
Prof. Else Sandset: CONTRA
EVT is of course a highly effective treatment strategy with a NNT of 2.6 when used within 6 hours of ischaemic stroke onset, but still there are some limitations to this treatment. The most important limitation to EVT might be the fact that the treatment is still not available to many patients. Furthermore, the data for mild ischemic strokes and distal vessel occlusions, are still lacking and we need to wait for the results of the ongoing RCTs before treating those patients outside RCTs. Recent trials demonstrated a benefit of EVT in patients with large ischaemic cores, but the included patients might not be representative of the general population. Those patients were quite young and had a low number of comorbidities. Probably it is still important to consider the ‘frailty’ of a patient when considering EVT. Prof. Sandset ended here arguments with a patient-focussed perspective, by saying that it is important to take your time to talk to family and patients to achieve shared decision making in those situations.
After this intense debate, around 90% of the audience agreed that there are still some limits to mechanical thrombectomy.
Keynote lecture: Better translation for clinical recovery
Prof. Rick Dijkhuizen
Prof. Dijkhuizen spoke about the important translation of basic stroke recovery research to clinical trials. Research about stroke recovery has been limited by a lack of standardisation, variable clinical responses and incomplete recovery. Important initiatives have been initiated which provide recommendations to overcome these limitations: ISRRA, STAIR, Multi-PART. Treatment testing in animals should be standardised, multicentre and use translational outcome measures. Basic science studies remain important for detection of new pathways and targets for treatments. Translational imaging, like diffusion tract MRI or fMRI could potentially bridge the gap to clinical neurorecovery trials.
This was nicely demonstrated by prof. Dijkhuizen In the next part of his talk with the example of repetitive transcranial stimulation (rTMS). rTMS can be used post-stroke to modulate the cortical excitability. To bring rTMS from bench to bedside, a large platform was setup within UMC Utrecht. First, a meta-analysis showed that starting rTMS within 1-month post-stroke, was the most optimal timing. Preclinical research with rat models and skilled research as an outcome measure was started, for which the results are still blinded. In addition, a phase 2 clinical trial (B-stars), investigating the effect of contralateral cTMS (continuous theta burst stimulation) on upper limb recovery, has started. The results of this trial were recently published in Stroke (Vink et al. 2023) and showed a significant effect on upper limb recovery compared to the group with sham stimulation. A large national multicenter phase 3 RCT, called B-STARS2 will soon start, and we are all looking forward to the results of a large, definitive trial in the field of neurorehabilitation.
Did GSSW get its priorities right? Evidence from international stroke research priority setting exercises
Prof. Terry Quinn (UK)
In the last talk of the 2023 GSSW edition, prof. Quin summarized ways of getting our research priorities on the right track. To define our priorities, we can use published data, the opinions of different experts or the research goals from guidelines. However, most importantly as academic researchers we need to synergize our research goal with people who suffered from a stroke. It is not always straightforward to get to know the real priorities of patients, because they might be reluctant to discuss certain topics with their physicians. Within the registry of Stroke Care Quality (RES-Q +) project, a chat bot was developed for patients to ask their questions more easily. Following social media is another strategy to get to know patient’s interests. In a more formal prioritisation exercise, all stroke stakeholders are included. The three most used methods are the: `James Lind Alliance`, `Global Health Forum Child Health and Nutrition Research Initiative` and the `Delphi Consensus method`. In stroke rehabilitation and long-term care, a top 10 of research questions included psychological and cognitive problems and fatigue among other things. However, it is important to note that priorities are likely to be contextual, vary with time and by included participants. A study about the effect of priority setting on published articles, didn’t show an impact on the articles that were published. To end this ESSW: Prof Quinn concluded that ESSW could focus on more of the priority areas and the priority for research is to focus on priority setting and implementation!
As ESSW 2023, closed, the snowy weather trapped most of us in Garmisch with no choice but to enjoy an extra snowy day in Garmisch to continue discussions with our colleagues!