By Christian Boehme
Twitter: @chris7ianb
Hyperacute Management
The last session of day 1 on hyperacute management was chaired by Else Charlotte Sandset from Oslo, Norway and Marc Ribo from Barcelona, Spain.
Yijun Zhang (China) commenced with EDARAVONE DEXBORNEOL IN TREATMENT OF LARGE ARTERY ATHEROSCLEROSIS STROKE. She pointed out the importance of large artery atherosclerosis as the predominant etiology of ischemic stroke in the Chinese population. This study was a post-hoc analysis of the TASTE trial and the TASTE-SL trial. This study assessed the effects of edaravone dexborneol in 658 patients with LAA-etiology stroke with treatment within 48 hours of onset and a duration of 14 days. The drug showed an OR of 1.44 for excellent functional outcome on the mRS with no difference in safety outcomes after 3 months. Yijun concluded that in patients with LAA-stroke, injectional or sublingual edavarone dexborneol could increase the proportion of patients achieving an excellent outcome at 90 days compared to edavarone alone or placebo.
Next, Yufei Wei (Beijing, China) presented TIMING OF ANTIHYPERTENSIVE TREATMENT INITIATION IN ANTERIOR VERSUS POSTERIOR CIRCULATION ACUTE ISCHEMIC STROKE. This post-hoc analysis of the CATIS-2 trial included over 2,000 patients categorized into two subgroups, anterior and posterior circulation strokes, excluding singular watershed infarcts. The rate of death and major disability (mRS³3) was 12.4% in anterior circulation stroke and 8.3% in posterior circulation stroke regarding early antihypertensive treatment.
The study showed that posterior circulation stroke patients were younger and more often had diabetes, and anterior circulation infarcts had a higher burden of multiple lesions, possibly due to the fact that symptomatic intracranial stenosis was more frequent in the anterior circulation. Anterior circulation stroke patients were more susceptible to blood pressure fluctuations which lead to a passive decrease in cerebral perfusion. This may exacerbate secondary neuronal damage in the ischemic penumbra. Further studies are warranted to explore the underlying mechanisms of these findings.
Davide Carone (Oxford, United Kingdom) followed with a presentation on PATIENTS RANDOMIZED TO GLENZOCIMAB SUFFERED LESS HEMORRHAGIC TRANSFORMATION WITH GREATER BENEFIT IN LARGER BASELINE INFARCT CORE. Davide showed that mechanical thrombectomy related ICH is moderated by glenocizumab (frequency and size). Additionally, glenocizumab reduced the risk of hemorrhagic transformation associated with larger strokes at presentation. Also, the influence of hemorrhage on functional outcome is moderated by glenocizumab. He concludes that, in recognition of unbalanced groups, glenocizumab-treated patients had a trend for smaller lesion volumes than placebo recipients at 24 hours after treatment. The smaller follow-up infarct volumes were due to both a less important hemorrhagic transformation (frequency and volume) and less ischemic injury and the results suggest a more pronounced effect in patients with larger cores. Finally, he concludes that reductions in hemorrhagic transformation volume are drivers of clinical outcome. The results are somewhat surprising given the general results from the ACTISAVE trial which we heard this morning in the main session.
Greg Albers (Stanford, United States) reported SECONDARY ANALYSES FROM THE TIMELESS TRIAL where tenecteplase was tested against placebo in the late time window of IVT. In the subgroup of M1 occlusions, use of tenecteplase resulted in a higher proportion of favorable functional outcome (mRS 0-2) at 90 days (46% vs. 31%). On the contrary, in the M2-occlusion subgroup there was no difference in achievement of favorable functional outcome with 50% achieved with tenecteplase and 58% with placebo. In wake-up stroke patients, final infarct volume growth showed a trend in favor for tenecteplase (25.8 ml vs. 37.7 ml, p=0.052). 90-day mRS ordinal shift and functional independence were numerically higher, and infarct growth was less, in patients with M1 occlusion receiving tenecteplase compared with placebo.
Steven Bush (Parkville, Australia) followed with INTRAVENOUS THROMBOLYTIC IS ASSOCIATED WITH INCREASED FIRST PASS EFFECT IN THROMBECTOMY. This study from the IRIS collaboration (n=685 patients) tested if bridging thrombolysis increased the likelihood of angiographic first pass effect (FPE), which is considered to have beneficial effects on outcomes and safety. Bridging thrombolysis increased the aOR of FPE by 27% translating to a NNT of 4 to move 1 patient into the FPE group. The odds of a patient having a mRS of 0-2 at 90 days increased by 170% with FPE when compared to non-FPE thrombectomy. For patients that achieved eTICI2c or 3 revascularization, the odds of having a mRS 0-2 increased by 40% when FPE was achieved. In these patients the odds for having ICH or procedural complications decreased by 45% with FPE but FPE had no impact on death or sICH. Steven concluded that bridging thrombolysis significantly increases the chance of achieving FPE and the benefit of FPE on functional outcomes and safety was confirmed even when adjusting for TICI score and procedural time.
João Pedro Marto (Lisbon, Portugal) presented results from the ENDOVASCULAR TREATMENT FOR ISOLATED CERVICAL INTERNAL CAROTID ARTERY OCCLUSION – ETIICA STUDY. The study included 998 patients from multiple centers and is the largest study assessing the outcome and safety of EVT in patients with ischemic stroke and isolated cervical internal artery occlusion. The study showed no difference in 3-month mRS, 3-month favorable outcome or 3-month mortality when applying EVT + best medical treatment or best medical treatment alone. Furthermore, the risk of any ICH was higher in the EVT group. João concluded that in patients with isolated cervical internal artery occlusion, EVT was associated with similar odds of disability and mortality, but potentially higher risk of ICH. RCTs are warranted to find the optimal treatment for these patients.
Nabila Wali (Amsterdam, Netherlands) presented ADMISSION SYSTOLIC BLOOD PRESSURE AND OUTCOMES AFTER ENDOVASCULAR TREATMENT IN ACUTE ISCHEMIC STROKE: A COHORT STUDY FROM THE EVA-TRISP COLLABORATION.
The study found that both lower and higher admission systolic blood pressure was associated with poor functional outcome (mRS 3-6) with the turning point being at around 150 mmHg. The same applied to diastolic blood pressure with the turning point being at around 80 mmHg. Lower systolic blood pressure was associated with mortality and higher systolic blood pressure was associated with higher NIHSS after 24 hours and sICH risk. Each 10 mmHg decrease or increase showed a significant effect on 90 day poor functional outcome. Nabila concludes that EVT was most effective in patients with a systolic blood pressure of approximately 150 mmHg.
Davide Strambo (Lausanne, Switzerland) concluded as last speaker of the day in this session with INFLUENCE OF STROKE SEVERITY AND OCCLUSION SITE ON ENDOVASCULAR THERAPY EFFECT FOR POSTERIOR CEREBRAL ARTERY OCCLUSION STROKES, which is a secondary analysis of the PLATO study. This study aimed to assess, if in acute ischemic stroke from isolated posterior cerebral artery occlusion, the association of EVT + medical management with 3-month disability and safety outcomes is modified by baseline stroke severity and the segment of arterial occlusion within PCA (P1 vs. P2). In 1059 patients, 35% received EVT and IVT was administered in 40% of each group. In patients with a baseline NIHSS >6, EVT was associated with a higher odds for functional independence, whereas in patients with an NIHSS of 0-6, EVT was associated with a worse outcome. On the other hand, EVT was associated with a higher odds for death. This effect was fairly more pronounced in patients with an NIHSS 0-6 at admission compared to patients with more severe strokes. There were no differences in ordinal mRS shift, excellent outcome, independence, sICH or mortality when comparing P1 vs. P2 occlusions. Davide concludes that in isolated PCA occlusion, baseline NIHSS appears to be an important modifier of the association of EVT and outcomes. EVT was associated with more favorable disability outcomes than medical management only in moderate-to-severe strokes. sICH-risk was increased with EVT irrespective of baseline stroke severity. Mortality was higher with EVT compared to medical management in both minor and severe stroke, but to a greater extent in the latter group. These results might be important for future hypothesis generation in future randomized trials of EVT in PCA occlusions.
