by Christian Boehme, ESO Social Media and PR Committee
Department of Neurology, Medical University of Innsbruck, Austria
Twitter: @chris7ianb
Gisele Sampaio from São Paulo, Brazil and Keith Muir from Glasgow, United Kingdom, chaired this afternoon session on the hottest topics in stroke thrombolysis.
Pierre Seners (Paris, France) sparked off the session with ARTERIAL RECANALIZATION DURING INTER-HOSPITAL TRANSFER FOR THROMBECTOMY. The study evaluated the incidence and predictors of arterial recanalization during inter-hospital transfer for thrombectomy, as well as the relationship between recanalization during transfer and clinical outcomes. Inter-hospital recanalization was determined by comparison of the baseline and post-transfer arterial imaging and was defined as revised Arterial Occlusive Lesion (rAOL) score 2b or 3. Of 520 patients from 2 prospective cohorts in primary stroke centers, 111 (21%) experienced inter-hospital recanalization of which ¾ were partial recanalizations. IVT-use had an OR of about 7 for recanalization. Pre-transfer variables independently associated with recanalization were intravenous thrombolysis, more distal occlusions, and smaller clot burden. Recanalization during transfer was associated with less inter-hospital infarct growth and greater inter-hospital NIHSS score improvement, with greater benefit from complete vs partial recanalization. Recanalization was independently associated with reduced 3-month disability with greater benefit from complete than partial recanalization.
Pierre concludes that substantial rates of recanalization are observed during inter-hospital transfer with a strong association with favorable clinical outcomes, even for partial recanalization. Broadening thrombolysis indications in primary stroke centers and developing
therapies that increase the rate of recanalization during transfer will likely improve clinical outcomes.
Ye Liu (Shanghai, China) was next with TENECTEPLASE THROMBOLYTIC THERAPY FOR ACUTE ISCHEMIC STROKE IN CHINA. A MULTI-CENTER REAL-WORLD STUDY.
This study retrospectively collected data using alteplase or tenecteplase in a 1:1 ratio for acute ischemic stroke <4.5 hours of onset in China. The primary outcome was the rate of sICH within 72 hours after thrombolysis and secondary outcomes included functional outcomes, among others. Patients treated with tenecteplase had better 90-day functional outcome and less any ICH compared to alteplase. No difference was found in the risk of sICH, systemic bleeding and death within 90 days. Ye concludes that thrombolysis with tenecteplase was associated with better 3-month functional outcomes compared to alteplase in acute ischemic stroke patients with no increased risk of sICH.
Lina Palaiodimou (Athens, Greece) followed with TENECTEPLASE VERSUS ALTEPLASE IN THE TREATMENT OF ACUTE ISCHEMIC STROKE WITHIN 4.5 HOURS: A SYSTEMATIC REVIEW AND META-ANALYSIS.
This meta-analysis included all available RCTs that investigated efficacy and safety of tenecteplase 0.25mg/kg compared to alteplase for the treatment of acute ischemic stroke <4.5 hours of onset. 9 RCTs were included with 2,717 patients treated with tenecteplase versus 2,676 patients treated with alteplase. Tenecteplase was associated with a higher likelihood of excellent functional outcome (RR 1.07) and reduced disability compared to alteplase, while good functional outcome was similar between the groups. The meta-analysis showed similar rates of sICH and 3-month mortality. Lina concludes that there is similar safety of tenecteplase 0.25 mg/kg to alteplase, and tenecteplase might be superior to alteplase in achieving excellent functional outcome.
Johannes Kaesmacher (Bern, Switzerland) presented RUNNING ALTEPLASE INFUSION UPON RECANALIZATION WITH THROMBECTOMY: A SUBSTUDY OF THE IRIS META-ANALYSIS.
This study assessed whether the effect of IVT+EVT versus EVT alone is modified by whether
the infusion of IVT was still running at the timepoint of proximal flow restoration. The study used the IRIS individual participant data and assessed the treatment effect heterogeneity of IVT before EVT vs. EVT alone in groups with running or finished IVT-infusion upon recanalization. In 39% of patients, IVT was still running upon recanalization and outcomes between IVT+EVT were not different if IVT was running or not at time of recanalization. The effect of a running IVT infusion does not appear to be due to IVT. Johannes concludes that this analysis does not corroborate previous studies suggesting a positive clinical effect of IVT on outcomes if IVT is running after proximal recanalization. There is no apparent benefit of “delaying” IVT in these patients for the sake of overlap.
Philipp Bücke (Bern, Switzerland) presented INTRAVENOUS THROMBOLYSIS IN PATIENTS WITH RECENT DOAC INGESTION – A TARGET TRIAL ANALYSIS AFTER LIBERALISATION OF OUR GUIDELINES. Philipp points out the increase of patients using DOACs, mainly driven by aging of the population and expansion of indications.
This single-center observational study reports results on the safety and efficacy of off-label IVT after changing institutional guidelines allowing IVT for all patients with recent dOAC intake regardless of dOAC-activity, last-intake or reversal. Previous research by Meinel et al. reported exciting results on this topic and warrant extensive research. Safety and efficacy outcomes with recent DOAC intake (<48 h) otherwise qualifying for IVT were compared to patients not receiving IVT totaling 98 patients. IVT was given in 50% with median DOAC-activity level of 93 ng/ml. SICH occurred in no patient receiving IVT and in 2 of 49 patients not receiving IVT. Mortality rates at 3 months were comparable and IVT patients were more likely to have good outcome or return to baseline mRS. There was no significant difference in major bleeding or asymptomatic ICH.
Philipp concludes that after liberalizing the institutional approach to IVT regardless of recent dOAC intake, no safety concerns were observed. The association of IVT with better outcomes warrants prospective randomized studies like the upcoming DO-IT registry and trial which are underway to answer this question.
Marius Matusevicius (Stockholm, Sweden) followed with SAFETY AND OUTCOMES OF DABIGATRAN REVERSAL WITH IDARUCIZUMAB PRIOR TO IVT TREATMENT IN PATIENTS WITH ACUTE ISCHEMIC STROKE: A SITS REGISTRY STUDY.
This study investigated safety and outcomes of IVT after dabigatran reversal using idarucizumab in acute ischemic stroke patients. Data on IVT treated patients from the SITS International Stroke Thrombolysis Registry were analyzed for occurrence of any parenchymal hematoma (PH), sICH and death within 3 months. The secondary outcome was functional independence (mRS 0-2) at 3 months. Among >180,000 IVT treated patients, 142 received dabigatran reversal. After propensity score matching analysis with a good balance at baseline,
patients treated with dabigatran reversal before IVT had similar results in all outcomes as compared to patients without prior OAC. Marius concludes that, IVT treatment after dabigatran reversal was safe and had similar outcomes to IVT without previous OAC.
Fabiano Cavalcante (Amsterdam, Netherlands) was next with a talk on ACUTE STENTING WITH OR WITHOUT INTRAVENOUS THROMBOLYSIS IN STROKE PATIENTS WITH CAROTID TANDEM LESIONS.
This study assessed the effect of acute stenting during EVT, with and without IVT. Individual participant data from a meta-analysis of the IRIS collaboration were used. All patients with carotid tandem lesions and available information on intraprocedural stent placement were included. A total of 340 of 2334 patients directly transferred to EVT-capable centers with carotid tandem lesions were included, with 1/3 of patients receiving acute stenting. Stenting during EVT was associated with better functional outcomes. No effect heterogeneity was observed for patients receiving IVT plus EVT versus EVT alone.
Fabiano concludes that in stroke patients eligible for EVT presenting directly to EVT-capable centers, acute stenting of carotid tandem lesions is associated with better functional outcomes, also in patients treated with IVT.
Adnan Mujanovic (Bern, Switzerland) finished the session with EFFECT OF INTRAVENOUS THROMBOLYTICS ON DELAYED REPERFUSION FOLLOWING INCOMPLETE MECHANICAL THROMBECTOMY.
Adnan pointed out that 60% of endovascularly treated ischemic stroke patients with incomplete reperfusion show complete delayed reperfusion at 24h, which is associated with favortable outcomes compared to non-reperfusion. The study investigated the association between intravenous thrombolysis (IVT) and delayed reperfusion occurrence. Pooled individual-patient data from 3 RCTs (EXTEND-IA, EXTEND-IA TNK part 1 & 2) and 2 prospective stroke studies were analyzed. Out of 832 patients, 61% had delayed reperfusion.
Receiving IVT was associated with delayed reperfusion. Adnan concludes that pre-treatment with IVT was associated with the occurrence of delayed complete reperfusion among
