Controversies in Stroke I

By: Prof. Anita Arsovska, MD, PhD, University Clinic of Neurology, Medical Faculty, University “Ss Cyril and Methodius”, Skopje, Republic of North Macedonia, FESO, FEAN, SAFE Board Member

The 23rd of May started with a very exciting and interactive morning session from 08:15-09:45 in the Gold Room,  entitled Controversies in Stroke I, chaired by Martin Dichgans (Germany) and Turgut Tatlisumak ( Sweden). The session started with a burning question: Intravenous thrombolysis before endovascular trombectomy? Yes or no? And than Yvo Roos (The Netherlands) tried to convince the audience to answer yes, providing an overview from the recent studies and own experience. He actually concluded that the answer is still coming and that we need to wait and see the results of DIRECT-MT (expected at ISC 2020) and MrClean No-IV and other trials expected later that year, however in the meantime, we need to include patients in trials or stick to the current evidence….IVT+IMT.

Afterwards, Urs Fischer (Switzerland) in a very charming way gave an excellent lecture entitled IVT before EVT? Not Always! He personally disclosed that he actually loves thrombolysis and it is the drug that he loves the most, however, first we have to answer the following questions: Preinterventional reperfusion: how often and how good? Is IVT plus MT better than MT alone in IVT eligible patients? Which patients should be included in trials? Does one approach fit all? Quoting the latest studies including his own rich experience, he concluded that IVT is currently the standard of care in all patients with LVO, IVT should only be skipped in the framework of well designed RTCs, and only patients with low probability of early recanalization after IVT and immediate access to direct MT should be included.We need an initiative to tailor stroke treatment strategies in the future (precision medicine).

The session continued with the second topic : Restarting oral anticoagulation after ICH – No (Roland Veltkamp, Germany) and Yes (Karin Klijn, The Netherlands). Dr. Veltkamp stated that there is limited evidence that would support restarting someone with an OAC-related ICH on an OAC and that we need to personalize therapy election and shared decision making as best preventive approach. His “opponent” Dr. Klijn, after presenting current evidence, concluded that we should recommencing OAC in high risk ischemic event; microbleeds have no influence; if AF: OACs are preferable over Vit K antagonists; there should be no rush (unless very igh risk ischemia), probably best after 7-8 weeks, it is still unsure if NOACs are safe to be started sooner and we need to randomize our patients in the multiple RTC’s that are ongoing/starting soon.

The third topic elaborated : Extending the window for reperfusion therapy- Do we need perfusion imaging-yes (“defended” by Henry Ma, Australia) and no- presented by Götz Thomalla from Germany. Basically, Dr. Ma presented the benefits of the perfusion imaging, that can identify the ischemic core- poor outcome and risk of haemorrhage, identify the ischemic penumbra- potential benefit, exclude stroke mimics and provide precision medicine, concluding that yes, we do need perfusion imagiing to extend the reperfusion time window for reperfusion. On the other hand, Dr. Thomalla presented a more practical approach, firstly asking the audience if at their stroke center, they have perfusion imaging available for acute stroke imaging 24/7? The actual situation is that 45% had it only during office hours or not at all, 38% had CT perfusion, 11% had CT perfusion and MRI and only 4% had MRI and perfusion imaging. He later asked also a very useful question: At your stroke center, which CT perfusion parameter do you use to define the ischemic core? And surprisingly, the majority of the participants did not know (45%), and the rest of them had doubts between absolute or relative cerebral blood flow of volume. After detailed overview of current studies and evidence, he concluded that perfusion imaging is valuable for research and helpful as diagnostic tool in acute ischemic stroke; there is uncertainty as to the optimal perfusion parameters and thresholds, there are limitations to quantification of ischemic core by CT perfusion, we do not need perfusion imaging to guide MT in extended or unknown time of symptom onset or to guide IVT in unknown symptom onset, penumbral imaging requiring perfusion is only needed to guide IVT on kknown late time window; for the vast majority of patients, we do not need perfusion imaging to guide reperfusion treatment with IVT or MT and Stroke centers must have perfusion imaging available 24/7 but should not waste time in doing perfusion imaging in the majority of patients in whom it is not required!