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Author: Dr. Inna Lutsenko,

ESO Social Media and PR Committee,

Neurologist, Hietzing Hospital, Austria

Twitter: @inna_lutsenko

We are looking back at 2021, where during the ESOC, also available virtually as in 2020, we learned new approaches to evidence-based stroke treatment.

Switching to Tenecteplase for Stroke Thrombolysis

Researchers from the New Zealand Central Region Hyper-Acute Stroke Network described in their paper (1) the process of switching to tenecteplase, motivated primarily by probable improved LVO recanalization in a setting of geographic barriers to thrombectomy access and ease of administration. The switch of a regional stroke service from alteplase to tenecteplase for ischemic stroke was associated with clinician satisfaction, improved patient functional outcomes at 3 months, shorter door-to-needle times and equivalent safety outcomes. The key point of the implementation of the switch to another thrombolytic was direct communication with stakeholders which made the transition faster and more reliable. 

Restarting Anticoagulants in Atrial Fibrillation Patients With Intracerebral Heaemorrhage

Another significant trial was presented by the  APACHE-AF Investigators from the Netherlands (2). This prospective, randomized, open-label, phase 2 trial was carried out at 16 hospitals in the Netherlands and aimed to estimate the rates of non-fatal stroke or vascular death in patients with atrial fibrillation, suffered from intracerebral hemorrhage, when treated with apixaban compared to avoidance of anticoagulation. Resuming anticoagulation with apixaban in patients with intracerebral hemorrhage increased the rate of hemorrhagic events but reduced the rate of ischemic events, and no benefit on the combined outcome was seen in both groups. It was concluded that enrollment in large RCTs will inform best treatment modalities for such patients. 


Reinitiating NOAC After Acute Ischemic Stroke

The Swedish registry-based TIMING trial (Timing of Oral Anticoagulant Therapy in Acute Ischemic Stroke With Atrial Fibrillation), carried out at 34 stroke units, aimed to investigate the efficacy and safety of early versus delayed initiation of NOAC in patients with atrial fibrillation suffering from ischemic stroke (3). Early initiation of NOAC was noninferior to its delayed start after acute ischemic stroke in such patients. Numerically lower rates of ischemic stroke and death and the absence of symptomatic intracerebral hemorrhages implied that the early start of NOAC was safe and should be considered for acute secondary stroke prevention in patients eligible for NOAC treatment (3).

Since 2021 many neurological departments have implemented both thrombolytics, Alteplase and Tenecteplase, and used it successfully in the acute stroke treatment.
Anticoagulants were also successfully reinitiated in patients with atrial fibrillation after ischemic stroke according to clinical guidelines, and we are awaiting news on this treatment during the upcoming ESOC2024. 

References

  1.  Karim Mahawish et al. Switching to Tenecteplase for Stroke Thrombolysis. Real-World Experience and Outcomes in a Regional Stroke Network. https://www.ahajournals.org/doi/10.1161/STROKEAHA.121.035931 
  2. Schreuder FHBM, van Nieuwenhuizen KM, Hofmeijer J, Vermeer SE, Kerkhoff H, Zock E, Luijckx GJ, Messchendorp GP, van Tuijl J, Bienfait HP, Booij SJ, van den Wijngaard IR, Remmers MJM, Schreuder AHCML, Dippel DW, Staals J, Brouwers PJAM, Wermer MJH, Coutinho JM, Kwa VIH, van Gelder IC, Schutgens REG, Zweedijk B, Algra A, van Dalen JW, Jaap Kappelle L, Rinkel GJE, van der Worp HB, Klijn CJM; APACHE-AF Trial Investigators. Apixaban versus no anticoagulation after anticoagulation-associated intracerebral haemorrhage in patients with atrial fibrillation in the Netherlands (APACHE-AF): a randomised, open-label, phase 2 trial. Lancet Neurol. 2021 Nov;20(11):907-916. doi: 10.1016/S1474-4422(21)00298-2. PMID: 34687635.
  3. Oldgren J, Åsberg S, Hijazi Z, Wester P, Bertilsson M, Norrving B; National TIMING Collaborators. Early Versus Delayed Non-Vitamin K Antagonist Oral Anticoagulant Therapy After Acute Ischemic Stroke in Atrial Fibrillation (TIMING): A Registry-Based Randomized Controlled Noninferiority Study. Circulation. 2022 Oct 4;146(14):1056-1066. doi: 10.1161/CIRCULATIONAHA.122.060666. Epub 2022 Sep 6. Erratum in: Circulation. 2022 Nov 8;146(19):e279. PMID: 36065821; PMCID: PMC9648987.https://pubmed.ncbi.nlm.nih.gov/36065821/