European Stroke Organisation Conference
May 22–24, 2019

Alan C. Cameron, MB ChB, BSc (Hons), MRCP

The 5th European Stroke Organisation Conference (ESOC 2019) has opened with a fantastic session in Milan on Wednesday! The conference was opened by ESO President Bart van der Worp, Conference Chair Jesse Dawson, and Chair of the Local Organising Committee Danilo Toni, who welcomed over 5,500 participants from 94 countries to the conference, which has doubled in size since inception over the last four years.

Ten landmark studies were presented at the official welcome. Key highlights include results from RESTART, which answers whether to start or avoid antiplatelet therapy after ICH in patients taking antiplatelets for the prevention of occlusive vascular disease. Remarkably, restarting antiplatelet therapy does not increase major haemorrhagic events. In contrast, restarting antiplatelet therapy may reduce recurrent ICH and protect against recurrent major vascular events. This provides reassuring evidence on restarting antiplatelet medication for secondary prevention of occlusive vascular disease in patients with ICH.

RESILIENT demonstrates the overwhelming efficacy of mechanical thrombectomy persists when implemented in the challenges of a developing country healthcare system such as Brazil. In this setting, thrombectomy decreases disability with a number needed to treat of only 6.6, has low complication rates and no increase in symptomatic ICH compared to medical therapy. We must now ensure the tremendous benefits of thrombectomy are available to more patients globally, including developing countries. 

On the topic of thrombectomy, ASTER2 found no difference in recanalization with combined aspiration and stent retriever compared to stent retriever alone, although the combined approach was more effective in intracranial ICA or tandem lesion. Operators should use the technique they trust for now, but further research in this area is needed. 

Talking therapy and self-directed rehabilitation improves quality of life and independence for stroke survivors at 12 months in the TACAS study, with 2 sessions better than 1. The intervention has an NNT of 7.9 and costs only around 60 euros. Talking therapy and self-direction rehabilitation is, therefore, an effective, simple and inexpensive approach to improve outcomes. 

In an individual patient data meta-analysis of the EXTEND, ECASS4-ExTEND and EPITHET trials, alteplase at 4.5-9 hours or after wake-up stroke with perfusion mismatch improves functional outcomes at 3 months. The benefits and risks were similar to alteplase at 0-4.5 hours, and the benefit was predominantly in patients with automated perfusion mismatch. Consideration should be made to extending the thrombolysis time window in this context to benefit more stroke patients worldwide. 

The RATULS trial demonstrates that robot assisted training in patients with moderate to severe arm functional limitation does not improve upper limb function compared to enhanced upper limb therapy or usual care, although robot training and enhanced upper limb therapy improve upper limb impairment, and enhanced upper limb therapy improves hand function and mobility. We also heard that remote ischaemic per-conditioning is safe but does not affect outcomes in the RESCUE BRAIN study, whilst a thrombolysis-specific paramedic acute stroke treatment assessment tool may reduce hospital and social care costs but does not increase the proportion of patients receiving thrombolysis or affect clinical outcomes in the PASTA study.

The RESTORE BRAIN trial demonstrates that selective GABA-A a5 receptor antagonism is safe but does not improve functional outcomes at 3 months. The THAWS trial shows that lower dose alteplase in patients with wake-up or stroke of unknown onset with DWI-FLAIR mismatch is associated with similar outcomes compared to standard therapy, although the conclusions that can be drawn are limited in the context of early study termination following the WAKE-UP trial. 

The official welcome and large clinical trial session was a fabulous start to what is sure to be an excellent conference. A number of fascinating studies were presented, and the clinical implications will change practice to improve the outcomes of stroke patients worldwide. Looking forward to more exciting results ahead!