Aurora Semerano, MD
European Stroke Organisation-World Stroke Organization 2020 Virtual Conference
November 7-9, 2020
Session: Scientific Communications 16: Prognosis After Acute Stroke Interventions
Revascularization therapies, including intravenous thrombolysis and endovascular thrombectomy, have shown to reduce mortality and disability after stroke in randomized clinical trials, as well as in the real world. However, even when the revascularization treatment is effective, a significant amount of patients experiences poor outcome. Investigating the mechanisms and the predictors of poor prognosis despite acute stroke interventions was the goal of the 8 lectures of this interesting session, chaired by Prof. Mike Charma from Canada and Prof. Else C. Sandset from Norway.
Dr. Chen Chen, from China, illustrated her work aimed at determining patient characteristics of Asian and non-Asian patients with acute ischemic stroke included in the ENCHANTED study: Compared to non-Asian patients, Asian patients were at increased risk of hemorrhagic transformation and neurologic deterioration during hospitalization after thrombolysis treatment, potentially suggesting that distinctive monitoring for complications is needed in subgroups of patients after acute stroke intervention.
Dr. Morin Beyeler, from Inselspital Bern, Switzerland, discussed his study analyzing very long-term outcome (median 30 months) after endovascular thrombectomy in a real-world scenario. Successful reperfusion (eTICI≥2b50) was associated with lower mortality in long-term follow up. Interestingly, when adjusting for final reperfusion grade, the occurrence of embolization in new territory detected during angiographic procedure was independently associated with reduced survival time.
Dr. Salvatore Rudilosso, from Hospital Clínic, Barcelona, Spain, showed that clinical improvement at 24 hours from endovascular thrombectomy is a potent surrogate marker of long-term outcome in a large multicentric cohort from the prospective registry of all stroke centers in Catalonia. Even in the subgroup of patients with posterior circulation stroke, early neurological course is confirmed as a predictor of long-term functional outcome. He suggested that clinical endpoints based on percentage improvement after thrombectomy may be usefully included in future clinical trials.
Dr. Anceline Dong, from France, explored the predictive factors of poor outcome in patients who achieved fully recanalization (mTICI 3) after endovascular thrombectomy, in a large cohort from the ETIS multicenter prospective clinical registry: Older age, higher admission NIHSS, absence of rtPA, cardioembolic stroke, and evolution of NIHSS in the first 24 hours were all independently associated with worse functional prognosis. She suggested that these patients could be a target population for neuroprotective treatments in the future.
Dr Xabier Urra, from Hospital Clínic, Barcelona, Spain, looked at the potential prognostic factors and their treatment modifying effects in a large population-based cohort of stroke patients with proximal occlusion. The majority of poor prognostic factors in stroke also predicted more substantial benefit from endovascular thrombectomy. Interestingly, greater pre-stroke disability and higher glucose levels showed a trend towards reduced benefit from the endovascular procedure. Recognizing these factors is pivotal for individual decision-making and for identifying patients in need of additional treatments.
Dr. Rob A. Van der Graaf, from the Netherlands, aimed at quantifying the importance of the individual predictors of poor outcome despite successful reperfusion (eTICI≥2b) after endovascular thrombectomy, in a nationwide cohort from the MR CLEAN registry. Analyzing the additive prognostic value of grouped variables, “patient” factors and “post-procedural” factors resulted to be the greatest contributors to outcome prediction. Preventing post-procedural adverse events, such as symptomatic intracranial hemorrhage and pneumonia, has a great potential to further improve outcome in patients achieving successful reperfusion.
Dr. Hermann Negerbauer, from Germany, presented the preliminary data from the DESTINY-R, a prospective multicenter registry including ischemic strokes affecting more than 50% of the MCA territory. He showed that outcomes after decompressive hemicraniectomy in a real-world scenario were comparable to those of randomized clinical trials when age of included patients is taken into account. No differences in the effectiveness of surgery were found in subgroups of patients according to age, presence of aphasia, and timing of intervention. He concluded that low absolute numbers of favorable and independent outcome, as well as low absolute quality of life and health scores, emphasize the need for individual decision about decompressive surgery.
Dr. Francesco Arba presented data from the Italian registry of endovascular thrombectomy in acute stroke (IRETAS), addressing safety and efficacy of combined (rtPA+endovascular thrombectomy) vs. direct endovascular thrombectomy in patients with stroke from isolated basilar artery occlusion. In patients treated with endovascular therapy before 6 hours from symptom onset, combined therapy was associated with better functional outcome compared to endovascular thrombectomy alone. Moreover, he found that distal embolization of the thrombus was more frequent in patients treated with direct endovascular therapy.