Ammad Mahmood, MBChB, BMedSci
European Stroke Organisation Conference
May 4-6, 2022
For the first time since 2019, the European Stroke Organisation Conference was able to meet again in person in Lyon, France, with over 4,000 delegates joining in person and virtually.
Tenecteplase in AIS
Much anticipated tenecteplase phase III trial results were top of the bill to open the conference. First up were the results of the Canadian AcT trial comparing tenecteplase 0.25mg/kg to alteplase in 1600 patients routinely eligible for IV thrombolysis. Non-inferiority margins were met, and safety outcomes were comparable between groups. This was a substantial addition to the body of evidence in favor of non-inferiority of tenecteplase 0.25mg/kg compared to alteplase. Adaptation of guidelines in light of these findings may be on the horizon, though results from further trials such as the ATTEST-2 trial will be of great value.
Next up was the NOR-TEST 2 Part A trial comparing tenecteplase at the higher 0.4mg/kg dose to standard dose alteplase. The trialists aimed to recruit a moderately severe stroke population following criticism of the first NOR-TEST trial including largely minor strokes with a significant number of mimics. Following interim review after around 200 participants were recruited, the trial was halted early due to an excess of poor functional outcomes and serious adverse events in the tenecteplase group. Though the higher dose of tenecteplase may well be implicated, and is unlikely to be revisited in further trials, there was significant imbalance in the baseline characteristics with tenecteplase participants having significantly worse baseline functional status and rate of co-morbidities. The complete results are published in The Lancet Neurology.1
The TASTE-A trial compared tenecteplase versus alteplase in the mobile stroke unit setting in a single centre study in Melbourne. The primary outcome was the volume of the perfusion lesion on CT perfusion imaging on arrival to hospital after initiation of thrombolysis. Tenecteplase was associated with a smaller perfusion lesion on arrival in hospital in otherwise matched groups, indicating the potential for early reperfusion with tenecteplase at this early timepoint. Further data is anticipated, and the current results are also published in The Lancet Neurology.2
Pre-hospital triage of acute stroke
In a first for the ESOC large trials session, a presentation was delivered by paramedic authors presenting the results of a study examining whether NIHSS training of paramedics could aid pre-hospital triage through structured communication with the hospital team. They found longer on scene times with shorter in hospital times but no difference in the primary outcome of likelihood of a correct stroke diagnosis.
Secondary prevention education in India
A large study conducted in India examined the role of secondary prevention education of stroke survivors using smartphones to deliver messages and videos as well as a workbook to educate patients regarding medication adherence and lifestyle factors that can reduce recurrent stroke risk. Medication adherence and lifestyle factors were impacted, but there was no difference in the rate of recurrent stroke.
Apixaban versus aspirin in ESUS
The ATTICUS trial compared patients with ESUS meeting further risk criteria randomized to apixaban or aspirin and monitored intensively for AF with a primary outcome of new ischemic lesions on MRI at 12 months. No difference was found in the groups, meaning a further neutral trial of DOACs in ESUS. A significant proportion (28%) of ESUS patients in this enriched population were found to have AF on intensive screening.
Timing of tracheostomy in patients with severe stroke
The SETPOINT-2 trial compared tracheostomy in the first 3 days with later tracheostomy in ventilated patients with severe stroke. No difference in functional outcome at 6 months was seen, and other secondary outcomes were not significant. The standard approach of tracheostomy in cases of failed extubation was advocated.
General anesthesia versus sedation for EVT
The AMETIS studied compared general anesthesia with sedation in 273 patients undergoing thrombectomy. No difference was seen in functional outcome or periprocedural complications in either group.
EVT in basilar artery occlusion
Finally, the results of the ATTENTION trial comparing EVT with best medical care in basilar artery occlusion presenting within 12 hours of suspected basilar occlusion were presented. A significant benefit of EVT was seen with an adjusted risk ratio of 2.1 (1.5-3.0) and an absolute risk difference of 24.2% (15-33.5). The result was warmly received as the first positive trial of EVT in a basilar artery occlusion population.
- Kvistad, C et al. Tenecteplase versus alteplase for the management of acute ischaemic stroke in Norway (NOR-TEST 2, part A): a phase 3, randomised, open-label, blinded endpoint, non-inferiority trial; The Lancet Neurology. Published online May 4, 2022. DOI: https://doi.org/10.1016/S1474-4422(22)00124-7
- Bivard et al. Comparison of tenecteplase with alteplase for the early treatment of ischaemic stroke in the Melbourne Mobile Stroke Unit (TASTE-A): a phase 2, randomised, open-label trial; The Lancet Neurology. Published online May 4, 2022. DOI: https://doi.org/10.1016/S1474-4422(22)00171-5