What's Hot at ISC 2018?

January 19, 2018

The American Heart Association/American Stroke Association's International Stroke Conference (ISC), being held January 23 to 26  at the Los Angeles Convention Center, is set to deliver a host of new exciting clinical trial results, as well as new guidelines for the treatment of acute ischemic stroke.

"This year's ISC meeting will be particularly exciting," program chair, Bruce Ovbiagele, MD, professor and chair of neurology, Medical University of South Carolina, Charleston, commented to Medscape Medical News. "There are so many new trials coming out that will potentially change the landscape of care for large-vessel occlusion strokes and also for other patients with stroke. I think we are going to have another landmark meeting like the 2015 ISC, where all the new endovascular trials were announced."     

Among the major new trials being presented at this year's ISC are several that build on the recent success of the endovascular thrombectomy procedure. These include:

  • DEFUSE 3: This National Institutes of Health–funded trial is looking to expand the therapeutic window for thrombectomy out to 16 hours from time of stroke onset. "The DEFUSE 3 trial is seen as complementary to the recently reported DAWN trial, which showed a benefit of thrombectomy when used out to 24 hours in patients selected by clinical mismatch," Dr Ovbiagele commented. "DEFUSE differs in that the patients were selected for inclusion using imaging techniques to identify those who had a large potentially salvageable area of brain. It will be interesting to see if the results are different with these different ways of selecting patients."  

  • Further results from DAWN: The meeting will also hear the latest subgroup analyses from the DAWN trial, which will focus on the different technique involved in measuring the core infarct as well as which patients in particular benefitted. "We will also hear about the practicalities of using clinical mismatch to identify suitable patients and how this can be applied in the real world — incredibly important information," Dr Ovbiagele said.

  • ARISE II: This trial is evaluating a new type of stent retriever known as EmboTrap (Neuravi) for the removal of the clot in patients with large-vessel ischemic stroke.

  • EXTEND-IA TNK: Another trial in patients with large-vessel occlusions who are planned to have thrombectomy, this study is focusing on the thrombolytic given beforehand and is comparing the current standard tissue plasminogen activator (tPA) infusion with the newer tenecteplase (TNK) bolus.  Dr Ovbiagele commented, "The question is whether the more fibrin-specific TNK, which can be given as a bolus, will lead to better outcomes. It would be particularly convenient to use a bolus thrombolytic such as TNK in patients who presented at one hospital for thrombolysis but needed to be transported to another hospital for endovascular treatment."

  • COMPASS: This trial is comparing a new technique of aspiration vs use of a traditional stent retriever for clot removal. "Pilot studies have suggested that aspiration may be better, and this is one of the largest trials to compare the two techniques to date," Dr Ovbiagele said.

In other areas, key clinical trials of interest being presented at the ISC include the following:

  • PRISMS: This trial is also in an acute ischemic stroke population but includes patients with mild and nondisabling strokes and is evaluating the use of tPA in this group.  Dr Ovbiagele explained: "Patients with mild and nondisabling strokes do not at present receive thrombolysis because they were excluded from the initial landmark trials with tPA, But these patients often worsen over time and their outcomes are not always benign, so it will be very interesting to see if tPA benefits this group."

  • FASTRACK: This UK trial is evaluating pharyngeal electrical stimulation to reduce aspiration pneumonia in patients with dysphagia after acute stroke. "Aspiration pneumonia is a big problem and causes increased mortality, so anything that can reduce this complication will be welcome. The trial was stopped early, but we don't know if it was positive or not," Dr Ovbiagele noted.

New Acute Ischemic Stroke Guidelines

A particularly exciting part of the meeting will be release of the new acute ischemic stroke guidelines.

"This is the first time new guidelines have actually been unveiled at this meeting," Dr Ovbiagele noted. "Usually they are published first and then discussed at the meeting later, so they really will be hot off the press."

In addition, the guidelines will include some of the latest clinical trial results, even some presented at this meeting, and members of the writing committee will discuss how the various recommendations were reached, he said. "So much has happened in the field of acute ischemic stroke in the last few years, so these guidelines are much needed and much anticipated."

He added that the new guidelines will be broader than other previous sets of guidelines. "We have taken a different approach this time. The guidelines will not just be focused on acute stroke treatment but will also address prevention of recurrent strokes and will include lifestyle issues as well as acute interventions."  

The ISC meeting will also feature the "TED Talk" spinoff, "CED Talks" or "Cerebrovascular Education Discovery Talks." Dr Ovbiagele notes that like TED Talks, these will feature leaders in the field who will deliver visionary speeches without scripts and with minimal slides on their specialist subject.    

The Cross Fire debates will also be back. "These were so popular last year that we're doing them again," Dr Ovbiagele said. Topics for discussion will include the use of hemicraniectomy in patients over age 60  years, how long to monitor for atrial fibrillation (AF) after a cryptogenic stroke, and whether  or when to restart oral anticoagulation therapy in patients with AF who have had a hemorrhagic stroke.    

Another particular feature of this ISC is the large number of collaborations with other international associations. Dr Ovbiagele noted: "We have joint sessions with eight different international organizations. This is an opportunity for us all to think more globally."  

Three preconference symposia are being held on Tuesday, January 23. The topics will be hemorrhagic stroke in the real world; a nursing symposium; and stroke in the lab, which will focus on translating basic neurobiology and vascular biology to the clinic and vice versa — essentially, Dr Ovbiagele commented, "how we can learn from the basic neurobiologists and they can learn from us."  

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