COMMENTARY

Key Takeaways From the Latest Stroke Guidelines

Hans-Christoph Diener, MD, PhD

Disclosures

October 13, 2021

This transcript has been edited for clarity.

Dear colleagues, I am Christoph Diener from the faculty of medicine at the University of Duisburg-Essen in Germany. This month I would like to report on several new publications from the European Stroke Organisation on the management and prevention of stroke.

Managing Blood Pressure in the First 24 Hours

The first study deals with the management of blood pressure in acute ischemic stroke. Its findings indicate that elevated blood pressure should not be treated on the way to the hospital. Routine blood pressure lowering is also unnecessary in patients with acute ischemic stroke whose values are below 220/110 mm Hg. However, in patients with values above 220/120 mm Hg, blood pressure should be lowered very slowly. In patients who are candidates either for thrombolysis or thrombectomy, blood pressure should be maintained below 180 or 105 mm Hg during the procedure and for the next 24 hours. In patients with intracerebral hemorrhage who arrive at the hospital within 6 hours, blood pressure should be kept below 140 mm Hg.

Space-Occupying Brain Infarctions

The second publication offered guidelines on the management of space-occupying ischemic strokes. In patients with malignant middle cerebral artery infarction, surgical decompression is recommended in a time window of 48 hours in patients below the age of 60. However, both patients — if possible — and their families must be made aware that survival may be associated with severe neurologic deficits.

Surgical decompression surgery might also be considered in patients with space-occupying infarction older than 60 years, and decompression surgery may be performed in space-occupying cerebella infarcts. In patients with malignant middle cerebral artery strokes, it is not recommended to use corticosteroids, hyperventilation, or hypothermia.

New Guidelines on Transient Ischemic Attacks (TIA) and Minor Stroke

The next guideline deals with the management of TIA. Every patient with a TIA should be seen within 24 hours by a stroke specialist, stroke clinic, or a stroke unit. In addition to brain imaging, CT angiography and MR angiogram should be performed to exclude hemodynamically relevant stenosis or occlusions of the brain-supplying arteries.

A separate set of guidelines discussed the short-term use of dual antiplatelet therapy in patients with high-risk TIA or minor stroke. In patients with high-risk TIA, defined as an ABCD2 score of 4, or a mild stroke, defined as NIHSS of 3 or less, 21 days of dual antiplatelet therapy is recommended, followed by aspirin monotherapy. Dual antiplatelet therapy can be done either with clopidogrel plus aspirin or ticagrelor plus aspirin. However, the combination of ticagrelor plus aspirin has a higher bleeding risk than the combination of clopidogrel plus aspirin.

Treatment Options for Patients With Carotid Stenosis

The fifth publication offered a set of guidelines on endarterectomy or stenting in high-degree carotid stenosis. In patients with asymptomatic carotid stenosis greater than 60% and a high risk of stroke, carotid surgery is recommended. In patients with symptomatic severe carotid stenosis, defined as 70%-99% stenosis, carotid endarterectomy is recommended. In patients who are below the age of 70, stenting can be considered as an alternative.

Either surgery or stenting should be performed within 2 weeks after the initial event, and the indication should be made by an interdisciplinary team of neurologists, neuroradiologists, and vascular surgeons.

Rare Thrombosis Complications Following COVID-19 Vaccinations

The sixth and final publication I wanted to highlight is an expert opinion on cerebral sinus venous thrombosis following COVID-19 vaccination. This occurs due to thrombocytopenia caused by antibodies against antiplatelet factor 4. Most cases have been observed with vector vaccines like the one from AstraZeneca or Johnson & Johnson, and women are more frequently affected than men.

Heparin or heparinoids should be avoided for treating this condition. Instead, it can be treated with corticosteroids, immunoglobulins, or plasmapheresis. However, we must remember that the risk of this complication after COVID-19 vaccination is much, much lower than the risk of getting sinus venous thrombosis in the context of a COVID-19 infection.

Ladies and gentlemen, I am Christoph Diener from the faculty of medicine at the University of Duisburg-Essen in Germany. Thank you very much for listening and watching.

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