Recent Updates: Stroke, Migraine, and Dermatomyositis

Hans-Christoph Diener, MD, PhD


December 20, 2022

This transcript has been edited for clarity.

Ladies and gentlemen, dear colleagues, I am Christoph Diener from the Faculty of Medicine at the University of Duisburg-Essen. I wanted to report new studies, which were published in October 2022.

The most important and relevant studies were published in the stroke field. There were two studies from China that clearly showed that thrombectomy is effective in occlusion of the basilar artery.

The first study was the ATTENTION study in 340 patients with occlusion of the basilar artery. They were randomized in a proportion of 2:1 to thrombectomy or best medical treatment within a time window of 12 hours. About one third received systemic thrombolysis.

The primary endpoint was modified Rankin scale from 0 to 3, which was achieved in 46% with thrombectomy and 23% with best medical treatment. Mortality after 90 days was dramatically reduced from 55% to 37% with thrombectomy. There were about five intracranial hemorrhages in the thrombectomy group.

The second study, also done in China, recruited 217 patients with occlusion of the basilar artery. Here, the time window was 6-24 hours. Overall, 20% received thrombolysis. Again, the primary endpoint was modified Rankin scale, from 0 to 3. This was achieved in 46% with thrombectomy vs 24% with best medical treatment. Mortality after 90 days was 31% with thrombectomy vs 42% with best medical treatment. There were six symptomatic intracranial hemorrhages [in the thrombectomy group] vs one [in the best medical treatment group].

We have two studies that clearly show that, in a time window up to 24 hours, thrombectomy is effective in occlusion of the basilar artery, improves functional outcome, and reduces mortality, with a very small risk for intracerebral hemorrhage.

The caveat is these studies were done in Chinese patients and not in Caucasian patients. These patients, much more frequently than Caucasian patients, have a preexisting stenosis of the basilar artery, so many of them required balloon dilatation and stent implantation before thrombectomy. I think there is no doubt now that thrombectomy is effective.

The next study, from the Netherlands, investigated whether it makes sense to decrease increased blood pressure in people who have a suspicion of stroke on the way to the hospital. They asked paramedics to apply either a patch with glyceryl trinitrate 5 mg or placebo on the way to the hospital.

They recruited 380 patients. This study had to be terminated prematurely because there was no benefit on the modified Rankin scale and there was a significant bleeding risk in the active treatment group. This clearly shows that lowering blood pressure on the way to the hospital or early in the hospital in patients with ischemic stroke has no benefit.

Let me move to prevention of migraine with monoclonal antibodies. We have now monoclonal antibodies like erenumab, which acts at the CGRP receptor, or other ones like fremanezumab, galcanezumab, and eptinezumab.

A study group in the Netherlands investigated whether treatment with monoclonal antibodies has an impact on blood pressure. They prospectively followed 109 patients on erenumab 140 mg and 87 patients on fremanezumab 225 mg over a period of 12 months.

In the erenumab group, there was a significant increase in blood pressure by about 5 mm Hg, which I did not see in the fremanezumab group or in control participants who were not treated with monoclonal antibodies. The good news is that only three patients on erenumab needed antihypertensive treatment. The bottom line is that there is a need to measure blood pressure in patients undergoing migraine prevention with monoclonal antibodies.

Another study in Denmark is very important because they investigated whether erenumab 140 mg works in trigeminal neuralgia. They randomized 80 patients to receive erenumab 140 mg or placebo, and there was no benefit of erenumab. This shows that, obviously, release of CGRP plays no role in trigeminal neuralgia.

The last study investigated intravenous immunoglobulins 2 g/kg body weight in 95 patients with dermatomyositis. They were treated every 4 weeks for 16 weeks. There is no surprise that the immunoglobulins improved the condition in 80% of the patients compared with 44% on placebo. The caveat here is that immunoglobulins can have side effects, and six patients in the active treatment group had a thromboembolic event.

Ladies and gentlemen, I've shared some interesting studies published in October 2022. The most exciting and relevant for clinical practice is that thrombectomy is highly effective in patients with basilar thrombosis through a time window of 24 hours.

I am Christoph Diener from the University of Duisburg-Essen. Thank you very much for listening and watching.

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