Diener's Top Studies From the 2023 International Stroke Conference

Hans Christoph Diener, MD, PhD


March 14, 2023

This transcript has been edited for clarity.

Dear colleagues, I am Christoph Diener from the University Duisburg-Essen in Germany. I would like to report studies that were presented at the International Stroke Conference in the United States in February 2023.

Thrombectomy in Large Core Stroke

Let me start with two studies that were published in The New England Journal of Medicine. Stroke physicians were reluctant to use thrombectomy in people with severe strokes and a large core. Why? There was possibly no benefit and an increased risk of bleeding into the ischemic area. Two studies were presented that investigated this research question, and they were both terminated prematurely because thrombectomy was clearly superior to standard of care.

The first study, SELECT2, was an international study. It was a 24-hour time window of patients with severe stroke, ASPECTS score of 3 to 5, and infarct volume between 70 and 150 mL. There were 180 patients in each group. There was a clear benefit of thrombectomy in terms of modified Rankin scale. There was no difference in bleeding into the brain.

The second study, ANGEL-ASPECT, was performed in China. It included 456 people with large stroke, ASPECTS score of 3 to 5, and infarct volume of 70-100 mL. Although this study was terminated prematurely, there was a clear benefit of thrombectomy via modified Rankin scale shift and a small increase in bleeding.

This means that thrombectomy is effective in a large range of patients with ischemic strokes in a time window of 24 hours.

Tenecteplase vs Alteplase

The next study was a study that, again, compared tenecteplase and alteplase, the TRACE-2 study, published in The Lancet. I think you all know that tenecteplase is given as a bolus and alteplase is given as an initial bolus followed by a 1-hour infusion. This study, in China, randomized 1031 patients to either tenecteplase or alteplase. After 90 days, there was no difference in modified Rankin scale scores of 0 to 1, which is perfect or very good recovery. There was no difference in bleeding complications.

The problem is that, in many countries, tenecteplase is not approved for the treatment of stroke. In some countries, it's not even available at the moment due to problems with the production of the drug.

Direct Thrombin Inhibition

The next study looked at the possible benefit of a direct thrombin antagonist in people who receive thrombolysis with alteplase. Why? The recanalization rate of systemic thrombolysis is only about 40% and there is a risk for reocclusion of the vessel that was opened by thrombolysis. This study in China had 817 patients with ischemic stroke, in a time window 4.5 hours. There was no benefit of adding argatroban to alteplase in people with ischemic stroke. Fortunately, there was also no difference in bleeding complications. The benefit of an additional thrombin antagonist is obviously not there in people with ischemic stroke.

Statins for Stroke

There is another very important study, which was published in Stroke and was done in the Finnish health registries. They looked at patients who did not receive a statin after ischemic stroke. The study had almost 60,000 patients, and 27% of these patients did not receive a statin within 90 days after stroke.

After 1 year and after 12 years, the mortality was significantly higher in people who were not treated with the statin. The rate of recurrent ischemic stroke and cardiovascular events was clearly increased. This is a very strong argument to give statins after ischemic stroke not only in people who have high cholesterol but also in people who have normal cholesterol.

Cardiac CTA

The last study looked at 370 patients with acute ischemic stroke in the early phase and performed cardiac CT angiography. The investigators found a thrombus in the left atrial appendage or in the left ventricle in about 12% of these patients, and there was a higher detection rate in people with atrial fibrillation. Unfortunately, they did not publish the results of coronary angiography in these patients, and they did not perform a comparison with echocardiography. This means that we do not know the real benefit of early cardiac CT angiography in people with ischemic stroke.

Dear colleagues, ladies and gentlemen, these were interesting studies from the International Stroke Conference held in the United States in February 2023. Thank you very much for listening and watching.

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