Welcome to the ESOC 2021 Virtual Conference Calendar

Background And Aims

Current evidences support short-term DAPT in minor ischemic stroke or TIA based on studies performed in patients with a broad range of non-cardioembolic stroke mechanisms. However, the efficacy and safety of DAPT use in ischemic stroke patients with large artery atherosclerosis are still uncertain. We undertook a systemic search and formal meta-analysis to compare DAPT vs mono-antiplatelet therapy in patients with etiology presumed to be symptomatic LAA.

Methods

We conducted a systemic online search for completed randomized controlled trials that 1) compared DAPT vs MAPT in patients with acute ischemic stroke or TIA, 2) were confined to or had available subgroup data regarding population with symptomatic extra- or intracranial artery stenosis. Study-level meta-analysis was performed for outcomes including ischemic stroke recurrence, ICH, and major bleeding with Mantel-Haenszel method and random effect models, and was described as risk difference and 95% CI.

Results

Eight trials including 4,294 patients were pooled. Comparing to MAPT, DAPT significantly reduced IS recurrence (6.2% vs 9.7%). Across all agents, out of 100 treated patients, 3 fewer had recurrent ischemic stroke with DAPT. However, there was evidence of agent heterogeneity (p=0.03), with clopidogrel added to aspirin and ticagrelor added to aspirin showing benefit but not cilostazol. The safety endpoints including ICH and major bleeding did not differ significantly.

Conclusions

In patients with symptomatic large artery extracranial or intracranial atherosclerosis, DAPT was superior to MAPT in preventing IS recurrence without increasing bleeding risks. The optimal DAPT regimens and duration of treatment in this population need to be clarified in further studies.

Trial Registration Number

Not applicable

Background And Aims

Contemporary clinical practice guidelines for the management of acute ischemic stroke (AIS) regard a history of intracerebral haemorrhage (ICH) as a contraindication for thrombolysis. However, recent retrospective cohort studies reporting the off-label use of intravenous recombinant tissue plasminogen activator (IV-tPA) in patients with previous ICH suggest that they may in fact benefit from IV-tPA. This study aims to evaluate whether IV-tPA use in these patients is associated with poorer safety and efficacy outcomes.

Methods

For this systematic review and meta-analysis, we searched Embase, PubMed and Cochrane Library from inception to 9 April 2021. We included relevant full-texts that reported on at least one of the following outcomes: symptomatic ICH (sICH), 3-month modified Rankin scale (mRS) score and 3-month mortality.

Results

The systematic review included 7 retrospective cohort studies comprising 5,760 AIS patients who had received IV-tPA, of which 134 had previous ICH. The outcomes of sICH (OR: 1.57, 95% CI: 0.78-3.15, p=0.21) and excellent functional outcome as measured by a 3-month mRS score of 0-1 (OR: 0.78, 95% CI: 0.37-1.65, p=0.78) were similar in patients with and without previous ICH. There was a trend towards higher 3-month mortality in patients with previous ICH (OR: 1.69, 95% CI: 0.98-2.91, p=0.06), although this did not reach statistical significance (Figure).

Conclusions

In this study, we report that the use of IV-tPA in AIS patients with previous ICH is not associated with an increased risk of sICH or disability at 3 months. Further randomised controlled trials are urgently needed to establish its safety and efficacy.

Background And Aims

Previous studies showed conflicting results in the benefits of pretreatment with IVT before endovascular treatment (EVT) for acute ischemic stroke (AIS) patients with large vessel occlusions (LVOs). The aim of this study was to investigate the clinical efficacy and safety of EVT alone versus bridging therapy (BT) in AIS with LVOs.

Methods

A systematic review and meta-analysis of all available studies evaluating clinical outcomes between BT and EVT alone were conducted by electronic searching the NCBI/NLM PubMed and Web of Science database from inception to October 20, 2020. Primary outcomes focus on 90 days good outcome and mortality. Secondary outcomes included successful reperfusion, and sICH. The random-effect model was applied if P＜0.10 for Cochran’s Q test or I²＞50% for Higgins I² statistics, otherwise the fixed-effect model was performed.

Results

A total of 93 studies enrolling 45,190 patients were admitted in present analysis. In both unadjusted and adjusted analysis, BT was associated with a higher likelihood of 90 days good outcome (crude odds ratio [cOR] 1.361, 95%CI 1.234-1.502 and adjusted OR[aOR] 1.369, 95%CI 1.217-1.540), successful reperfusion (cOR 1.271, 95%CI 1.149-1.406 and aOR 1.267, 95%CI 1.095-1.465) and lower odds of 90 days mortality (cOR 0.619, 95%CI 0.560-0.684 and aOR 0.718, 95%CI 0.594-0.868) compared with EVT alone. The two groups did not differ in sICH (cOR 1.062, 95%CI 0.915-1.232 and aOR 1.20, 95%CI 0.95-1.47) after evaluating by sensitivity analyses and adjusting for publication bias.

Conclusions

BT benefited more in clinical outcome without increasing the risk of safety compared with EVT alone in AIS patients with LVOs.

Trial Registration Number

Not applicable

Background And Aims

Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) often receive delayed or no aneurysm treatment. Recent studies suggest that functional outcome following early aneurysm treatment for poor-grade aSAH patients may be better than assumed in the past. We aimed to investigate pre-interventional predictors of functional outcome in poor-grade aSAH patients to aid in individualized decision-making.

Methods

We conducted a systematic review and meta-analysis. We included studies investigating the association of pre-interventional predictors with functional outcome in adult patients with confirmed poor-grade aSAH, defined as World Federation of Neurological Surgeons (WFNS) grade or Hunt and Hess (H-H) grade IV-V. Studies had to use multivariable regression analyses to estimate adjusted predictor effects. We calculated pooled adjusted odds ratios (aOR) and 95% confidence intervals (CI) with a random effects model.

Results

We included 28 studies with 3372 patients. The likelihood of favorable outcome increased significantly with younger age (aOR 1.1, 95% CI 1.0-1.1, per year), WFNS grade or H-H grade IV as opposed to V (aOR 2.9, 95% CI 1.9-4.3), decreasing modified Fisher grade (aOR 2.5, 95% CI 2.1-3.0, per grade), intact pupillary reflex (aOR 2.9, 95% CI 1.6-5.1), presence of clinical improvement before aneurysm treatment (aOR 3.3, 95% CI 2.0-5.3), and absence of intracerebral hematoma on admission imaging (aOR 2.3, 95% CI 1.3-4.1).

Conclusions

We identified pre-interventional predictors that help discriminate between poor-grade aSAH patients with better and with worse prognosis. These predictors need evaluation in prospective studies and can aid in selecting patients for aneurysm treatment.

Trial Registration Number

Not applicable

Background And Aims

The effect of the COVID pandemic on stroke networks performance are unclear, particularly with consideration of drip & ship versus mothership models. We systematically reviewed and meta-analyzed variations in stroke admissions, rate and timing of reperfusion treatments during the COVID pandemic versus the pre-pandemic timeframe.

Methods

The systematic review followed registered protocol (PROSPERO-CRD42020211535), PRISMA and MOOSE guidelines. We searched MEDLINE, EMBASE and Cochrane CENTRAL until 9/10/2020, for studies reporting variations in ischemic stroke admissions, treatment rates and timing in COVID vs control-period. Primary outcome was the weekly admission incidence rate ratio (IRR=admissions during COVID-period/admissions during control-period). Secondary outcomes were (i) changes in rate of patients undergoing reperfusion treatment and (ii) time metrics for pre- and in-hospital phase.

Results

Twenty-nine studies were included in qualitative synthesis, with 212960 patients observed for 532 cumulative weeks (325 control-period, 207 COVID-period). COVID-period was associated with a significant reduction in stroke admission rates (IRR=0.69, 95%CI, 0.61-0.79) and a higher relative presentation with large vessel occlusion stroke (RR=1.62, 95%CI, 1.24-2.12). Proportions of patients treated with intravenous thrombolysis remained unchanged, while endovascular treatment increased (RR=1.14, 95%CI, 1.02-1.28). Onset-to-door time was longer for drip&ship compared to mothership model (+32 minutes vs -12 minutes, p_{meta-regression}=.03).

Conclusions

Despite a 35% drop in stroke admissions during the pandemic, proportions of patients receiving reperfusion and time-metrics were not inferior to control-period, justifying allocation of resources to keep stroke networks up and running.

Trial Registration Number

Not applicable

Background And Aims

Perception is the ability to interpret and integrate information from the senses (hearing, smell, somatosensory, tactile, taste and vision). Up to 75% of stroke survivors have perceptual disorders, with limited evidence to inform clinical care. We aimed to describe all research on interventions for perceptual disorders in stroke, identifying evidence gaps.

Methods

A scoping review (protocol CRD42019160270) with extensive stakeholder input. We searched 14 electronic databases and grey literature, and tracked citations (no language/date limitations). Pairs of authors screened abstracts and full texts independently. Extraction covered study, participant, intervention (using TIDieR guidelines) and outcome data. This was synthesised narratively, then mapped.

Results

82,459 titles were screened, with 83 included studies, including 32 case reports (38.6%) and 24 RCTs (29%). Sample sizes were small (Mean 11.5, SD=14.3), most included only adults (94%) with females a minority in 74% of studies. Primarily visual (43%) and somatosensory deficits (35%) were addressed.

Ninety-six interventions were described. These included pharmacological and brain stimulation approaches, with the majority using rehabiliation approaches (84.4%). These typically tried to restore the lost function, were provided in hospital, health care professional led (not technology-based), for under one month. Key descriptors on the ‘who’ and ‘how’ of delivery were often absent.

The most frequent outcome reported was perception (74.7%).

Conclusions

We have comprehensively mapped interventions for perceptual disorders post stroke. The limitations in evidence are clear, with specific gaps relating to childhood stroke and auditory, tactile, taste and smell disorders and the lack of assessment of daily life impact.

Trial Registration Number

Not applicable

Background And Aims

To compare the diagnostic yield of echocardiography and cardiovascular MRI (CMR) to detect structural sources of embolism, in patients with ischemic stroke with a secondary analysis of non-stroke populations.

Methods

We searched MEDLINE/Embase (from 01.01.2000 to 31.01.2021) for studies including CMR to assess prespecified sources of embolism. Comparison included transthoracic and/or transesophageal echocardiography. Two authors independently screened studies, extracted data and assessed bias using the QUADAS-2 tool. Estimates of diagnostic yield were reported and pooled.

Results

Twenty-seven studies with 2525 patients were included in a study-level analysis. Most studies had moderate to high risk of bias. Persistent foramen ovale, complex aortic plaques, left ventricular and left atrial thrombus were the most common pathologies. There was no difference in the yield of left ventricular thrombus detection between both modalities for stroke populations (4 studies), but an increased yield of CMR in non-stroke populations (28.1%vs16.0%,P<0.001, 10 studies). The diagnostic yield in stroke patients for detection of persistent foramen ovale was lower in CMR compared to transoesophageal echocardiography (29.3%vs53.7%,P<0.001, 5 studies). For both echocardiography and CMR the clinical impact of the management consequences derived from many of the diagnostic findings remained undetermined in the identified studies.

Conclusions

Echocardiography and CMR seem to have similar diagnostic yield for most cardioaortic sources of embolism except persistent foramen ovale and left ventricular thrombus. Randomized controlled diagnostic trials are necessary to understand the impact on the management and potential clinical benefits of the assessment of structural cardioaortic stroke sources.

Trial Registration Number

PROSPERO CRD42020158787

Background And Aims

The available evidence supports an association between atrial high-rate episodes (AHRE) burden and thromboembolic risk, but the necessary extent and duration of AHRE to increase the risk of thromboembolic events remains to be defined. The aim of this systematic review and meta-analysis was to identify the minimum AHRE burden associated with increased thromboembolic risk by deriving pooled estimates of the thromboembolic risk associated with various thresholds of AHRE burden.

Methods

We searched PubMed and Scopus until 01/09/2020 for literature reporting AHRE duration and thromboembolic risk in patients with implantable electronic devices. The outcome assessed was stroke or systemic embolism. Risk estimates in each study were reported as hazard ratio (HR) or relative risk (RR) alongside 95% confidence intervals (CI). We employed the Paule-Mantel estimator and heterogeneity was calculated with I² index.

Results

Among 27 studies including 61,919 patients, 23 studies reported rates according to the duration of the longest AHRE and 4 studies according to the cumulative day-level AHRE duration. In patients with cardiac implantable devices due to heart failure or severe dysrhythmias, AHREs lasting >30 seconds significantly increased the risk of stroke or systemic embolism (HR:4.41, 95%CI:2.32–8.39, I²:5.5%), which remained consistent for the thresholds of 5 minutes, 6 and 24 hours. Patients with previous stroke or TIA and AHREs lasting >2 minutes had a marginally increased risk of recurrent stroke or TIA.

Conclusions

This systematic review and meta-analysis suggests that the AHRE threshold of >30 seconds is associated with increased risk of stroke or systemic embolism.