Welcome to the WSC 2021 Interactive Program

Background and Aims

ACST-2 is an international randomised trial comparing carotid endarterctomy (CEA) with carotid stenting (CAS), randomising patients for whom a carotid procedure is considered definitely necessary, both procedures seem anatomically feasible, and there is substantial uncertainty as to which of the two would be better for such individuals.

Primary objectives: compare 1) peri-procedural risks (myocardial infarction [MI], stroke and death within the first month after the allocated CEA or CAS), and 2) long-term (up to 5 or more years) prevention of stroke, particularly disabling or fatal stroke, in subsequent years.

Methods

Logrank analyses will compare stroke rates between those allocated CEA and those allocated CAS in specific time periods, with the main trial analyses on an ‘intention-to-treat’ basis. By the end of the recruitment period, there will be about 5 years follow-up, with analyses of the early effects of CEA vs CAS on the annual incidence of various types of stroke, disabling stroke and fatal stroke. Continued follow-up will allow more powerful analyses of these longer-term outcomes.

Results

By December 2020, 3638 patients from`133 centres in 33 countries were randomised; 2554 (70.2% men) and 1084 women with a median ipsilateral carotid stenosis of 80% (range 60-99%). 1290 patients (35.5%) had coronary artery disease, 224 (6.1%) had atrial fibrillation, 1088(29.9%) were diabetic and 91%, 8.4% 88.3% and 85.6% were taking antiplatelet, anticoagulant, BP-lowering and lipid-lowering treatments. Follow-up was 4.85(IQR2.41-7.76) years.

Results will be presented at WSC.

Conclusions

ACST-2 is the largest trial comparing CEA and CAS; these results will provide future guidance to clinicians worldwide.

Background and Aims

This study aimed to disentangle temporal course benefit and risk of ticagrelor-aspirin treatment in patients with a minor ischemic stroke or transient ischemic attack (TIA) who carried CYP2C19 loss-of-function (LOF) alleles in the CHANCE-2 (ticagrelor or Clopidogrel with aspirin in High- risk patients with Acute Non- disabling Cerebrovascular Events II) trial.

Methods

The efficacy outcome was major ischemic event defined as the composite of ischemic stroke or non-hemorrhagic death. The safety outcome included moderate-to-severe bleeding and any bleeding. Time course analyses of ischemic benefit and hemorrhagic risk were performed at different timepoints by week and time periods before and after 21 days.

Results

A total of 43, 3, 4 and 1 of 54 fewer major ischemic events and a total of 28, 38, 10 and 7 of 90 excess bleedings occurred in the ticagrelor-aspirin group at the first, second, third and fourth week, respectively. Whereas, the risk of moderate-to-severe bleeding was consistent low in the ticagrelor-aspirin group. The reduction of major ischemic events by ticagrelor-aspirin predominately occurred in the first week (absolute risk reduction 1.34%, 95% CI 0.29% to 2.39%) and attenuated but remained in the next three weeks. The absolute increase in bleeding seen in the first week (0.87%) remained in the next three weeks.

Conclusions

Among patients with minor ischemic stroke or TIA who were carriers of CYP2C19 LOF alleles, the benefit of ticagrelor-aspirin was present from the first week and persisted throughout 21-day period of dual antiplatelet therapy, supporting 21 days treatment with ticagrelor and aspirin in these patients.

Background and Aims

People who suffer an ischaemic stroke are at risk of recurrent vascular events. We assessed whether allopurinol, a xanthine oxidase inhibitor, reduced white matter hyperintensity progression (WMH) and systolic blood pressure (SBP) following ischaemic stroke.

Methods

In this multicenter, prospective, randomised, blinded, controlled trial we assigned participants within 30-days of ischaemic stroke or TIA to receive allopurinol 300mg twice daily or placebo for 104 weeks (registration number NCT02122718). All participants had brain MRI performed at baseline and week 104 and ambulatory blood pressure monitoring at baseline, week 4 and week 104. The primary outcome was the WMH Rotterdam Progression Score (RPS). Secondary outcomes included change in day-time SBP. Analyses were by intention to treat.

Results

We randomised 464 participants (232 per group). A total of 372 (189 with placebo and 183 with allopurinol) attended for week 104 MRI and were included in analysis of the primary outcome. The RPS was 1.33 (SD 1.79) with allopurinol and 1.51 (SD 1.89) with placebo, between group difference -0.17, 95% CI -0.52 to 0.17, p=0.33. The change in day-time SBP at week 4 was -2.3 mmHg (SD 12.92) with allopurinol and 0.8 (SD 10.74) with placebo, between group difference -3.33, 95% CI -5.55 to -1.11, p=0.0034. At week 104, the between group difference in day-time SBP was -2.95 mmHg, 95% CI -6.00 to 0.10, p=0.058.

Conclusions

Allopurinol use did not reduce WMH progression in people with recent ischaemic stroke or TIA but did lower SBP. Further research should explore whether this blood pressure change is clinically important.

Background and Aims

Whether treatment with intravenous alteplase prior to mechanical thrombectomy (MT) in acute ischaemic stroke (AIS) patients with large vessel occlusion is beneficial remains a matter of debate. We aimed to determine whether patients experiencing AIS due to occlusion of the intracranial internal carotid artery or the M1 segment of the middle cerebral artery who are referred to an endovascular stroke centre and who are candidates for intravenous alteplase will have non-inferior functional outcome at 90 days when treated with MT alone (direct MT) with stent retrievers compared to patients treated with combined intravenous thrombolysis (IVT) with alteplase plus MT (IVT+MT) with stent retrievers.

Methods

We conducted prospective, randomized (1:1), open-label, blinded-endpoint (PROBE) trial at 44 academic tertiary care centers in Europe and North America, utilizing an adaptive statistical design. Primary efficacy, defined as functional independence (mRS 0-2) at 90 days, was assessed for non-inferiority of the experimental arm to the standard arm using a one-sided type 1-error rate of 5% with a pre-specified non-inferiority margin of 12%. Secondary objectives were to study causes of mortality, dependency and quality of life.

Results

A total of 410 patients were randomly assigned either to the direct MT group (xy patients) or to the intravenous alteplase plus MT group (xy patients). Direct MT was …..

Conclusions

Among patients with ischaemic stroke due to proximal anterior vessel occlusion within 4.5 hours from onset, direct mechanical thrombectomy compared with intravenous alteplase plus mechanical thrombectomy was…..