Welcome to the WSC 2021 Interactive Program

Background and Aims

In patients with acute mild-moderate ischemic stroke or high-risk transient ischemic attack (TIA) in the THALES trial, combination of ticagrelor and aspirin for 30 days reduced stroke or death but increased risk of severe bleeding in comparison to aspirin alone. We investigated the short-term time course for benefit and risk of ticagrelor-aspirin in these patients.

Methods

We evaluated the cumulative incidence of efficacy and safety of treatment for varying timepoints during 30-day follow-up. The efficacy outcome was major ischemic events defined as a composite of ischemic stroke or non-hemorrhagic death. The safety outcome was major hemorrhage defined as a composite of intracranial hemorrhage or fatal bleedings. Net clinical impact was defined as the combination of these two endpoints.

Results

The reduction of major ischemic events by ticagrelor occurred in the first week (4.1% vs 5.3%; absolute risk reduction [ARR] 1.15%, 95% CI 0.36% to 1.94%), and remained throughout the 30-day treatment period. An increase of major hemorrhage was seen during the first week which remained relatively constant in the following weeks (absolute risk increase, approximately 0.3%). Cumulative analysis showed that the net clinical impact favored ticagrelor-aspirin in the first week (ARR 0.97%, 95% CI, 0.17% to 1.77%) and remained constant throughout the 30 days.

Conclusions

In patients with mild-moderate ischemic stroke or high-risk TIA, net clinical benefit was seen in the first week and remained during the entire 30-day study period. This analysis supports 30 days of dual antiplatelet therapy with ticagrelor and aspirin in these patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifiers: NCT03354429

Background and Aims

A sizable portion of patients with AIS, though treated within the recommended time windows for reperfusion therapies (RTs) still suffer from incomplete recanalization, or from recurring or downstream obstruction translating in unsatisfactory neurologic recovery. Glenzocimab, a novel antibody fragment targeting platelet GPVI, is tested to safely improve the efficacy of RTs.

Primary ACTIMIS study goal is to evaluate glenzocimab safety on top of RTs in AIS patients. The first study milestone was to complete the escalating dose phase and to choose a safe dose for the phase 2.

Methods

A multinational, randomized, double blind, placebo-controlled, single escalating dose study. All patients eligible to tPA (AIS onset ≤ 4.5hr), 50% of them also to thrombectomy received either placebo (n=12) or glenzocimab following a sequential escalating dose scheme, 125mg, 250mg, 500mg and 1000mg (n=12 per dose). The primary endpoint was the occurrence of symptomatic and non-symptomatic intracranial hemorrhages (ICHs), serious adverse events (SAEs), bleeding-related events (BREs) and deaths.

Results

Sixty patients were included. Of the 39 SAEs, 17 were ICHs, 1 symptomatic and 16 non-symptomatic ones. Of the 22 other SAEs, none was related to study drug, 17 recovered and 5 had a fatal outcome. Ten non-ICH BREs occurred, 2 of them were considered as SAEs. There was no dose-effect trend for any of the safety parameters.

Conclusions

Glenzocimab showed a favorable safety profile with an overall rate of 1.7% of symptomatic ICH, similar to that of i.v. thrombolysis in routine practice. The 1000mg dose was selected for phase 2.

Background and Aims

Mechanical Thrombectomy has been established as a highly cost-effective therapy for large vessel occlusion stroke (LVOs) since 2015. However, access to MT for eligible LVOs patients is limited due to informational & diagnostic, geographical and financial barriers. MT 2020+ is a global stroke campaign aimed at accelerating access to mechanical thrombectomy (MT) using public health interventions (PHI) through a regional committees (RCs) global network.

Methods

MT2020+ conducted an electronic survey in 22 RCs of different income levels in from November 2020-February 2021 with a questionnaire that included MT eligible patients, centers, operators, procedures and reimbursement. MT access was defined as the proportion of estimated MT eligible patients receiving MT. Linear regression models were used with countries classified by World Bank income classification.

Results

For high, upper middle and lower middle income countries, MT access was 15.75 %, 3 % and 0.06 %, MT Centers per million population were 0.95, 0.53 and 0.08 and MT operators per million population were 1.38, 0.81 and 0.10, respectively.

On univariate analysis, MT access rate was significantly associated with: income class ( p <0.011), reimbursement for MT (p <0.001) and % of GDP spent on healthcare (p = 0.001). On multivariate linear regression models, the factors that independently predict MT access were World Band income class (p <0.029) and reimbursement (p= 0.002).

Conclusions

There is a vast disparity in MT access across the globe. Country income and existence of reimbursement for MT in a given country were independently predictive of MT access for LVOs. These findings help prioritize PHI to accelerate MT access.

Background and Aims

Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is marker of early ischemia in acute ischemic stroke (AIS). Aims of this study were to measure rate of ASPECTS decay & its correlation with radiologic and clinical outcomes.

Methods

Data of patients with AIS were reviewed. AIS patients who underwent two Computed Tomography (CT) head scans within 6 hours of stroke onset included. Posterior circulation strokes excluded. Demographics, last known normal time, National Institute of Health Stroke Score (NIHSS) were noted. CT Head, CT Angiogram (CTA) cerebral angiograms were analyzed. Radiologic outcome included final infarct size. Clinical outcome included NIHSS at discharge. Good outcome was 50% or more improvement in NIHSS and poor outcome was death or < 50% improvement in NIHSS.

Results

107 patients screened. 85 underwent Mechanical Thrombectomy (MT), 46 included in the study. Good outcome in 25 (54.3%) and poor outcome in 21 (45.7%). Groups differed in hypertension (p=0.008) and dyslipidemia (p=0.033). Poor outcome group had greater ASPECTS decay (p=0.046), rate of ASPECTS decay (p=0.049), higher final infarct volume (p=0.000) and lower TICI-3 reperfusion (p=0.003). Final infarct volume was significantly associated with ASPECTS decay (Spearman’s coefficient 0.432, p=0.003) and ASPECTS decay rate (Spearman’s coefficient 0.465, p=0.001). ASPECTS decay Rate >1.6 was associated with poor clinical outcome (p=0.011).

Conclusions

Rapid rate of ASPECTS decay is associated with higher infarct volume and poor clinical outcome in anterior circulation acute ischemic stroke. It may be a tool for prognostication of patients undergoing MT after interfacility transfer.

Background and Aims

Patients with large vessel occlusion (LVO) stroke are often initially admitted to a primary stroke center (PSC) and subsequently transferred to a comprehensive stroke center (CSC) for endovascular thrombectomy (EVT). This interhospital transfer delays initiation of EVT. To identify potential workflow improvements, we analyzed pre- and interhospital time metrics for patients with LVO stroke who were transferred from a PSC for EVT.

Methods

We used data from the regional emergency medical services and our EVT registry. We included patients with LVO stroke who were transferred from three nearby PSCs for EVT (2014-2021). The time interval between first alarm and arrival at the CSC (call-to-CSC time) and other time metrics were calculated. We analyzed associations between various clinical and workflow-related factors and call-to-CSC time, using multivariable linear regression.

Results

We included 198 patients with LVO stroke. Mean age was 70 years (±14.9), median baseline NIHSS was 14 (IQR: 9-18), 136/198 (69%) were treated with intravenous thrombolysis, and 135/198 (68%) underwent EVT. Median call-to-CSC time was 162 minutes (IQR: 137-190). In 133/155 (86%) cases, the ambulance for transfer to the CSC was dispatched with the highest level of urgency. This was associated with shorter call-to-CSC time (adjusted β [95% CI]: -27.6 minutes [-51.2 to -3.9]). No clinical characteristics were associated with call-to-CSC time.

Conclusions

In patients transferred from a PSC for EVT, median call-to-CSC time was over 2.5 hours. The highest level of urgency for dispatch of ambulances for EVT transfers should be used, as this clearly decreases time to treatment.

Background and Aims

The COVID-19 pandemic increased the burden on emergency neurologists and posed big challenges to acute stroke treatment. The workflow for stroke treatment was suddenly changed at Hospital das Clinicas/Sao Paulo University, the largest hospital in South America, due to the pandemic. From March 30 until August,2020, he worflow for acute stroke treatment underwent major changes and the Neurology team had to adapt to the new setting. We hypothesized that door-to-imaging and door-to-needle times would increase from April-August, 2019 (Pre-COVID) to April-August, 2020 (Post-COVID).

Methods

Data were prospectively collected as part of the Hospital das Clínicas Stroke Database project. We analyzed age, gender, NIH stroke scale, door-to-imaging and door-to-needle times for patients treated with thrombolysis within the Pre-COVID and Post-COVID periods. The data were compared with unpaired t-tests or Mann-Whitney tests.

Results

The number of intravenous thrombolysis procedures decreased 27%, from 55 (Pre-COVID) to 40 (Post-COVID). There were no significant differences in age, gender, NIH Stroke Scales, door-to-imaging (Pre-COVID: median, 41 minutes; Post-COVID: median, 36 minutes; p=0.796) or door-to-needle times (Pre-COVID: median, 17 minutes; post-COVID: median, 15.5 minutes; p=0.704) between the Pre-COVID and Post-COVID periods.

Conclusions

Contrary to our hypothesis, no significant differences were observed in door-to-imaging or door-to-needle times. These results suggest that an experienced team can quickly adapt to changes in code stroke, and preserve quality of care during the pandemic.