What a great meeting! As usual, ESOC was the perfect opportunity to meet colleagues from all around the world and listen to the top experts in the field of stroke. Additionally, we received some great news from the positive RCTs such as ELAN, ENRICH and INTERACT3 (Press Release). The exclamations of Prof. Werner Hacke (“Finally! Waited more than 20 years for a positive RCT in ICH!”) and Prof. Valeria Caso (“So good news to our ICH patients! After these results I will leave Munich so happy!”) perfectly summarized the enthusiasm of all attendees.

However, many other studies deserved our attention.

During the poster walk, I attempted to summarize some of the many interesting posters displayed on Thursday and Friday.

Among the posters on ACUTE MANAGEMENT, I would like to highlight the poster on EMERGENT CAROTID STENTING FOR ACUTE ISCHEMIC STROKE DUE TO TANDEM OCCLUSION: A META-ANALYSIS by Romoli et al. aiming to assess the safety and efficacy of emergent carotid stenting for tandem occlusions. After pooling the results from 46 studies, the authors found that emergent carotid stenting was associated with better functional outcomes and higher chance of successful recanalization, despite carrying an increased risk of sICH. These results provide important insights into the best approach for patients with tandem occlusion receiving EVT. This study was recently published on the Journal of NeuroInterventional Surgery (DOI: 10.1136/neurintsurg-2022-018683). Nevertheless, questions about the optimal timing and type of antithrombotic therapy after stenting still remain to be answered.

On the ACUTE MANAGEMENT topic, the individual patient data meta-analysis presented by Joundi et al. on the ASSOCIATION BETWEEN BLOOD PRESSURE VARIABILITY AND OUTCOMES AFTER ENDOVASCULAR THROMBECTOMY FOR ACUTE ISCHEMIC STROKE also caught my attention. By including data from 5 studies (n=3309 patients), the authors found an association between higher blood pressure variability (BPV) within the first 24h after EVT and poorer 3-month outcomes. The authors suggest that early BPV may become a novel target to improve AIS patients’ outcome after EVT. There results have made me reflect on the class of intravenous antihypertensive drugs commonly used within the first hours after EVT. If equally effective in reducing blood pressure, should we prioritize drug classes shown to have a positive impact on BPV?

On IMAGING, the work by Alhabi et al entitled INCIDENCE AND IMPACT OF THROMBUS MIGRATION BEFORE ENDOVASCULAR TREATMENT: RESULTS FROM THE ACT TRIAL showed that Tenecteplase treatment (0.25mg/kg) before EVT results in higher rates of distal thrombus migration in comparison with Alteplase (0.9mg/kg). Additionally, distal thrombus migration was associated with better functional outcomes, regardless of the thrombolytic agent used. This data, reinforces the benefits of Tenecteplase and also emphasizes the role of bridging in patients with LVO.

Focusing on PROGNOSIS AND OUTCOME and outside the scope of acute stroke treatment, I found the study by Richter et al, A PROSPECTIVE SINGLE-CENTER OBSERVATIONAL STUDY ON RAPHE HYPOECHOGENICITY AS A PREDICTOR OF POST-STROKE DEPRESSION very innovative. In AIS patients the investigators performed transcranial sonography to assess the echogenicity of the brainstem raphe. Among 99 participants, approximately one-quarter had brainstem raphe hypoechogenicity which was shown to be independently associated with the diagnosis of post-stroke depression at three months. Post-stroke depression affects a large proportion of our patients and has an enormous impact in their quality of life. Anticipating which patients are more likely to develop this complication may help in the development of individualized approaches targeted for earlier diagnosis, treatment, or even prevention.

And that’s it!

Looking forward to the ESOC 2024 in Basel! Join us in celebrating the 10^th ESOC anniversary!

It was fun and exciting to meet up again with colleagues from all around the world for this year’s ESOC 2023 in Munich, Germany. We enjoyed amazing talks and high-quality posters in all different fields of stroke research. I got the opportunity to share some of the posters that caught my eye during the session on Thursday (Conference Day 2).

Among the posters on RISK FACTORS AND PREVENTION, I would like to highlight COMBINED INFLAMMATORY BIOMARKERS PREDICT RECURRENT IPSILATERAL ISCHAEMIC STROKE IN PATIENTS WITH CAROTID ATHEROSCLEROSIS by Sarah Gorey et al. from Ireland. They hypothesized that a combination of elevated hsCRP and IL-6 levels would be associated with recurrent ipsilateral ischaemic stroke in individuals who suffered a stroke/TIA with concomitant ipsilateral internal carotid stenosis. Over a median 4-year follow-up, they showed that in 267 patients from three prospective cohort studies, a combination of high hsCRP and IL-6 levels predicted recurrent ischemic stroke at a high sensitivity and specificity while solely elevated IL-6 levels did not. Of note, patients with combined high inflammatory biomarker levels (hsCRP ≥ 2 mg/l and IL-6 ≥ 7 pg/ml) showed a recurrence rate of 11% for ipsilateral ischemic stroke. In this cohort, roughly 56% of patients received carotid revascularization and 50% had a ³70% carotid stenosis. This concept could guide patient-tailored treatment decisions (surgical/interventional and anti-inflammatory) in the future.

Marie H Kristiansen et al. from Denmark contributed the poster THE JAK2V617F MUTATION IS COMMON IN ISCHEMIC STROKE. They analyzed the prevalence of JAK2V617F mutation in 591 consecutive patients with ischemic stroke and TIA. 3% of the general population acquire the mutation, however, whether the mutation is a risk factor for thrombosis in the absence of myeloproliferative neoplasms is unknown. An increased prevalence of the JAK2V617F mutation in a stroke population would suggest this link. The study revealed that 1 in 10 stroke/TIA patients carry the JAK2V617F mutation, leading to an OR of 2.4 compared to matched controls, whereupon the prevalence was a lot higher in stroke rather than TIA and only 8 out of 63 patients were diagnosed with MPN. This research could contribute to a better understanding of possible pathophysiological links between arterial and venous thrombosis in a subgroup of patients. As a matter of fact, future trials could possibly target JAK2V617F positive stroke patients for anticoagulation or JAK2 inhibitors in secondary prevention, perhaps in ESUS patients.

From the topic SERVICE ORGANISATION, I would like to highlight a poster for all morning persons and early birds out there, like me. The poster TIME OF DAY OF ENDOVASCULAR TREATMENT MODULATES CLINICAL OUTCOME AFTER STROKE by Vanessa Granja Burbano and colleagues tackled the question if the time of day of EVT is associated with clinical outcome and a benefit of successful recanalization. Patients from the German Stroke Registry were analyzed in 6-hour intervals starting at 5am regarding times of groin-puncture. In analyses adjusted for age, IVT-administration, NIHSS and time to treatment, morning EVT was associated with lower mRS scores and higher probability of functional independence at 90 days after stroke. Also, the association of successful recanalization and functional independence after 90 days was stronger in morning EVT compared to evening EVT. Finally, the benefit from successful recanalization persisted until 24 hours after onset for morning treated patients while it was lost after roughly 12 hours for evening-treated patients. This study supports the hypothesis that time of day effects (i.e. intrinsic circadian biology) influence stroke progression and outcomes as well as treatment benefits rather than EVT-procedural metrics. Nevertheless, neurologists and interventionalists will always be keen to bring their A-game, regardless of the time of day J

Among the LATE BREAKING ABSTRACTS, I want to emphasize results from the APRIL study. Maria Hernandez Perez et al. aimed to assess safety and efficacy of a novel TLR4-binding DNA aptamer (ApTOLL) in combination with EVT in acute ischemic stroke patients. In this phase Ib/IIa trial, anterior LVO moderate to severe stroke patients with an ASPECTS score of 6-10 were randomized to EVT±IVT plus ApTOLL in different dosages compared to EVT±IVT alone to assess differences in DWI lesion volume and grade of cerebral edema. The study demonstrated a significant reduction in DWI lesion volume and cerebral edema after 72 hours in the group receiving ApTOLL 0.2 mg/kg compared to placebo. Moreover, in patients receiving ApTOLL, the DWI lesion volume was significantly lower in patients with lower mTICI scores compared to placebo and also, the extent of white matter damage was lower. The effects seem to be dose-dependent as the other trial arm using a dosage of ApTOLL 0.05 mg/kg showed no benefits. Concerning these results, ApTOLL seems like a promising neuroprotective agent in combination with established reperfusion therapies and could be especially relevant for patients with futile recanalization and those with higher infarct core size at arrival. Also, ApTOLL seems to especially protect the white matter. We are looking forward to upcoming phase III trials and it will be interesting to see if there might be a benefit in patients who receive IVT alone.

I hope my brief summaries inspire you and that you keep your fingers crossed for the final publications of the studies.

It was exceptional to see so many Ukrainian colleagues participating in ESOC this year. We must encourage our Ukrainian friends to keep up the good work in the stroke network and avail them to restore stroke care in their country. Nevertheless, we must not forget all other countries affected by conflicts around the world. Our uttermost shared goal is to reduce the global burden of stroke and we can only do this together.

“Mankind must put an end to war before war puts an end to mankind.” – John F. Kennedy

Herzlich Willkommen zu ESOC 2023 in München!

What a wonderful first day of ESOC! A jam-packed day including a fascinating plenary and multiple scientific sessions, not to mention catching up with friends and colleagues from around the world. I have really enjoyed reading and viewing the posters today. Here are some that caught my eye…

Kicking off with pre-hospital stroke care, van de Wijdeven et al from Rotterdam examined prehospital stroke scales to identify LVO in the anterior circulation in a prospective cohort of 288 patients, and concluded that all pre-hospital stroke scales performed well for LVOs, but G-FAST (gaze-deviation in addition to FAST) was the only score to also predict M2 occlusions.

Barone et al, from Bologna, Italy looked for predictors of recurrence after TIA in the short and long term, and report that recurrent TIA is the main predictor for short term recurrent stroke, but hypertension is more important for long-term recurrent stroke, in a study of over 1000 patients attending TIA clinics in Bologna. These authors remind us of the importance of good management of risk factors like hypertension for secondary prevention. Additionally, Murthy et al from Weill Cornell, New York report low adherence with secondary prevention strategies amoung patients after ICH and suggest more study is required to establish an evidence base for appropriate cardiovascular preventive treatments after ICH. Also in the ICH section, Holloway et al report data from SSNAP detailing that in hospital mortality of ICH has fallen in the UK over the last decade but that outcomes of ICH still lag behind that of ischaemic stroke.

In the Neurointervention section, I was interested to see Enriquez et al’s poster externally validating a clinical prediction score for EVT in older adults: these authors report that the tool, comprising age, admission NIHSS, ASPECT and pre-stroke mRS could predict poor outcome after EVT, with a c-statistic of 0.75 (0.69-0.82). I will be watching out to see if this easily calculated tool can make the translation to clinical practice. Nearby, also in the Neurointervenion section, Madden et al present the Northern Irish experience with endovascular stenting of tandem occlusions- intrepretability of this report is limited by low number of cases and controls, but of note, early stent re-occlusion rates were high.

In Epidemiology and Risk Factors, Data from the German Stroke Registry authored by Meissner, report patient with diabetes mellitus undergoing EVT for LVO have worse outcomes compared to patients without diabetes even after controlling for comorbidities and stroke severity.

Neilson et al, from Glasgow report an interesting association between sensory-neural hearing loss and stroke of small vessel disease aetiology in a retrospective case-control study of 631 patients. These authors hypothesise that sensory-neural hearing loss may have an ischaemic basis.

I was interested to read about the DOAC dipstick point of care test described by Ziegler et al, from Mannheim: this technology could potentially be used to test urine samples from acute stroke patients for presence of DOAC metabolite to confirm presence or absence of DOAC in the system to aid acute decision making for thrombolysis, when accurate drug history is not possible. So far only 21 patients have been included in this study but keep an eye out for this interesting concept in future!

A number of groups reporting on inequalities and biases in stroke treatments and in stroke research caught my eye: Najm and colleagues from Calgary, Canada describe in their poster how patients who present with acute stroke of unknown time of onset are less likely to receive acute reperfusion therapies, but that these patients also older, more likely to be female, and have more severe strokes. We need to be careful in our selection of patients for acute stroke treatments not to over-exclude these patients from potentially very beneficial interventions. Similarly, Hahn and colleagues from Mainz describe that patients in registry data for whom data is missing is not random: these patients are also more likely to be more disabled,  with higher mRS both at baseline and after stroke treatment.

I was also struck by the stark data presented by Ouyang et al from a prospective population study in Ulaanbaatar, Mongolia, detailing the comparatively young age on onset of first stroke (59+/-13 years), and delay to CT scanning (10 hours) as well as low thrombolysis rates (0.9%).  Global inequalities in Stroke care and access to acute diagnostics and treatment remains a challenge.

Under the theme of Atherosclerosis, Dubenko et al from Kharkiv, Ukraine studied patients with carotid atherosclerosis with  acute stroke, remote stroke, without stroke and controls (no carotid stenosis) reported levels of E-selectin and Lp-PLA2 differed between groups, being highest in symptomatic carotid stenosis undergoing CEA after stroke. From Turkey, Arsava and colleague report an association between bone mineral density and calcification in intracranial atherosclerosis.

In the imaging section, Toeback and colleagues from Basel elegantly described how leptomeningeal collaterals are associated with large artery atherosclerosis, but these collaterals were not as prevalent in cardioembolic stroke, amoung a cohort of 147 patients.

Environmental exposures to vascular disease is topical and Clancy et al’s work on exposure to hazardous substances is worth a read: this group report a increased risk of vascular dementia with pesticides and fertilisers, but no association between small vessel disease and contact sport. They caution that larger epidemiological studies are required to investigate these associations further. Another topical theme is sleep, and Hyuk Sung Kwon and colleagues from Guri in South Korea presented their e-poster on the association between sleep duration and dissatisfaction with sleep quality and ischameic stroke in young patients (Poster ID P1147)

I was impressed by Alsubaie et al’s work, from Jeddah in Saudi Arabia, where they have improved their door to needle time for thrombolysis by implementing MSD guidelines and Code Drill simulation training (poster ID P914).  Similar simulation training reported by  Irvine et al in Belfast Northern Ireland, (E-Poster ID 1440) resulted in a 28 minute reduction in door-to-needle time!

In the Rehab and Recovery section, Aked et al from Lund, Sweden, report neuropsychiatric symptoms remain common 3-4 years after stroke with lots of over-lap existing between depression and fatigue highlighting that these outcomes which are very important to stroke patients are difficult to treat and require further study.  On a similar theme, Sanak et al from Czech Republic reported that in their cohort of 145 patients with excellent functional outcomes (measured by mRS, 0) stroke patients still reported poorer quality of life scores at 3 months, again highlighting the need for patient-centred outcome measures in stroke research. Finally, Kudiersky et al from Sheffield describe the feasibility and acceptability of aerobic training for stroke patients in the stroke unit, with knock on modest benefits in independence at 3 months. Patients described the intervention as giving them a “sense of achievement”, making them feel “mentally sharper”, feeling “knackered” after it but also that it was “something to look forward to” – and to be honest I can totally identify with them. That is how I feel about ESOC day 1 today, – physically fatigued, hopefully mentally sharper and looking forward to Day 2 tomorrow!

Bis Bald!