The XVII European Stroke Conference: Nice, France 13-16th May 2008

Establishment of a European stroke network

In an international press conference, it was annonuced on the third day of the 17th European stroke conference (15th May 08) that the European Commission will invest more than 21 million euros to support central research into strokes for a period of five years. Dr. Manuel Hallen, head of health research in the EU, announced the establishment of a “European Stroke Network” (ESN) with 30 institutional partners from 14 European countries at the XVII. European Stroke Conference in Nice. The Network is based on two complementary projects in the field of vascular and cerebral research, namely EUSTROKE (The European Stroke Research Network) and ARISE (Affording Recovery In Stroke), which are coordinated by Prof. Stephen Meairs in Mannheim and Prof. Ulrich Dirnagl in Berlin.

In his presentation in the press conference Dr Hallen mentioned that pooling of competences and resources promotes cooperation and collaboration amongst European teams, helps to avoid duplication of effort and increases our chances to make discoveries that can benefit human health. Research like this will give hope to reduce and eventually prevent strokes and future suffering of patients and their families. EUSTROKE aims at improving our understanding of the neurovascular unit in the brain, which should lead to better prevention and treatment of stroke. ARISE will investigate a number of novel, promising therapies, including safer thrombolytics, therapies to induce repair of lost function, as well as a fast way to selectively cool the brain. Together, they combine expertise in clinical as well as pre-clinical stroke research. A common ESN Trial Platform will help obtain clinical proof of principle and translate research findings into effective therapy of stroke. For the first time relevant comorbidities, gender, age and long term outcomes will be investigated. Services of this advanced ESN Trial Platform, which will boast over 350 European stroke centers, will be offered to the European stroke research community.

Johann Jakob Wepfer Prize 2008 awarded to Marie-Germaine Bousser

The Johann Jakob Wepfer Prize worth 20,000 euros, which has been awarded by the ESC Committee since 2005 for outstanding achievements in clinical work and basic stroke research, was this year awarded to the French doctor and scientist Professor Marie-Germaine Bousser, Paris, for her work in the field of stroke research, especially its genetic and molecular bases in the early forms encountered in young people. The award is coupled with the request to present a paper from her work, a request which she gladly took up with an excellent and as always highly interesting presentation “about some translations in vascular neurology”. The laudation was presented by the Dutch neurologist Prof. Jan van Gijn from the University Medical Center Utrecht, another outstanding pioneer in stroke research who captivated the over 2,500 listeners with his wit, charm and competence.

ESC 14th May 2008

PRoFESS drug Trial: insignificant results on all fronts

The main event on the second day of the European Stroke Conference was the announcement of the results of the long awaited Profess drug trial. The three lead main investigators of the trial were sharing an hour presentation at about 11GMT in a fully packed lecture theatre in the Acropolis in Nice/France. The first speaker was Dr. R,. Sacco, from University of Miami, Miami, USA. The title of his presentation was prevention regimen for effectively avoiding second stroke (Profess) trial: Comparison of a fixed- dose combination  of extended- release dipyridamole ( ER-DP)plus aspirin (ASA) with clopidogrel. He mentioned that 20,333 patients (mean age 66 years;36% female) were recruited from 695 sites in 35 countries. Median time from ischaemic stroke to randomisation was 15 days; 39.9% of patients were randomised within 10 days. He concluded that there is no significant difference in reducing the risk of recurrent strokes between the group of ischaemic stroke patients treated with fixed-dose combination of ASA plus ER-DP (200mg) given twice daily and the group of stroke patients treated with Clopidogrel alone.

Telmisartan versus Placebo

Dr. S. Yusuf from McMaster University in Canada was talking in the conference about  Telmisartan (one of the angiotensin receptor blocker) and whether it is reducing recurrent strokes in  patients with previous stroke and hypertension. He and his team compared the telmisartan group of patients with another group treated for their hypertension with placebo (other drugs but not telmisartan). Dr Yusuf concluded that there are no significant differences between the two groups and telmisartan has failed to show any significant reduction in recurrent stroke in hypertensive patients comparing to placebo. However, he confirmed that the potential benefit of telmisartan in treating hypertension is similar in all type of strokes.

Cognitive and functional outcomes after stroke

The last speaker in this session regarding Profess drug trial was Professor H. Diener from University of Duisburg-Essen, Essen in Germany. He mentioned that  the Prevention Regimen for Effectively Avoiding Secondary Strokes (PRoFESS) trial is the largest secondary stroke prevention trial to date, and investigated whether the fixed-dose combination of acetylsalicylic acid (ASA) plus extended-release dipyridamole (ER-DP) compared to clopidogrel, and telmisartan compared to usual care reduced the risk of further strokes. Angiotensin II receptor blockers are neuroprotective in animal models of stroke, and can theoretically reduce the risk of vascular dementia or severity of a recurrent stroke. Also there are experimental data to suggest that dipyridamole may have an effect on cognitive decline in dementia due to subcortical ischaemia through several mechanisms including: prevention of new vascular lesions; anti-oxidant and anti-inflammatory effects; and an increase in cerebral perfusion. Therefore the effect of telmisartan and ASA plus ER-DP on both the severity of recurrent stroke, and cognitive function were assessed. 
 Patients aged 50 years or older with an ischaemic stroke within 120 days and who where stable were included in the trial. A fixed-dose combination of ASA (25 mg) plus ER-DP (200 mg), given twice daily, compared to once-daily clopidogrel (75 mg), and telmisartan (80 mg once daily) compared with placebo were investigated using a 2 x 2 factorial study design. Severity of recurrent stroke was assessed by modified Rankin. Cognitive function was assessed by serial changes in Mini Mental State Examination. Professor Diener concluded that there are no significant differences between the patients groups regarding the cognitive and the functional outcomes.

ESC 13th May 2008

Second TIA satellite symposium

There was a discussion in the symposium today 13th May 08 regarding the term TIA and whether it should be called unstable TIA, acute cerebral ischaemia or acute cerebral vascular syndrome. It was clear in the conference today that there was no consensus on the term TIA. At the end of the session Dr. Peter Sandercook/UK wanted the audience to have a vote by raising hands to chose which term they think it is more suitable to replace the TIA one.
In the next session regarding TIA and its differential diagnosis Prof. Henerrici, Germany mentioned that TIA and stroke should have the same emergency workout. He referred to a study in his centre which is going to be presented as a poster later today in which his team has studied 120 patients with TIA. It was found that the risk of stroke is 11.7%. Prof Hennerici mentioned in his lecture that ABCD2 score and DW1 are useful in combination for TIA risk stratification.
The next speaker was Prof. Dienner from Germany who was talking about how to define outcome parameters of TIA in Randomised Controlled Trials (RCT). He concluded that TIA should not be an endpoint in RCT as it is very difficult to diagnose. There was another presentation regarding the MRI and its vascular contributions from Dr. Schwartz in Hannover. He pointed out that DW1 can show a positive proof of ischaemia or cytotoxic injury. However, there are few other differential diagnoses that MRI can help in exploring such as migraine, venous congestion, focal epilepsy and cortical arterial hypertension in pregnancy. It will help in making the diagnosis clear for arteriovenous malformation cases as well.
DWI MRI can help in planning the therapeutic intervention according the message from Dr. Schwartz in this TIA satellite symposium as part of the 17th European stroke conference in Nice, France.

ABCD2 score and TIA

The Study concluded that the ABCD2 score may be an useful tool not only to predict recurrence of minor stroke or TIA but also in screening for diagnosis. Patients with ABCD2 score of 3 and above might be targeted for rapid assessment and treatment if there are limited clinic resources. These results require validation in larger patient groups.

Antihypertensive therapy in thrombolysed stroke patients: Results from SITS-ISTR

The results of this study suggest a more active blood pressure lowering approach in moderate hypertension is indicated early after intravenous thrombolysis. In particular, not providing antihypertensive therapy in known hypertensives was associated with worse outcome and initiation of new antihypertensive therapy in moderate hypertension seemed to have a favourable outcome.

Is it time to reassess the SITS-MOST criteria for thrombolysis?

This study concluded that more than one-third of patients not fulfilling SITS-MOST criteria benefit from tPA treatment. The authors continued to say that extension of SITS-MOST criteria should be considered in future studies

Thrombolysis in young patients: the SITS-MOST data.

The data of this study confirm that outcomes are better in young ischaemic stroke patients compared to older ones after treatment with intravenous t-PA. However, a more detailed critical analysis of indicators that might predict outcome and/or different response to intravenous thrombolysis between the two age subgroups is warranted.

Ischemic Stroke Outcome at 90 Days

The authors mentioned that their data show a negative correlation between early plasma levels of inflammatory biomarkers – in particular TIMP-1, IL-6, CRP, and S-100 – and stroke outcome at 90 days. Patients with full recovery in functional scores show a different time course of biomarkers compared to those with poor clinical outcome. Interestingly 90d after stroke significant differences in levels of TIMP-1, MCP-1, IL-6, and CRP depending on stroke severity are still detected.

Risk factors for cerebral infarction

In a specialized session for the risk factors of stroke, this paper from Sweden concluded that conventional cardiovascular risk factors remain major determinants of stroke. The relative importance of individual risk factors is changing over time with increasing contribution of atrial fibrillation and hypertension and decreasing contribution of smoking in men. The prospects for better primary prevention of stroke are evident. This study was done on 66 610 patients reported to the Swedish National Quality Register for Stroke Care (Riks-Stroke).

Metabolic syndrome (MetS) in lacunar stroke (LS|)

This study concluded that the prevalence of MetS in ischaemic stroke patients is high. LS patients without white matter lesions (WML) significantly more often had MetS than LS patients with WML. As no difference was found between the LS patients without WML and cortical stroke (CS) patients, MetS is possibly more strongly related to atherosclerotic disease (e.g. LS without WML) than with small vessel disease (LS with WML). The results therefore suggest a different, non-atherosclerotic pathophysiology underlying LS with WML.

Effectiveness of statin treatment in patients with a recent TIA or ischemic stroke

The benefit of statins in patients with acute ischaemic stroke or TIA has been demonstrated in Randomised controlled trial. Effectiveness in daily practice may however be violated by a different patient population and less patient compliance.
This study concluded thattThe effect of statins on the occurrence of vascular events within 3 years in this study is similar to the effect observed in RCT’s.

Prevention regimen for effectively preventing second strokes (PRoFESS) Trial

There is a high risk of recurrent stroke following an initial stroke or transient ischaemic attack. A combination of acetylsalicylic acid (ASA) and extended release dipyridamole (ER-DP) or clopidogrel were superior to ASA in secondary stroke prevention trials. The Prevention Regimen for Effectively Avoiding Secondary Strokes (PRoFESS) trial, the largest secondary stroke prevention trial to date, investigated whether the fixed-dose combination of ASA plus ER-DP compared to clopidogrel reduced the risk of recurrent strokes. There will be another study in the conference regarding Profess trial. The results of which will elucidate the role of telmisartan in addition to usual care in the prevention of recurrent stroke.

Endarterectomy versus Angioplasty in patients with Symptomatic Severe carotid Stenosis

This trial was stopped prematurely after the inclusion of 527 patients for reasons of both safety and futility. The 30-day risk of any stroke or death was significantly higher after stenting (9.6%) than after endarterectomy (3.9%), resulting in a relative risk of 2.5 (95% CI, 1.2 to 5.1). Long-term outcomes after a mean follow-up of more than 3 years will be presented.

Examination of depression in those with mild stroke

This study concluded that despite minimal functional disability, community dwelling subcortical stroke survivors report depression that is sustained over time and is at a higher proportion than those in the community without stroke. Recognition of risk factors for depression over time in this sub-group is critical for optimizing post-stroke care.

Blood biomarkers to improve prediction of the prognosis in ischaemic stroke

This systematic review concluded that no class of marker, other than those of cardiac damage, was reasonably consistently associated with poor outcome. Methods were weak: none assessed if the biomarker added predictive ability to a clinical model, few were blinded & cohorts were no ideal. The authors suggested that future studies should: prespecify outcomes, blind measurement of biomarker and outcome, examine unselected cohorts of stroke patients & assess if biomarkers add power to validated clinical models.

Effect of intravenous thrombolysis in acute ischaemic stroke on outcome in daily practice

Thrombolysis with intravenous thrombolysis has been proven effective for treatment of patients with acute ischaemic stroke randomised clinical trials. In daily practice, the effect of thrombolysis may be less because of co-morbidity, less strict contra-indications and treatment by less experienced doctors.
This study ,however, confirms that intravenous thrombolysis for acute ischaemic stroke improves outcome also in standard practice, outside the setting of a randomised clinical trial.

Mobile versus Hospital Based Telestroke Service. A Controlled Analysis

Telemedicine is increasingly used to provide acute stroke expertise for hospitals without full-time neurological services.
This study from Germany concluded that Teleconsultation using a laptop workstation and broadband mobile telecommunication is technically stable and allows remote clinical decision making. There remain disadvantages regarding videoconference quality on the hub side and lack of video-transmission to the spoke side.