Leading neurologists and cardiologists came together to present the latest research in the field at the American Heart Association/American Stroke Association’s International Stroke Conference for 2024, held in Arizona between February 7-9.

Here is the limbic‘s pick of research results and findings at ISC 2024.

Earlier anticoagulation reversal associated with improved survival for ICH

Earlier administration of anticoagulation reversal in patients with intracerebral haemorrhage is associated with reduced in-hospital mortality or discharge to hospice and increased likelihood of discharge home, a US study suggests.

The findings, which were published in JAMA Neurology [link here] and presented at ISC 2024, should encourage intensive efforts to accelerate the evaluation and treatment of such patients in emergency settings, said the researchers.

They analysed data from 9492 patients (median age 77, 45% female) in the American Heart Association’s Get With The Guidelines Stroke registry.

From 2015 to 2021, patients in 465 hospitals presented with anticoagulation-associated intracerebral haemorrhage (ICH) within 24 hours of symptom onset.

Some 7469 (78.7%) patients received reversal therapy, including patients on warfarin (85%) and those on a non–vitamin K antagonist oral anticoagulant (70%).

For those with documented workflow times, findings showed the median onset-to-treatment time was 232 minutes and the median door-to-treatment time was 82 minutes, with a door-to-treatment time of 60 minutes or less in 1449 (27.7%).

A door-to-treatment time of 60 minutes or less was associated with decreased mortality and discharge to hospice (adjusted odds ratio, 0.82), but there were no differences in functional outcome between the groups, said the authors led by Yale Centre for Brain and Mind Health, Yale University School of Medicine.

Factors associated with faster administration of reversal interventions included white race, higher systolic blood pressure, and lower stroke severity.

Tenecteplase for stroke – a benefit beyond 4.5 hours?

Tenecteplase therapy initiated 4.5 to 24 hours after stroke onset is unlikely to improve outcomes for patients with occlusions of the middle cerebral artery or internal carotid artery, a US study suggests.

The TIMELESS (Thrombolysis in Imaging Eligible, Late Window Patients to Assess the Efficacy and Safety of Tenecteplase) trial compared tenecteplase or placebo administered to 458 patients with ischemic stroke 4.5 to 24 hours after they were last known to be well.

Patients were only included if they had evidence of occlusion of the middle cerebral artery or internal carotid artery and salvageable tissue as determined on perfusion imaging.

Findings published in the New England Journal of Medicine [link here] and presented at ISC 2024 showed no significant between-group differences, with the median score on the modified Rankin scale at 90 days 3 in each group. The adjusted common odds ratio for the distribution of scores for tenecteplase as compared with placebo was 1.13.

When it came to safety, there was also no substantial difference observed for 90-day mortality (19.7% in the tenecteplase group and 18.2% in the placebo group) or in the incidence of symptomatic intracranial haemorrhage (3.2% and 2.3%, respectively).

Writing in an accompanying editorial [link here], US neurologist Professor Dana Leifer said the trial results tentatively suggested that pretreatment with tenecteplase before thrombectomy may be beneficial in patients with occlusions in the M1 segment when administered in the 4.5-to-24-hour window,  but was unlikely to help patients who presented with large-vessel occlusions and who did not undergo thrombectomy.

No steroid benefit for stroke patients

Adjunctive methylprednisolone therapy prescribed to patients receiving endovascular treatment for acute ischemic stroke does not significantly improve disability, a Chinese study suggests.

The MARVEL (Methylprednisolone as Adjunctive to Endovascular Treatment for Acute Large Vessel Occlusion) randomised clinical trial involved 1680 patients with stroke and proximal intracranial large-vessel occlusion presenting within 24 hours of time last known to be well, who were recruited between February 2022 and June 2023, with a final follow-up in September 2023.

Patients (median age 69, 43% female) were randomly assigned to intravenous methylprednisolone (n = 839) at 2 mg/kg/d or placebo (n = 841) for three days adjunctive to endovascular thrombectomy.

Findings published in JAMA [link here] showed that the median 90-day modified Rankin Scale score was 3 in the methylprednisolone group versus 3 in the placebo group (adjusted generalised odds ratio for a lower level of disability, 1.10).

However, data also indicated that there was a lower mortality rate (23.2% vs 28.5%; adjusted risk ratio, 0.84) and a lower rate of symptomatic intracranial haemorrhage (8.6% vs 11.7%; adjusted risk ratio, 0.74) in the methylprednisolone group compared with placebo.

Head positioning key to neurological improvement in stroke

Positioning patients with large vessel ischaemic stroke with their heads flat rather than raised in hospital beds before thrombectomy significantly improves neurological function, according to late-breaking results presented at ISC 2024.

US researchers say their findings suggest that zero-degree positioning may be an appropriate change to the standard of care for stroke patients before thrombectomy, with hospital beds typically set at a 30-degree incline for the head.

The multicentre randomised clinical trial called Zero Degree Head Positioning in Acute Large Vessel Ischemic Stroke (ZODIAC) included 92 patients from 12 stroke centres in the US. Patients were randomised to either group and underwent repeat NIHSS scoring every 10 minutes until moved to cath lab table for thrombectomy.

Investigators found that at both 24 hours after surgery and a week after discharge, the zero-degree group had less neurological deficits. However, by three months post surgery, there were no differences between the groups.

“Many thrombectomy patients have delays until the procedure can be started, whether due to slow internal hospital processes, multiple patients arriving at the same time or if the patient needs to be transferred to another hospital,” said lead study researcher Professor Anne Alexandrov (PhD), a professor of nursing and neurology at the University of Tennessee Health Science Centre in Memphis.

“Optimising blood flow to the brain while patients are waiting for surgery, is essential to minimise the risk of neurological deficits and ultimately disability.”