Controversies in stroke were laid bare at the recent European Stroke Organisation Conference (ESOC) in Gothenburg, Sweden, in a special session that saw experts rallying to convince the audience of their perspectives regarding several key topics.
With three key questions framed for the audience, Yes/No votes were collected for or against the statements as a baseline measurement (Table 1). Then, two invited speakers – one for, one against – took to the podium to try and swing the votes in their favour.
Should patients with suspicion of large vessel occlusion (LVO) be transferred to the stroke centre, bypassing the next stroke unit?
Professor Gary Ford (UK) was backed up by the audience (63%) as he began his argument in support of the first topic. Time = brain, thus taking patients “direct to the mothership” – as he put it – would keep the time from LVO onset to treatment under 170 minutes. According to the evidence, he continued, this strategy appears to achieve better clinical outcomes.
However, this approach relies on significant paramedic training, as well as rapid and sustainable time-to-intervention. In addition, it demands a suitable infrastructure, and collaboration between regional stroke teams is paramount – a pitfall that his opponent Professor Marc Ribo (Spain) underlined.
In the real-world, remarked Professor Ribo, many regions are not equipped with appropriate systems that can facilitate the approach. In addition, not all patients are suitable for mechanical thrombectomy, and it beggars the question as to what should be done with other patients (e.g. haemorrhagic strokes, stroke mimics and so on)?
During the audience vote at the end of the debate, Professor Ribo clearly had shifted opinion, with 65% voting against, and only 35% in favour.
Should patients with mild symptoms and occlusion of a proximal intracranial artery have intra-arterial thrombectomy?
The audience heard that “mainstream” opinion would dictate not to treat minor strokes associated with LVOs, as good outcomes are expected anyway. But that view was not shared by Professor Jan Gralla (Switzerland), nor the audience, who were 83% in favour of thrombectomy following the first vote.
In support of his viewpoint, Professor Gralla relayed data where untreated patients have shown marked increase in their NIH Stroke Scale (22% of cases), and clinical deterioration at discharge (33%) or at three months (41%). Therefore, endovascular treatment seems reasonable and safe given the circumstances.
Professor Ángel Chamorro (Spain), however, argued that such data was biased, with only a few patients having received intravenous thrombolysis prior to the decision to use thrombectomy. What’s more, recent multicentre data has unveiled no difference in functional outcomes between patients treated with either intravenous thrombolysis or endovascular intervention. With this in mind, he postured that endovascular therapy could be reserved for when symptoms worsen.
Apparently his argument worked, as once again the audience turned on its head for the final vote:
Yes = 35%, No = 65%.
|Should patients with suspicion of large vessel occlusion (LVO) be transferred to the stroke centre, bypassing the next stroke unit?||Yes, 63% |
|Should patients with mild symptoms and occlusion of a proximal intracranial artery have intra-arterial thrombectomy?||Yes, 83%|
|Should patent foramen ovale (PFO) closure in cryptogenic stroke become routine for secondary stroke prevention?||Yes, 27%|
Should patent foramen ovale (PFO) closure in cryptogenic stroke become routine for secondary stroke prevention?
The final topic up for discussion was initially met with decisive opinion from the audience, with 73% voting against routine PFO closure in cryptogenic stroke. Challenging their perceptions was Professor Marie-Luise Mono from Switzerland, who reasoned that meta analysis data confirms the strong link between PFO and cryptogenic stroke. Furthermore, she said that a routine closure regimen would only translate to a relatively low number of procedures, with a feasible level of cost-effectiveness.
But for Professor Peter Rothwell (UK), there was no room to budge, and he further captivated audience opinion with his argument that if you consider the prevention of disabling strokes, the aforementioned “low” treatment number would actually increase dramatically. In addition, he argues that we need more data, as there are no randomised controlled trials comparing PFO closure to oral anticoagulants, despite the latter having seemingly efficacious outcomes in smaller subgroup analyses. Similarly, there is a paucity of data regarding other alternatives to PFO closure, particularly implantable devices.
The end result? An even wider lead for the “No” camp, at 85%.
Reale G. ESOC 2018 – Controversies in Stroke. Available at: https://eso-stroke.org/esoc/esoc-2018-controversies-in-stroke/; Accessed May 21, 2018.
Table 1. Baseline and final audience scores noted before and after (respectively) each topic was discussed.