International Stroke Conference 2020

This year’s International Stroke Conference (ISC) was not in a charming foreign locale but the less-exotic destination of Los Angeles. As of this writing, many of these breaking presentations are available only as slide decks and abstracts pending peer-reviewed full-text publication in scientific journals. These preliminary data represent windows into their likely downstream effects on stroke care.

One of the most notable emerging themes over the last few years is a movement toward use of tenecteplase rather than alteplase in stroke. Tenecteplase is less expensive and is given as a single bolus dose rather than requiring a prolonged infusion. The Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK) Part 2 trial looked specifically at dose response to tenecteplase in achieving recanalization in large vessel strokes.⁴ These authors did not observe a difference in outcomes whether 0.4 mg/kg or 0.25 mg/kg was used, but bleeding was marginally increased by the higher dose. A group from the University of Texas at Austin also presented their initial experience incorporating tenecteplase into practice as their primary thrombolytic. In their limited case series, outcomes and safety appeared consistent with their prior experience with alteplase.

Two studies also looked at outcomes associated with mobile stroke units (MSUs), ambulances equipped with non-contrast CT and the capability of administering thrombolytics and anticoagulant reversal agents in the field. An observational study from Melbourne, Australia, sought to quantify the effect of MSU dispatch on subsequent endovascular intervention.5 As with thrombolytic therapy, stroke unit dispatch expedited downstream stroke care. However, MSU dispatch to 2,348 cases in their first year yielded only 100 cases of prehospital thrombolysis. A similar observational study in Berlin documented increased thrombolysis and improved three-month outcomes associated with MSU care. Similar to the low yield in the Melbourne study, there were more than 14,500 dispatches to yield only 450 cases of thrombolytic administration.

Last, and most interesting, are the first data regarding whether thrombolytics are necessary prior to endovascular therapy in eligible patients. The entire existence of the endovascular industry stems from the utter lack of efficacy for thrombolytics in large vessel occlusion. The Randomized Study of Endovascular Therapy with Versus Without Intravenous Tissue Plasminogen Activator in Acute Stroke with ICA and M1 Occlusion (SKIP) tested the necessity of alteplase administration as a bridge to endovascular therapy and observed neither an advantage nor reliable disadvantage to its use. Intracranial hemorrhage, however, was increased in those who received alteplase prior to endovascular therapy. These data are just the first of multiple trials looking at this question and will add another layer of decision making to the triage of stroke patients in the emergency department.

The opinions expressed herein are solely those of Dr. Radecki and do not necessarily reflect those of his employer or academic affiliates.