The last few months have been full of new developments in the management of acute and post-acute events of cerebrovascular accidents (CVA). A session of French language neurology days (April 4-7, 2023, Lyon) allowed Pr Nathalie Nasr (CHU Poitiers) to present the synthesis.
Thrombectomy strengthens his position
Patients with extensive ischemia are instead ruled out of mechanical thrombectomy given concerns about the associated risk of hemorrhage and associated complications. In recent months, several studies have led to a revision of this position, thanks to three important studies: RESCUE-JAPAN LIMIT [1]and very recently ANGEL-ASPECT [2] and SELECT2 [3].
The first two were carried out in an Asian population in which the associated management differs, in particular concerning the dosage of the thrombolytic treatment: they nevertheless described a greater improvement in the primary endpoint (modified Rankin score [mRS] illustrating the disability) thanks to a thrombectomy performed within the first 24 hours compared to management in accordance with the recommendations. But the last one, SELECT2, made it possible to achieve comparable results within a Western population, with a relative risk of achieving functional independence three times higher in the thrombectomy group versus standard treatment (20% versus 7% in 90 days) with no difference in mortality or intracranial hemorrhagic complications.
Two other Chinese studies have for their part looked at strokes of the basilar trunk, a context in which the interest of this same thrombectomy remains debated: the two trials, CAUTION [4] et BAOCHE [5], evaluated the improvement in the mRS score compared to a reference management when thrombectomy was considered within 12 hours and 24 hours respectively after the estimated onset of the stroke. Both confirm the additional prognostic benefit obtained in the interventional group, knowing however that the second was methodologically less satisfactory: thrombectomy allowed 46% of treated patients to achieve an mRS score of 0-3 at 90 days compared to 23% in the group control (adjusted rate ratio 2.06, p<0.001) in the first and, in the second, in 46% and 24% of patients respectively (adjusted rate ratio 1.81, p<0.001), despite an increase in risk of symptomatic intracranial hemorrhage (5% vs 0 and 6% vs 1%).
Consequently, ” should we continue to use thrombolysis before thrombectomy? » asked Nathalie Nars. For now, the European ESO/ESMINT position [6] remains to not change practices with recourse to thrombolysis still recommended, but should not prevent or delay thrombectomy. However, practices in this area have evolved since European recommendations recommend using tenecteplase in preference to alteplase, at a dose of 0.25 mg/kg she insisted. As a reminder, a dosage of 0.4 mg/kg is associated with more haemorrhagic transformation.
TIA and secondary prevention
Finally, the management of transient ischemic attacks (TIA) and minor strokes can still be optimized, insisted the neurologist who recalled that they now represent 65% of all cerebrovascular events thanks to primary prevention: more following the publication of three important clinical trials on the subject (CHANCE, POINT and THALES), dual anti-platelet aggregation (aspirin + ticagrelor or aspirin + clopidogrel) is recommended during the 3 weeks post-event. At the beginning of the year, the post hoc analysis of the CHANCE-2 trial showed that subjects not responding to clopidogrel due to the presence of a loss of function on the CYP2C19 gene derive an additional benefit from the combination using ticagrelor rather than that combined with clopidogrel. People carrying this gene represent 25% of the population of Caucasian origin, and up to 60% of those of Asian origin.
Finally, the neurologist insisted on the existing room for improvement concerning the optimization of patient care in the field of secondary prevention: on the one hand, following the TST [8], the American recommendations of 2022 established the LDL-cholesterol target at a maximum threshold of 70 mg/dL and no longer 100 mg/dL. Those of the European society of 2021 recall the usefulness of GLP1 agonists in diabetic patients in secondary prevention.