Published: Thursday 18 May 2017
The European Stroke Organisation Conference (ESOC) 2017 took place this week from 16-18 May in Prague, Czech Republic.
The third day of ESOC saw some exciting late breaking trials:
- The SPACE 2 Study – A Comparison of Stenting, Endarterectomy and Best Medical Management
- The PRASTRO-1 Study – A Comparison of Prasugrel and Clopidogrel (Standard of Care)
- The GOLIATH and ANSTROKE studies - General or Local Anaesthesia During Endovascular Therapy (including mechanical thrombectomy)?
SPACE 2 Study – A Comparison of Stenting, Endarterectomy and Best Medical Management
Carotid endarterectomy (CEA) is a surgical procedure to remove plaque from narrowed arteries in the neck, to reduce the risk of stroke. Carotid stenting (CS) is an alternative procedure whereby a mesh (stent) is placed in the narrowed artery instead. The SPACE 2 study adds to the volume of evidence demonstrating minimal differences between carotid endarterectomy and carotid stenting and a low overall rate of procedural complications in patients with asymptomatic carotid stenosis (meaning the patient has carotid artery narrowing in the neck, but with no symptoms).
Prof Tilman Reiff (University Hospital Heidelberg, Germany) presented results from this study in patients with an asymptomatic carotid stenosis, adding to the growing evidence of the relative risks and benefits of these interventions. The key finding was that in 400 patients, randomised to receive either Carotid endarterectomy vs carotid stenting, there was a low rate of periprocedural (occuring before, during or soon after the procedure) within 30 days, with only five events (2.5%) in each arm.
PRASTRO-1 Study – A Comparison of Prasugrel and Clopidogrel (Standard of Care)
Clopidogrel is a commonly prescribed 'antiplatelet' drug which reduces the risk of a patient developing blood clots and consequently having a stroke. Prasugrel is another, newer antiplatelet drug.
The PRASTRO-1 study demonstrated no significant advantage of prasugrel over clopidogrel in patients with non-cardioembolic stroke (all strokes apart from those where a clot travels from the heart to the brain). The study compared prasugrel to clopidogrel to determine whether the newer antiplatelet drug, which is felt to be less liable to patient resistance, has equivalent efficacy to the current standard of care. Prof Kazunori Toyoda (Suita- Osaka, Japan) presented the study’s results from 3,747 patients with non-cardioembolic stroke.
Key findings from the study were that there was no significant difference between drugs for the primary outcome of ischaemic stroke, myocardial infarction (heart attack), or other vascular death, with an equal rate of ‘any stroke’ in both the clopidogrel and prasugrel groups. Although event rates were similar, the study did not demonstrate ‘non-inferiority’ of prasugrel, which means that it did not demonstrate that prasugrel was as effective as clopidogrel.
The GOLIATH and ANSTROKE studies - General or Local Anaesthesia During Endovascular Therapy (eg mechanical thrombectomy)?
Endovascular therapies include mechanical thrombectomy, where a guide wire can be inserted in an artery at the patient's groin, and be used to guide a mesh into the brain to remove a stroke causing clot. There is uncertainty regarding the effect of the anaesthetic approach during endovascular therapy for ischaemic stroke (a stroke caused by a clot. Observational studies suggest that general anaesthesia (GA) during endovascular therapy is associated with worse outcomes compared to conscious sedation (CS) where the patient is awake. The results of the GOLIATH and ANSTROKE randomised studies should help physicians choose the best strategy for their patients.
The GOLIATH Study assessed whether general anaesthesia caused greater infarct (stroke) growth and worse outcomes during endovascular therapy compared to conscious sedation. A total of 128 patients were included in the study, results presented by Prof Claus Simonsen (Aarhus University Hospital, Denmark).
The key findings were that there was no difference in acute infarct (stroke) size between groups, but the final infarct volume was higher with conscious sedation. Endovascular therapy under general anaesthetic did not result in a worse outcome.
The ANSTROKE Study compared general anaesthesia and conscious sedation in 106 patients undergoing endovascular therapy for acute ischaemic stroke. The study was conducted at the Sahlgrenska University Hospital in Sweden. The key finding of the ANSTROKE study was that for patients who underwent general anaesthesia, 42.2% were independent at three months after their stroke, whereas this figure was 40% for those who underwent conscious sedation. This meant that there was no statistically significant difference in outcome between the anaesthesia types used.