Reviews and Insights From ESOC 2022

Neurology Learning Network Section Editor, Amrou Sarraj, MD, shares study findings from 3 presentations given at the European Stroke Organisation Conference that took place May 3 to 6, 2022 in Lyon, France. Dr Sarraj has provided breaking news, research reviews, and insights from on-site at the conference and continues to share his “hot takes” on ESOC sessions.

Tenecteplase in Wake-up Ischemic Stroke Trial (TWIST)

In the Tenecteplace in Wake-up Ischemic Stroke Trial (TWIST), 578 patients were enrolled with 288 in the tenecteplace (tNK) group and 290 in the control group. The COVID-19 pandemic created a decrease in enrollment, originally including 600 patients, and halted tNK production.

Trial outcomes were as follows:

Efficacy:

• Shift on mRS score (primary outcome): acOR: 1.18 (0.88-1.58); P = .27

• mRS 0-1: 45% tNK vs 38% control; aOR: 1.33 (0.94-1.87); P = .10

Safety:

• Mortality: 9.7% tNK vs 7.9% control; aHR: 1.29 (0.74-2.26); P = .37

• Symptomatic intracerebral hemmorage (ICH; SITS-MOST): 3.1% TNK vs 1% control; aOR: 3.12 (0.83-11.7); P = .09

• Any ICH: 11.5% TNK vs 10.3% control; aOR: 1.14 (0.67-1.94); P = .64

Researchers found that while the TWIST trial failed to demonstrate improved outcomes with tNK, early termination of the trial may have impacted the study power. Results were in line with prior studies that demonstrated efficacy and safety of intravenous (IV) thrombolysis using alteplase in patients with wake-up stroke.

Intravenous Thrombolysis in Patients With Ischaemic Stroke and Recent Direct Oral Anticoagulants Intake – An International Collaboration

In this international, multicenter, retrospective cohort study, 20,448 patients receiving intravenous thrombolysis (IVT) from more than 50 centers were included. Of patients, 830 that were on prior direct oral anticoagulant (DOAC) within 48 hours of stroke onset were compared with 19,618 controls without DOAC.

Study finding include:

• 252 of 830 patients received DOAC reversal, 225 had DOAC measurements, and 355 received IVT without knowledge of DOAC intake.

• sICH: 4.5% overall; 2.5% (1.6-3.8%) DOAC vs 4.5% (4.2-4.8%) control; aOR: 0.47 (0.29-0.78); P = .003

• Sensitivity analysis in patients with DOAC intake ≤24 hours and/or DOAC levels >30ng/mL and no reversal: aOR: 0.31 (0.11-0.84); P = .022

No differences were found in the following

• mRS 0-2: aOR: 1.07 (0.87-1.32); P = .503,

• Shift on mRS score: aOR: 0.94 (0.80-1.09); P = .419

• Mortality: aOR: 1.36 (0.99-1.87); P = .06

The presenters concluded that while the study had significant limitations, including potential selection bias and retrospective design, the results did not demonstrate a signal for harm with IVT in patients receiving DOACs within 48 hours of stroke.

Treatment of Hyperglycemia in Acute Stroke: Results From the Trial of Exenatide In Acute Ischaemic Stroke (TEXAIS)

TEXAIS is a phase II, multicenter Prospective Randomized Open-Blinded Endpoint (PROBE) trial with 350 patients randomized to receive exenatide 5 mg bid subcutaneous vs standard of care. Of patients, 177 were randomized to the intent-to-treat (ITT) for the exenatide group (EX) and 172 to standard care (Std Care; 4 patients withdrew consent).

Study findings were as follows:

Primary outcome: National Institutes of Health Stoke Scale (NIHSS) improvement of ≥8 points or NIHSS 0-1 at day 7: EX 61.2% vs Std Care 56.7%; aOR: 1.22 (0.79-1.88); P = .38

Secondary outcomes:

• mRS 0-2 at 90 days: EX 74% vs Std Care 74.7%; aOR: 0.96 (0.56-1.66); P = .89

• Mortality: EX 5.8% vs Std Care 4.7%; aOR: 1.21 (0.43-3.38); P = .71

• Median difference in NIHSS: 0.14 (-0.10 to 0.39); P = .26

Safety:

• Daily hyperglycemic episodes: difference in median -0.20 (-0.40 to 0); P = .05

• Nausea/vomiting: EX 3.5% vs Std Care 0%; risk difference: 0.034 (0.01-0.06); P = .03

Researchers conclude that despite not achieving significantly improved primary outcome, exenatide was easy to use and improved glycemic control.

References

Roaldsen MB. TWIST (Tenecteplase in Wake-up Ischemic Stroke Trial). Presented at: European Stroke Organisation Conference; May 6, 2022; Lyon, France.

Purrucker JC. Intravenous thrombolysis in patients with ischaemic stroke and recent direct oral anticoagulants intake – an international collaboration. Presented at: European Stroke Organisation Conference; May 6, 2022; Lyon, France.

Bladin C. Treatment of hyperglycemia in acute stroke: results from the Trial of Exenatide In Acute Ischaemic Stroke (TEXAIS). Presented at: European Stroke Organisation Conference; May 6, 2022; Lyon, France.