EAN 2023 | Recent developments in intravenous thombolysis

This session was all about new developments in the treatment of acute stroke and my talk was specifically on the developments on IV thrombolysis. So, this is indeed a very important treatment because it is the treatment that is available for most people other than just stroke unit care, of course, but for the reperfusion treatments, this is the treatment that is still available for most patients because unfortunately, most of the patients are not eligible for endovascular treatment. So, we started by discussing some important issues on the implementation. So, we know that the faster the treatment is delivered, so if the door to needle and of course the time from symptom onset to needle is shorter, the efficacy of the treatment is higher. So, it is still today a very important thing to remember that the faster we give the treatment, the better will be the efficacy and the outcomes. So, it is very important that we still strive to improve the methodology, the flow of the patients and all the aspects on the delivery of the treatment, pre-hospital and in-hospital, so that we can improve outcomes by delivering the treatment faster.

Also, we know that it is still the case that in several countries, most patients or a large proportion of patients are still not getting the treatment. We see and we were discussing also the results from a recent study we did in the European Stroke Organization and at the time it was still unpublished data, but now it’s published, so, it was published just a few days ago. We did an update of an analysis of the treatment deliveries, both IVT and EVT across Europe and it’s still very clear that there are very important disparities in the delivery of the treatment that are probably not just explained by local aspects related with the epidemiology of the disease. So, it should be that either patients usually arrive late or that there is something in the flow of the patients in hospital and pre-hospital that stops patients from receiving treatment, because the disparities are really huge. And we can see that if all countries were delivering the treatment in the same way as the three countries that are delivering the highest proportion of patients treated with TPA, then many, many patients would receive the treatment additionally each year to the ones that already receive it. So, probably there is a large margin for improvement in the delivery of these treatments, even in European countries. So that’s still an important topic today, although this is not based on recent evidence. It is something we know since the beginning, but we still have to think about it and it’s still something we can improve.

Then we were discussing, of course, the recent developments in the last years. Of course, there are several other indications that have been changing over the past decades. So, some diseases like having epileptic seizures or high glucose, these were contraindications, but with time we were able to understand that we can still treat these patients provided that we are careful concerning some differential diagnosis and other aspects. So, these were not so recent developments, but we were then we were focusing on the more recent. So, in the last 3 to 5 years, and there are very important changes in the indications that is established also in the ESO guidelines from 2021 and then the expedited recommendation on tenecteplase. And these were the documents we were reviewing and the trials, of course, that were the basis for these updates. So first, we were discussing wake-up stroke. So, we know the trial from Götz Thomalla, the WAKE-UP trial from 2018 in the New England Journal. This was a study that showed that using the DWI-FLAIR mismatch, this has a good correlation with the time from symptom onset that’s directional. And so, we can treat patients with a wake-up stroke that have this DWI-FLAIR mismatch with good results actually, with a reasonable number needed to treat to have improved outcomes. So that was the first and that is also already included in the guidelines. Also another development, is the extended time window in general, and we can use the perfusion mismatch concept. So, the tissue-based clock that allows us to, according to some parameters in CT perfusion or MR perfusion, we can still treat patients outside of the standard time window, although the effect is not so good as if we treat the patients on the early time window.

And then we were also, of course, discussing tenecteplase. Tenectaplase is a recent development, and we have the expedited guideline from the European Stroke Organization on that as well. And indeed, with the recent trials that were published in 2022, we are able to now recommend that in patients that have, especially large vessel occlusion, tenecteplase should be preferred. And then in the other patients, tenecteplase is a reasonable alternative as well and that can be used. And it is easier to administer, so, it has also these advantages. So, these were mostly what we were discussing. So, all the challenges we still have on the implementation, both in the early time window, so that we treat more patients and faster and also with these new developments, with the imaging developments. If we are able to implement this imaging protocols, which of course is also a challenge for the implementation of stroke care, but if we are able to implement this, then we can treat more patients, also based on these new paradigms for imaging decision based for TPA and tenecteplase. Then we were discussing this new developments in the use of tenecteplase, which also are still a challenge to implement. Also, there was a lack of TPA and tenecteplase in the last month. So there is something that we have to consider as well and even in the next years. So, I’m very curious to see how this will develop also in the next months.