ISC 2024 | Top news in stroke: head positioning, reteplase, and MMA embolization
Aristeidis Katsanos, MD, McMaster University, Hamilton, Ontario, Canada, highlights some of the key news to be shared at the 2024 International Stroke Conference. Firstly, results from the ZODIAC trial were presented that showed the substantial impact of head-of-bed positioning in large vessel occlusion (LVO) stroke care. Patients awaiting endovascular treatment who had a 0-degre positioning versus a 30-degree positioning showed significant improvements in neurological functioning. Secondly, the RAISE trial was presented which showed the superiority of reteplase over alteplase for intravenous thrombolysis in patients with acute ischemic stroke. Dr Katsanos points out key caveats, including the exclusion on patients undergoing endovascular thrombectomy from the trial and the increased bleeding risk associated with reteplase. Finally, Dr Katsanos highlights the large amount of positive data supporting embolization of the middle meningeal artery (MMA) for the treatment of subdural hematoma. This interview took place during the International Stroke Conference 2024 in Phoenix, AZ.
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Transcript (edited for clarity)
I would highlight three things that I found very interesting. So one is the ZODIAC trial and putting heads down in patients with LVO going for a mechanical thrombectomy. Very interesting results, something which honestly, I have been doing in my clinical practice. When I have a patient with an LVO, I try to put the head down, give some fluids, augment the cerebral perfusion. So the results of the trial, they are confirmatory to clinical practice, at least mine...
I would highlight three things that I found very interesting. So one is the ZODIAC trial and putting heads down in patients with LVO going for a mechanical thrombectomy. Very interesting results, something which honestly, I have been doing in my clinical practice. When I have a patient with an LVO, I try to put the head down, give some fluids, augment the cerebral perfusion. So the results of the trial, they are confirmatory to clinical practice, at least mine. But I think definitely they need to be replicated into a large trial to make sure and hopefully change also the guidelines. So this was the first thing.
The second I would say is the RAISE, the use of reteplase for acute ischemic stroke. After we had this big success of the tenecteplase trials, we have a new thrombolytic agent for acute ischemic stroke. So now reteplase with this trial proved not only noninferiority but also superiority over alteplase. Of course, if you see the trial and read the inclusion/exclusion criteria, you see that there are also some things that you have to keep in mind. First of all, you have to give it with two doses due to the shorter half-life. So that’s a limitation compared to tenecteplase. Second is that the patients in the trial, they were excluded if they were about to undergo endovascular thrombectomy. So this is another caveat that we need to take into consideration. The third and most important for me is that there was increased risk of bleeding, both intracranial and extracranial, which we need to consider. It didn’t translate into worse outcomes, but that’s definitely something that we have to keep in mind. And fourth is also the general generalizability of the trial. It was done in China so extrapolation of the findings to the rest of the world needs to be carefully done. And again, taking also into account that patients receiving EVT were excluded.
And the third thing, it’s not kind of like in my area of interest and those patients are mostly taken care of by neurosurgery, but I cannot not highlight that we have three positive trials, independent trials for MMA embolization in patients with subdural hematomas. That’s an amazing thing and, you know, seeing positive trials on the same topic, one after the other is really rewarding.
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