ESC Congress 2017 In Review -- Main Edition - 30

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of stroke, myocardial infarction, or death but the combination did reduce recurrent stroke [Johnston SC et al. N Engl
J Med. 2016]. Other studies have shown that long-term
combination antiplatelet therapy is not superior to monotherapy with aspirin or clopidogrel and in some cases, trial
results showed a higher bleeding risk.
In Prof Diener's opinion, there are good data showing that combination antiplatelet therapy with aspirin
and clopidogrel plus best medical treatment is superior
to stenting for patients with intracranial large vessel disease [Derdeyn CP et al. Lancet. 2014]. He also believes
that there are no good recommendations for patients
with aortic arch plaques but that the combination of
aspirin plus clopidogrel is probably as good as warfarin
[Amarenco P et al. Stroke. 2014].
In patients with AF and previous TIA or ischaemic
stroke warfarin is more effective than aspirin for secondary prevention of stroke [EAFT Study Group. Lancet.
1993]. For the prevention of recurrent stroke, systemic
symbolism, and haemorrhagic stroke, NOACs are superior to warfarin [Ntaios G et al. Int J Stroke. 2017].
In patients with small vessel disease the combination of
aspirin plus clopidogrel is not superior to aspirin monotherapy but carries a higher bleeding risk. Cryptogenic stroke
represents about 25% of all strokes; most are thromboembolic. It has been proposed that embolic strokes of
undetermined source (ESUS) are therapeutically relevant
and can be defined as a non-lacunar brain infarct without
proximal arterial stenosis or cardioembolic sources [Hart
RG et al. Lancet Neurol. 2014]. Two studies RESPÉCT-ESUS
and NAVIGATE-ESUS trials are in progress to determine
whether anticoagulation with dabigatran or rivaroxaban is
superior to aspirin in patients with ESUS.

Mikael Mazighi, MD, Unité de Soins Intensifs
NeuroVasculaire, Hôpital Lariboisière, Paris, France,
described mechanical thrombectomy with intravenous
recombinant tissue plasminogen activator (IV tPA) as
the gold standard for acute ischaemic stroke.
Therapy should be started as soon as possible. IV tPA
should be administered within 4.5 hours of symptom
onset and thrombectomy should be performed within 6
hours [Prabhakaran S et al. JAMA. 2015]. There is no age
limit for this procedure. A meta-analysis of data from 5
randomised controlled trials showed that thrombectomy
is of benefit to most patients with acute ischaemic stroke
caused by occlusion of the proximal anterior circulation internal carotid artery and proximal middle cerebral
artery). Disability was significantly reduced at 90 days
compared with best medical therapy (adjusted common
OR 2.49, 95% CI, 1.76 to 3.53; P < .0001) [Goyal M et al.
Lancet. 2016] with a number needed to treat of 2.6.
A stent retriever is the first device of choice, but
newer devices like the contact aspiration technique
are being evaluated [Lapergue B et al. JAMA. 2017].
Older patients (> 80 years) and those with higher NIHSS
scores appear to benefit the most from thrombectomy.
The benefits of thrombectomy in patients with large
stroke volume need to be confirmed.
Prof Mazighi concluded that IV-tPA remains a relevant viable treatment in association with thrombectomy
for stroke ischaemia. Although effective for occlusions
in carotid and middle cerebral arteries, the benefit of
thrombectomy use in basilar artery occlusions and for
more distal occlusions in the anterior circulation remain
to be established.

Figure 2. Effects of Aspirin on Early Recurrent Stroke After TIA and Ischaemic Stroke
All Patients

Participants Presenting with TIA and Minor Stroke Only
Any ischaemic stroke
0-2 weeks HR, 0.35; 95% CI, 0.20 to 0.60; P = .0001
0-6 weeks HR, 0.38; 95% CI, 0.27 to 0.53; P < .0001
0-12 weeks HR, 0.46; 95% CI, 0.35 to 0.59; P < .0001

3.5

Risk for Event (%)

3.0

2.5

Control
Aspirin

2.0

1.5

1.0

0.5

Any ischaemic stroke
0-2 weeks HR, 0.46; 95% CI, 0.31 to 0.69; P = .0002
0-6 weeks HR, 0.42; 95% CI, 0.32 to 0.55; P < .0001
0-12 weeks HR, 0.47; 95% CI, 0.38 to 0.58; P < .0001

Weeks

Source: Rothwell PM et al. Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis
of randomised trials. Lancet. 2016; 88(10042):365-375. doi: 10.1016/S0140-6736(16)30468-8.

October 2017

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