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 16th
European Stroke Conference
Glasgow, United Kingdom 2007
"Glasgow Highlights"
Glasgow hosted the 16th European Stroke
Conference in the new conference facilities along the renovated waterside of the
famous river Clyde. In former times teeming with shipbuilders, the last week of
May 2007 found it teeming with the 2450 delegates, 251 nurses, support staff and
other attendees of the conference. It consisted on a 4-day program of courses,
plenary sessions, special subject platform presentations, full-day posters, and
special symposia. The weather cooperated for the most part. Participants were
scattered widely enough in the city's hotels as to appreciate the venue as well
as the meeting, and the proceedings were started off with a reception in the new
Science Center. Announcements were made in Scottish English, requiring some
translation for many, including some who use English in daily life.
The extensive schedule began 29 May with 10 special teaching courses, and an
inaugural two-day set of symposia for the Nurses, Physiotherapists, Speech and
Occupational Therapists and Study/Monitoring Assistants. The opening scientific
symposium 30 May featured a wide-ranging set of subjects for a pathway to better
stroke treatments. The Johann Jacob Wepfer Award lecture by the recipient, C.
Warlow, traced the course of clinical investigations in stroke reflected in his
own career and the disappointing evidence of mounting bureaucratic interference
in the conduct of clinical research.
Thereafter, the large number of papers forced another evidence of the growing
popularity of the meeting, parallel sessions. Attendance at all of them was
technically impossible but in this venue another constraint occurred that that
some were so popular the room assigned for the presentations was filled to
overflowing and some late-arriving would-be listeners barred from entry. In all,
95 presentations were made on the first day plus 95 posters, over 150 oral
presentations and the no less than 262 posters (107 on acute stroke alone) on
the second, and over 125 oral presentations on the third. Company sponsorship
was cited for several of the main plenary sessions and separate
company-sponsored symposia parallel the meeting.
The opening plenary session featured a mixture of stroke problems. A two-center
report of CADASIL found whole brain atrophy a better guide to dementia measured
by global cognitive function than were the specific locations of lacunar
lesions, a challenge to the strategic infarct dementia literature.
New data was presented on major clinical subjects as well as detailed review of
recently-completed and published clinical trials. In the
NovoNordisk Factor VIIa
(FAST) trial, the primary outcomes of death and disability status at
90 days proved disappointing compared with the earlier smaller results.
Nonetheless, the agent's ability to limit hematoma growth was amply confirmed,
especially for those treated within 4 hours of onset, the 80 ug performing
better than the 20 ( see special presentation).
Ischemic stroke treatment, again including details of hemorrhagic complications,
was another major subject for plenary sessions.
The recently-published open-label multinational ischemic stroke trial ESPIRIT
was presented in more detail, including a review of the initial attempts
(SPIRIT) where an INR 3.0-4.5 for the warfarin arm have forced cessation due to
higher-than-acceptable hemorrhage rates in that arm. The revised project was
part of a multi-arm project with included arms for warfarin, aspirin, and the
combination of aspirin and long-acting dipyridamole. Warfarin was used at an INR
2-3, those with leukoariosis were excluded, and aspirin was given in a wide
range from 30 to 325 mg daily. A blinded adjudication committee assessed
reported end-points. The cumulative outcome events graphs overlapped at all
points in time, events for aspirin at 4.5% and for warfarin at 4.4% per year. In
the warfarin arm the lowest ischemic and hemorrhagic event rates occurred at an
INR 2.0-2.5.
The highlight for the meeting was the last-day presentation of the data from the
just-completed Phase III study of Desmoteplase (DIAS 2). This trial had tested
clinical efficacy and safety of two different dosages of
recombinant Desmoteplase (90 µg/kg and 125 µg/kg) onset within 3-9 hours
after onset of ischemic stroke symptoms; score of 4-24 on the NIHSS with
distinct penumbra (at least 20%) on imaging. The results were disappointingly
negative. Earlier studies had given hopes the usual brief time period after
onset of stroke could be extended and still to achieve favorable clinical
results with thrombolysis, and hopes were also disappointed that the MR mismatch
technique might predict success.
Other subjects for plenary sessions included headaches. Among risk factors, an
example of a wine was shown whose name and label indicated a migraine risk, but
the name of the vineyard was not disclosed, and one doubts it is commercially
available. A review of “thunderclap headache", cited the many usually-normal
test results and differential diagnoses. Included was a discussion of the
"reversible cerebral vasoconstrictive syndrome" equated by the speaker with the
Call-Fleming naturopathy, migraine, drug-induced and post-partook antipathies.
In another plenary session,
an increasingly popular debate format, complete with audience participation
selecting choices offered as questions, took the topic of the use of warfarin
for the elderly with atrial fibrillation. The two participants more agreed than
disagreed, in settings where full investigations of hemorrhage risk could be
carried out for a population prior to initiation of therapy. A recommendation
for search for microbleeds (MBs) was buttressed by a wide range of citations for
their high prevalence (6% in healthy elderly subject, 22-40% with those having
prior stroke, 38-68% with prior hemorrhage). It was countered with the
disappointed awareness of the lack of such technology in many clinical settings
world-wide, forcing a decision for anticoagulation based on other factors,
including the low (0.1-0.9%) risk for hemorrhage and only modest odds ration of
1.20 even on warfarin compared with the far higher rate of ischemic stroke for
the rising rate of atrial fibrillation as the population ages. This debate seems
likely to continue.
JP Mohr, New York, USA
Oral presentation form the
Novo Nordisk Factor VIIa "Fast Trial"
Please follow this link!
In addition video records from the
lunch satellite symposium on standards in acute and post-stroke treatment are
available:
Please follow the links!
CD
Rom from the16th ESC Glasgow, United Kingdom 2007
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