12 ISC NEWS DAY 2 | THURSDAY, FEBRUARY 6, 2025 StrokeConference.org #ISC25 Carotid pathologies — including carotid stenosis, carotid webs, carotid dissection and intraluminal thrombosis — are complex conditions requiring critical expertise. Understanding the latest in imaging advances, delicate decisions on care and more are the focus of a session on Thursday, “Hot Topics on Hot Carotids.” For decades, the key measurement for determining the risk of cerebrovascular events by atherosclerotic carotid disease has been based on the degree of stenosis. But that’s just one part of a bigger, evolving picture. Luca Saba, MD, dean of the School of Medicine at the University of Cagliari in Italy, said the “degree of stenosis” approach originated from landmark trials like NASCET and ECST that were conducted beginning more than 40 years ago when the only method for assessing carotid arteries was angiography. “Since angiography could only measure the degree of stenosis, this became the main parameter of interest,” Saba said. “The enormous impact of those trials, with high levels of evidence, effectively transformed this measure into dogma. However, in the past 40 years, significant advances have been made.” Saba, who is also a professor of radiology and chair of his university’s radiology department, will address those advances in his presentation, “Degree of Stenosis Isn’t Everything.” “The introduction of CT, MRI and ultrasound allows us to visualize not just the degree of stenosis, but also the underlying cause — the carotid plaque,” he said. “Over the last 20 years, it has become clear that certain morphological and structural characteristics of plaque are linked to increased vulnerability, higher risk of rupture and greater potential for risks. “Today, thanks to advancements in imaging technology, we have the ability to better characterize the plaque itself and more accurately stratify cerebrovascular risk.” Saba said degree of stenosis is an indirect parameter, and there is a growing capability of including other measurements and diagnostic tools. “The goal is to shift the focus from stenosis alone to the concept of plaque vulnerability,” he said, including demonstrating the role of different imaging techniques in identifying features that make plaque vulnerable. Intraluminal thrombus in carotid arteries is a highly dangerous condition in which a thrombus is stuck to the wall but weakly attached, meaning it could detach from the vessel at any moment, causing the patient to have a stroke. Johanna Ospel, MD, PhD, will discuss the best methods for treating these patients in her presentation, “The Intraluminal Thrombus of Damocles.” “This is a pretty precarious situation, since any mechanical manipulation that we perform during interventions could also dislodge the thrombus,” said Ospel, neuroradiology fellow and stroke researcher at the University of Calgary in Alberta. “There is a high risk of doing nothing and a high risk when intervening,” she said. “Patients with intraluminal thrombi must be watched very closely because they can have a stroke at any minute. If that happens, rapid treatment is necessary, so every minute counts.” Ospel said it is the condition’s rarity that makes it particularly challenging because it’s unlikely there will ever be enough patients to do a randomized controlled trial to fully study it. “Therefore, multicenter, retrospective pooling data is absolutely critical to gather large enough datasets to make any evidence-based treatment decisions,” she said. “This is a main difference compared to more common causes of stroke, such as carotid stenosis or atrial fibrillation, where randomized trials are feasible and have been done or are underway.” Two other presentations will be included in the session Thursday: “Caught in the (Carotid) Webs” by Shadi Yaghi, MD, FAHA, associate professor of neurology at Brown University, and “Occluded Carotid: A Fait Accompli” by Edgar A. Samaniego, MD, MS, clinical professor of neurology at the University of Iowa. Cumming School of Medicine in Alberta. The answer could depend on the results of the two other landmark trials, DISTAL (see above) and DISCOUNT (below), evaluating the efficacy of EVT for the management of acute ischemic stroke with more distal occlusions, Dr. Goyal said. Differing results will necessitate an analysis of the trials’ differences to determine criteria for future trials. “If the results are similar in all three trials, however, we may need to be more cautious in terms of how aggressive we are when selecting patients for endovascular therapy,” said ESCAPE-MeVO co-investigator Michael Hill, MD, director of the stroke unit for the Calgary Stroke Program. ESCAPE-MeVO findings were was published simultaneously in the New England Journal of Medicine. Endovascular therapy did not provide an added benefit in patients with distal vessel occlusion stroke Consistent with the DISTAL and ESCAPE-MeVO trial results, the DISCOUNT trial, reporting on the effect of mechanical thrombectomy plus usual care for patients with acute ischemic stroke due to distal vessel occlusion, found mechanical thrombectomy did not provide an added benefit. The open-label trial involving 22 French University hospitals randomized 488 patients with acute ischemic stroke involving the anterior or posterior circulation secondary to a distal vessel occlusion within six hours of symptom onset or within 24 hours if no hypertensive signal on fluid attenuation inversion recovery acquistion 1:1 to mechanical thrombectomy with best medical treatment or best medical therapy alone. The primary outcome was the rate of good clinical outcome defined as a mRS ≤2 at three months and evaluated by an independent assessor blinded to the intervention arm. An interim analysis was planned at the end of the follow-up of the first 163 patients randomized, with a stopping rule for futility defined as a conditional power of <30%. In the control group, 77% of patients (59/77 patients) observed a mRS ≤2 at three months versus 60% (45/75 patients) in the experimental arm. Intracranial hemorrhage was reported in 28 patients in the control arm (29%) and 28 patients in the experimental arm (44%). “The DISCOUNT trial was stopped after the analysis of the first 163 randomized patients because results seemed to disfavor mechanical thrombectomy, and due to a safety issue and the low conditional power of 6.3%,” said the study’s principal investigator Frédéric Clarençon, MD, PhD, head of interventional neuroradiology at the Pitié Salpêtrière Hospital in Paris. Expanding the scope of carotid pathologies Ospel Saba Clarencon LATE-BREAKING SCIENCE continued from page 7 Treatments seek to bring better outcomes in existing and rare conditions. Hot Topics on Hot Carotids 2–3 p.m. | Thursday, Feb. 6 Room 515B UPCOMING SESSION
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