Recent Findings in Neurology: Multiple Sclerosis and Stroke

Hans-Christoph Diener, MD, PhD


April 06, 2022

This transcript has been edited for clarity.

Dear colleagues, I am Christoph Diener, from the medical faculty of the University Duisburg-Essen in Germany, and I want to report what happened in the first 6 weeks of 2022 in neurology, focused on multiple sclerosis and stroke.

Let me start with the spectacular publication in Science on the possible relationship between Epstein-Barr virus infections and multiple sclerosis. This paper is based on 10 million people in the American Army who were followed from 1993 to 2013. In this population, 925 people developed multiple sclerosis; serum samples were available from 801 people and 800 had positive titers against Epstein-Barr virus. This was much higher than in the control population. For cytomegalovirus infections, there was no difference.

When they looked at the conversion rate for Epstein-Barr virus in serum, this was the case in 97% of the patients with multiple sclerosis, but only in 57% in the control group. These data would suggest that there is an association between Epstein-Barr virus infection and multiple sclerosis, but this does not mean this is a causal relationship. There was a large amount of public press coverage of this study. The conclusion was that possibly a vaccination against Epstein-Barr virus would prevent multiple sclerosis, but unfortunately, this vaccination is not yet available.

Let me move to stroke. We all know that thrombectomy is also effective beyond the standard 6-hour time window. A group of researchers performed a meta-analysis, published in The Lancet, of 6 studies with 505 patients, where thrombectomy was compared with standard medical treatment in patients beyond the 6-hour time window. The outcome was modified Rankin after 90 days. It's not a surprise that, in this population, thrombectomy was significantly more effective than standard medical care; the odds ratio was 2.42. There was no difference in mortality between thrombectomy (16.5%) and standard medical care (19.3%).

Some patients, particularly Asians, can have symptomatic intracranial stenosis. Many years ago, the SAMMPRIS trial showed no benefit of stenting of intracranial stenosis beyond best medical therapy, but the complication rate of stenting has decreased dramatically in the last few years.

Therefore, a study group in China published a paper in JAMA Neurology where they treated 263 patients who had symptomatic intracranial stenosis either with drug-eluting stents or bare metal stents and followed these patients for 1 year. Again, it's not a surprise that the rate of restenosis after 1 year was much lower with drug-eluting stents (9.5%) compared with bare metal stents (30%). This translated also into a lower rate of recurrent strokes.

Now, let me summarize a few studies that were presented at the International Stroke Congress in the United States, in February 2022.

The first study was from Japan and published simultaneously in The New England Journal of Medicine. The investigators collected patients who had an intracranial occlusion of a large cerebral artery and a large stroke with an Alberta Stroke Program Early CT Score (ASPECTS) 3 to 5, and they compared thrombectomy with standard medical care. The percentage of patients with a modified Rankin scale score of 0 to 3 after 90 days was 31% in the thrombectomy group and 12.7% in the best medical treatment group, and this related to a relative risk of 2.43. Obviously, some patients with severe strokes can benefit from thrombectomy.

Another study from the United States was designed to compare the treatment at dedicated stroke centers with primary stroke units, and they looked at 84,903 patients between 2018 and 2020. Again, it's not a surprise that being treated in a comprehensive stroke center leads to a shorter time interval to the initiation of thrombolysis and thrombectomy, and to a better outcome.

Another study was a real-world study with 1000 patients with acute ischemic stroke, who were treated with thrombectomy. Of these patients, 50% had a good functional outcome. Unfortunately, this big study had no control group, and we are all convinced, I think, that thrombectomy dramatically improves the outcome of stroke patients.

The final study was a registry study in patients with sinus venous thrombosis. The investigators collected 1025 patients between 2015 and 2022, and they compared direct-acting oral anticoagulants (DOACs), which were taken by 33% of patients, with warfarin, taken by 52% of patients, and with 15% of patients who had either DOAC or warfarin and were switched between the two treatments.

After 1 year, there was no difference in the risk for recurrent sinus venous thrombosis or mortality between the two treatment groups. The rate of severe bleeding complications, including intracranial bleeds, was reduced by 65% with DOACs. This provides a very strong argument to use DOACs in patients with sinus venous thrombosis.

In summary, the International Stroke Congress did not include study findings that will change everyone’s clinical practice. Let’s hope that we see more promising results at the European Stroke Organisation meeting in May.

Ladies and gentlemen, I am Christoph Diener, from the faculty of medicine at the University of Duisburg-Essen. Thank you very much for listening and watching.

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