Over 4,500 participants saw the first presentation of results from a raft of trials at the 4th European Stroke Organisation Conference (ESOC) in Gothenburg, Sweden, in May. The findings provided multiple insights into stroke management, both positive and negative.

Most notable among the negatives was the NAVIGATE-ESUS trial, which tested the safety and efficacy of the anticoagulant rivaroxaban against aspirin for secondary prevention in patients with embolic stroke of undetermined source (ESUS). The trial was terminated early because rivaroxiban was no more effective than aspirin at preventing recurrent stroke, and was associated with a significantly higher risk of major bleeding and intracranial haemorrhage.

More encouraging were retrospective analyses of thrombectomy and thrombolysis trials. The AURORA trial was a pooled analysis of five trials of the use of thrombectomy beyond the standard 6 h window. The analysis confirmed that thrombectomy is highly effective when administered up to 24 h after stroke in selected patients. Similarly, a meta-analysis of randomized controlled trials of alteplase presented at the conference demonstrated that the benefits of thrombolysis were unaffected by sex, hypertension, prior stroke, aspirin use and prognostic score.

A 5-year follow-up of the TIA registry was also presented, revealing that the risk of ischaemic events or stroke after a transient ischaemic attack (TIA) or minor ischaemic stroke continues to increase beyond the first year and for at least 5 years. This increase was observed despite optimal risk management, highlighting the need for further work to reduce the long-term risk in patients with TIA or minor ischaemic stroke. Results of the CROMIS-2 study showed that in patients with atrial fibrillation who received anticoagulants after a TIA, microbleeds detected with MRI were predictive of intracranial haemorrhage. However, the findings were not sufficient to identify patients who should not receive anticoagulants.

Finally among the trial highlights, the results of the TICH-2 trial were mixed. The study tested the use of tranexamic acid in patients with intracerebral haemorrhage with symptom onset less than 8 h previously. Compared with placebo, the treatment had no effect on disability after 90 days. However, tranexamic acid did reduce the number of deaths in the days after intracerebral haemorrhage; larger studies will be needed to determine whether this effect is significant.

Also at ESOC 2018, the European Stroke Organisation presented the Action Plan for Stroke in Europe 2018–2030, which was developed in cooperation with the Stroke Alliance for Europe. Effectively a third Helsingborg Declaration, the Action Plan sets out targets for improving stroke services across the continent and ensuring provision of resources that match the societal impact of the disease. The plan covers seven domains, across which a total of 31 targets have been set for 2030. Four overarching targets apply to all domains, and include a reduction in the number of strokes in Europe by 10%, and treatment of at least 90% of patients with stroke in dedicated stroke units.