Joint roundtable by ASA, ESO and WSO, 21st May 2026

Key Take-Homes

1. Tenecteplase before thrombectomy improves early reperfusion
The BRIDGE-TNK trial adds evidence supporting TNK over alteplase as the pre-thrombectomy thrombolytic of choice. It may streamline care with better early reperfusion outcomes and faster procedures.

2. Low-intensity monitoring after IVT is safe for selected patients
OPTIMIST trial results support using reduced neuro-checks and vital monitoring in mild-to-moderate strokes (NIHSS <10) post-thrombolysis. This can safely reduce ICU admissions and nursing burden.

3. Task-shifting and digital health improve secondary stroke prevention
The PINGS 2 trial demonstrates that nurse-led mHealth interventions significantly improve BP control post-stroke in resource-limited settings, offering a scalable model for stroke prevention in LMICs.

4. Tyrofiban post-thrombolysis shows functional benefits with low bleeding risk
Adding tyrofiban early after IVT improves outcomes in patients not eligible for EVT, without increasing serious bleeding events. While promising, more trials in diverse populations are needed before routine use.

5. Neuroprotection may be back on the agenda – cautiously
Oral adaravone showed benefits in patients outside reperfusion eligibility. However, because the evidence comes exclusively from China, international replication is required to confirm its role in global stroke care.

The ESOC 2026 roundtable brought together global leaders from the European Stroke Organisation (ESO), the American Heart and Stroke Association (AHA/ASA), and the World Stroke Organization (WSO) to discuss recent landmark stroke trials. The webinar presented key findings with relevance for frontline stroke care worldwide.

1. The BRIDGE-TNK Trial – Tenecteplase Prior to Thrombectomy

This trial evaluated tenecteplase (TNK) versus no thrombolytic therapy prior to endovascular thrombectomy (EVT) in large vessel occlusion stroke. Most earlier bridging studies used alteplase, not TNK. In BRIDGE-TNK, 278 patients received TNK + EVT and 272 received EVT alone, all within 4.5 hours of symptom onset.

Findings:

  • TNK group showed better early reperfusion rates and more successful reperfusion before EVT.
  • Time from puncture to reperfusion was shorter.
  • Secondary outcomes also trended positively.

Clinical implication: TNK may offer improved workflow and outcomes in EVT-eligible patients, with potential to shift practice in pre-thrombectomy thrombolytic use.

2. OPTIMIST Main Trial – Low-Intensity Monitoring Post-Thrombolysis

The international OPTIMIST trial assessed whether low-intensity monitoring (LIM) was non-inferior to standard high-intensity monitoring (HIM) in patients with mild-to-moderate stroke (NIHSS <10) following intravenous thrombolysis.

Design & Protocol:

  • 4,922 patients across 114 hospitals in 8 countries.
  • LIM included frequent checks in the first 2 hours, then spaced out checks over 24 hours.
  • HIM involved intensive ICU-level surveillance throughout.

Results:

  • LIM showed no difference in functional outcomes at 90 days or safety outcomes (including sICH).
  • ICU use was significantly lower in the LIM group.
  • LIM was well accepted by patients and clinicians.

Clinical implication: For stable patients with mild/moderate stroke post-IVT, LIM is a safe, resource-efficient approach that could free up critical care capacity.

3. PINGS 2 Trial – Nurse-Led, mHealth-Facilitated BP Control in Africa

The PINGS 2 trial was a nurse-led secondary prevention study in Ghana using mobile health (mHealth) for blood pressure (BP) control after stroke.

Intervention:

  • BP self-monitoring at home
  • Weekly nurse check-ins
  • Phone reminders and educational messages

Results:

  • 67% in the intervention arm achieved systolic BP <140 mmHg at 12 months vs. 43% in usual care.
  • No significant difference in adverse cardiovascular events due to small sample size.
  • Cost: $540/year vs. ~$1,500 for more complex digital interventions.

Clinical implication: Task-shifting with low-cost digital support is an effective, scalable model for stroke secondary prevention in resource-limited settings.

4. TYROFIBAN Trial – Early Antiplatelet After Thrombolysis

This Chinese trial tested the use of the IV antiplatelet tyrofiban administered early after thrombolysis (mostly with alteplase) in patients not eligible for EVT. It aimed to reduce re-occlusion and improve outcomes.

Results:

  • Modified Rankin 0–1 at 90 days: 66% (tyrofiban) vs. 55% (placebo)
  • Low sICH risk: 1.7% in tyrofiban vs. 0% in placebo
  • Mortality 4% in both groups

Clinical implication: Tyrofiban shows promise in improving early functional outcomes post-thrombolysis, with acceptable bleeding risk. Confirmation in Western populations is needed.

5. Adaravone (Neuroprotection) – ERASE Stroke Trial

A Chinese trial of oral adaravone, a neuroprotective antioxidant, in patients ineligible for reperfusion therapy (e.g. beyond time window).

Design:

  • Double-blind RCT of 28-day oral adaravone
  • 3 positive Chinese trials to date
  • Significant shift in modified Rankin scale, particularly for minor disability

Limitations & Caveats:

  • Conducted entirely in China
  • Population largely untreated with IVT or EVT
  • Raises questions of generalisability

Clinical implication: Neuroprotection may be entering a new era, but Western validation trials are essential.