We welcome our readers to the fourth volume of the European Stroke Journal. Since its start, the journal has developed well with a steady increase in the number of submitted manuscripts. In the past year, the journal has passed entry in the Web of Science and Scopus, and other publication milestones are in the near future pipeline – so stay tuned!
How should mechanical thrombectomy trial results be applied in clinical practice?
This issue opens with the release of the Guidelines on Mechanical Thrombectomy in Acute Ischaemic Stroke prepared by the European Stroke Organisation (ESO) and the European Society for Minimally Invasive Neurological Therapy (ESMINT). Mechanical thrombectomy has become the cornerstone of acute stroke management in patients with large vessel occlusion. Recent studies have extended the time window from 6 hours to up to 24 hours in selected patients based on clinical and imaging criteria. The ESO/ESMINT guidelines addresses the strength of the evidence for the different time windows, but also addresses several other important issues related to the clinical application of endovascular therapy, providing expert opinion on areas that have been subject to debate.
Quality of stroke services – even low hanging fruits are not easily picked
Quality of stroke services is a recurrent theme in the European Stroke Journal. The current status of access to, and delivery of, acute ischaemic stroke treatments in Europe is addressed by Aguiar de Sousa et al, who report on the large survey of national scientific societies and stroke experts in 44 European countries. The report was an initiative from the
ESO/ESMINT, the European Academy of Neurology (EAN), and the Stroke Alliance for Europe (SAFE), and focuses on the main pillars of acute stroke management: stroke unit care, intravenous thrombolytic therapy, and mechanical thrombectomy. The survey showed large inequalities among and within different countries, demonstrating that probably the majority of stroke patients in Europe do not currently receive best evidence treatments. Treatment opportunities are missed, with large consequences for patients, carers and society. The survey links well to the ESO European Stroke Action Plan 2018-2030 (ESJ volume 3:4).
Two other articles in the current issue relate to the status and implementation of stroke services. Allen et al report a modelling study on maximising access to thrombectomy services for stroke in England of interest to stroke professionals and administrators in all regions in which similar analyses and actions are currently underway. In the largest study today, McGlinchey et al report on physiotherapy provision to hospitalised stroke patients, based on data from the UK Sentinel Stroke National Audit Programme. They found that several demographic and clinical factors were related to intensity of physiotherapy, which should alert practitioners to the inequalities also in this aspect of stroke management.
Stroke syndromes, risk factors, and determinants of outcomes
Gaps on several aspects of stroke prevention continue to be filled gradually by reports providing novel and more granular knowledge. The concept of nonfocal transient neurological attacks (TNA:s; defined as attacks with atypical, nonlocalizing cerebral symptoms such as unsteadiness, confusion or bilateral weakness) is well known to all stroke practitioners, and rises challenging questions on interpretation and management. In their study, Oudeman et al found that one-third of patients with a distant history of transient ischaemic attack or nondisabling ischemic stroke of the anterior circulation experienced nonfocal TNAs in the preceding six months. The prevalence of multiple nonfocal TNAs was higher in patients with carotid artery occlusion than in those patients without, suggesting a hemodynamic contribution.
Atrial fibrillation is one of the most important risk factors for ischaemic stroke, but which type is most risky - paroxysmal or sustained? Paciaroni et al found that after acute ischaemic stroke, patients with sustained atrial fibrillation had a higher rate of early ischaemic recurrence than patients with paroxysmal atrial fibrillation. However, after adjustment for relevant risk factors, sustained atrial fibrillation was not associated with a significantly higher risk of recurrence, suggesting that the risk profile associated with atrial fibrillation, rather than its pattern, is determinant for recurrence.
Are stroke preventive studies generalizable across different geographical regions? Most stroke scientists would probably presume so, but the study by Hoshino et al shows that the issue may be more complex. Based on data from the large PERFORM study, which showed a neutral results of a novel antiplatelet agent (terutroban) compared to aspirin in about 19000 patients with non-cardioembolic stroke/transient ischemic attack, a post-hoc analysis of Asians and non-Asians showed that Asian patients were at significantly higher risk of intracranial haemorrhage and major bleeding. The risk of recurrent stroke was also significantly higher in Asian patients among those with lacunar stroke. The findings demonstrate the need to consider population-specific approaches to secondary stroke prevention.
Many studies on imaging markers of cerebral small vessel disease have focused on progression of the disease and clinical counterparts. Van Leisen et al looked at regression of cerebral small vessel disease, and in their cohort found that 10 to 20% of the patients had either white matter hyperintensities regression, vanishing lacunes, or vanishing microbleeds.
Regression of small vessel disease markers was associated with similar cognitive decline compared to stable small vessel disease and did not accompany brain atrophy, suggesting that small vessel disease regression follows a relatively benign clinical course.
Clinical studies have linked fever after acute stroke, seen in one fourth to half of the patients, with worse outcome, but paradoxically clinical trials on hyperthermia prevention with high-dose paracetamol failed to demonstrate improvements in functional outcome or survival. Is fever after stroke the hen or the egg? De Jonge et al performed a systematic review of fever and outcomes in animal models of ischaemic stroke, and found that hyperthermia substantially increased infarct size, suggesting that the relation between fever and poor outcome observed in patients is at least in part causal.
As this editorial is prepared, the International Stroke Conference in Honolulu is ongoing. Later in spring we hope to meet our readers at the fifth European Stroke Conference in Milano. Many of you have submitted abstracts, and many of you have manuscripts in preparation. We welcome you to submit your best science to the European Stroke Journal.
Bo Norrving
Editor-in-Chief Lund University, Lund, Sweden
Email: bo.norrving@med.lu.se
Didier Leys
Vice Editor University of Lille, Lille, France
Karin Klijn
Associate Editor Radboud University, Nijmegen,
The Netherlands