Abstract
The second issue of the European Stroke Journal is published between the International Stroke Conference held in Los Angeles in February and the ESOC organised in Gothenburg in May. In this issue of the journal, several articles focus on two major areas in acute stroke care: (i) how to predict accurately middle- and long-term outcomes? (ii) how to do more for our patients?
How to predict accurately middle- and long-term outcomes?
Predicting middle- and long-term outcomes is of major interest to ensure an appropriate use of available facilities and to provide individualised therapeutic options. Several studies published in this issue were conducted in the setting of acute stroke trials. A multicentre study aimed at the development and validation of a prognostic score for disability at discharge and functional outcome at three months in patients with an acute ischaemic stroke, based only on clinical information available at admission: increasing age and increasing national institutes of health stroke scale (NIHSS) scores at admission were associated with worse outcomes, together with diabetes mellitus and atrial fibrillation. Another study aimed at identifying predictors of pneumonia in patients admitted for acute stroke: those at highest risks were older, men (vs. women), with pre-existing disability, previous respiratory disorders, more severe strokes, dysphagia and haemorrhagic (vs. ischaemic) strokes. These two studies provide interesting tools to predict outcomes that need now to be externally validated in other settings. Two other studies focused on long-term outcomes. One showed that, in patients with small-vessel disease, the cognitive outcome is influenced not only by education, a well-known association, but also by the so-called ‘pre-morbid intelligence’ evaluated by the National Adult Reading Test. If this finding, provided by an observational study conducted in small group of patients, is confirmed in other populations, pre-morbid intelligence will have to be considered for future studies, besides education. An ancillary study of the International Stroke Trial (IST)-3, conducted in the subgroup of Swedish patients recruited for this trial, showed that the functional outcome at six months is highly associated with the quality of life at 18 months and costs at three years. This study validates the use of three to six months functional outcomes as end-point for acute stroke trials.
How to do more for our patients?
The management of acute stroke has considerably changed over the last 25 years. The organisation of pre-hospital and in-hospital networks to decrease delays, stroke unit care, intravenous thrombolysis and more recently mechanical thrombectomy, contributed to improve outcomes at the population level. Decompressive surgery has also changed considerably the outcome in selected patients, but with a smaller impact at the population level, patients eligible being – fortunately – less frequent. However, despite these major improvements, there is still a lot to do. For patients with intracerebral haemorrhage, we are – almost – at the same level than 30 years ago: improvements are minor and do not really have an impact that we can measure at the population level. For ischaemic stroke, there is still a lot to do for a better use of what is already available. As mechanical thrombectomy is nowadays part of the therapeutic plan in a significant number of patients, and not available in all stroke centres, the question of whether the mothership model should be preferred to the drip and ship model is of major importance, knowing that the same rules cannot be applied in high-density areas with several stroke units and in areas with a low density of population and long distances to the closest neuro-interventional centre. A study published in this issue of the journal shows that the drip and ship model is probably the best provided the door-to-needle time can be reduced to 30 min and delays to be admitted in the thrombectomy centre can be reduced. This study confirms the crucial role of delays in the decision. Another question raised recently in centres where both intravenous thrombolysis and mechanical thrombectomy are available, is whether patients eligible for both should receive intravenous thrombolysis before thrombectomy or not. A group of American colleagues, using randomised controlled trials, suggest that intravenous thrombolysis before mechanical thrombectomy is associated with better outcomes, but, as they perfectly discussed many confounders could not be taken into account and should now be explored prospectively in future trials.
The presentation of the results of MR CLEAN at the World Stroke Congress in Istanbul in October 2014, followed by the publication of several trials in 2015 and 2016 showing the benefit provided by mechanical thrombectomy, is not the end of the story. This is just a step, and a lot has still to be done. The next two major stroke meetings to be held in 2018 will be excellent opportunities to be aware of these next steps. In the meantime, please remain connected to the European Stroke Journal (now accepted for indexing in the Emerging Sources Citation Index, which means that ESJ will be indexed and searchable within the Web of Science) and continue to submit the best of your manuscripts. We hope to see many of you in Gothenburg in May, and in Montreal in October.