Editorial

In this issue of the European Stroke Journal, you will find the report of the European Stroke Action Plan for Europe for the years 2018–2030. It follows two previous statements. The first one, called ‘declaration of Helsinborg’, was adopted in 1995. It consisted of a European consensus statement on the basic elements for policy in stroke and objectives of treatment. This declaration was prompted by the evidence of important differences in stroke incidence between European countries, five years after major geopolitical changes in Europe and the identification of factors that can be modified to prevent stroke. A plea was made to better organise stroke care, to measure the quality of care, to facilitate early diagnosis and potential future acute therapies (the first positive thrombolysis trial had just been published), to improve access to rehabilitation and to apply appropriate secondary prevention measures. The second Helsingborg Declaration published in 2006 was a statement on the overall aims and goals of five aspects of stroke management: organisation of stroke services, management of acute stroke (thrombolysis was still being implemented in practice at this time), prevention, rehabilitation, evaluation of stroke outcome and quality assessment. All these objectives were supposed to be achieved by 2015.

Following the same format, the European Stroke Organisation (ESO) prepared a European Stroke Action Plan for the years 2018–2030, in cooperation with the patient’s organisation Stroke Alliance for Europe (SAFE). The overall domains were those of the first two declarations with the addition of primary prevention and life after stroke. Four main targets for 2030 were identified: (1) reduction of the absolute number of strokes in Europe by 10%, (2) having more than 90% stroke patients in Europe admitted to a dedicated stroke unit, (3) having national plans for stroke that encompass the whole chain of care and (4) implementing national strategies for multisector public health interventions. Overall, this action plan identified 30 targets and 72 research priorities. The European Stroke Action Plan is necessary because, despite the important improvements in terms of prevention and acute management that occurred since 1995, not all patients have access to optimal stroke care, and huge disparities still exist between – and sometimes within – countries. Moreover, the burden of stroke is still increasing, partly because of ageing of the population and partly because of a better survival after myocardial infarction and stroke, two situations that render patients at higher risk for stroke compared to the general population. We need to put a stop to the increasing burden of stroke because nowadays strokes can be prevented, and many strokes are treatable provided patients have expeditious access to appropriate care.

The objectives of this action plan may seem ambitious, and they are, and they need to be. This declaration will not be enough per se to lower the burden of stroke in Europe, but declaring our ambitions is a necessary step to make policy makers aware of the ever-increasing burden of stroke if we do not intensify our efforts. Doctors, patients and policy makers must work together to alleviate the burden of stroke. Appropriate political decisions need to be guided by such declarations. In a period when money becomes more difficult to raise, priorities should be influenced by health professionals and patients’ organisations, to advice the decisions of politicians. This action plan will be an important tool to achieve these ambitious objectives.

In this issue of the journal, you will also find two protocols. The PISCES study aims at testing the hypothesis that aerobic fitness training has a neuroprotective effect after stroke, the primary outcome being hippocampal volume after four months. If this trial is positive, it will have the potential to identify a new treatment that could be translated to practice quite easily in many patients. The RUN DMC-intense trial aims at investigating the monthly incidence of diffusion-weighted imaging lesions in subjects with small-vessel diseases and to assess to which extent these lesions explain progression of imaging markers over time, their effects on cortical thickness, structural and functional connectivity and cognitive and motor performance and their potential role of the innate immune system in the pathophysiology of small-vessel disease. A better understanding of the role of these lesions may also generate hypotheses for prevention.

Two national studies are also of major interest. An online survey sent to stroke physicians within the United Kingdom showed a lack of consensus for when to initiate oral anticoagulation for secondary prevention in stroke patients with atrial fibrillation. Whereas they agreed that oral anticoagulation should be started soon (i.e. within three days) after the event in patients with transient ischaemic attacks, there were huge variations in patients with moderate and severe stroke, warranting the randomised trials that just have started in this field. The Dutch acute stroke audit was a benchmark of acute stroke care in the Netherlands. It provides interesting data from a huge number of patients (more than 60,000) who had a stroke in 2015 or 2016 and showed that one out of five patients received intravenous rt-PA (with a median door-to-needle time of 25 min) and 1 out of 25 underwent mechanical thrombectomy (with a median door-to-groin time of 64 min).

Two reviews from the United Kingdom are also published in this issue of the European Stroke Journal. One reports that oral care tends to be of poor quality and delegated to the least qualified members of the caring team. Although oral care is important, it tends to be neglected, which is an issue, as a poor oral hygiene is associated with an increased risk of aspiration pneumonia. A systematic review addressed the completeness of reporting of randomised controlled trials in patients with transient ischaemic attacks or stroke. The authors found that adherence to CONSORT guidelines has improved over time but are still not optimal.

Finally, besides offering our readership a new issue with excellent articles, we are also pleased to inform that the journal is now referenced in SCOPUS, besides being included in the Web of Science. We thank our readers for supporting the journal and look forward to report to you on the further progress of the European Stroke Journal.

Didier Leys, Vice Editor

University of Lille, Lille, France

Email: [e-mail]

Bo Norrving, Editor-in-Chief

Lund University, Lund, Sweden

Karin Klijn, Associate Editor

Radboud University, Nijmegen, The Netherlands