Abstract
With the second issue of the European Stroke Journal, we are pleased to inform our readers that our journal is now indexed in PubMed, which is a crucial milestone in its development. We thank all the authors and reviewers for their continuous support during these first years.
This second issue of the European Stroke Journal includes one European Stroke Organisation (ESO) guideline, six research articles and two protocols of on-going studies.
Telemedicine has been shown to be safe and to help increasing the use of evidence-based therapies in stroke. The telestroke committee of the ESO provides recommendations on the setup of telestroke networks in Europe. Telemedicine is a very useful tool in low-density areas where having access at a stroke expert on-site is almost impossible. Three types of participating centres are identified: the network centre, the telemedicine-assisted stroke unit, where stroke expertise is not available on a 24/7 basis and telethrombolysis units where patients can receive rt-PA in an emergency department before being referred to a stroke unit. Our readers will find in these recommendations interesting tools to setup a telestroke network in their area. We should bear in mind, however, that these recommendations should not be interpreted by health authorities as a way to decrease costs – in high-density areas the lack of stroke specialists needs to increase their number – or by those of the neurologists who have a poor interest for stroke as a way to be disengaged in its management.
Our colleagues from Utrecht are well known for their interest in subarachnoid haemorrhage, a disease that is unfortunately not managed in stroke units in many countries. They addressed a very important question, i.e. the profile of patients who experience early re-bleeding (within 24 h), a condition known to have a very poor outcome. They identified an irregular shape of the aneurysm as an independent predictor of early re-bleeding. However, as most patients with aneurysmal subarachnoid haemorrhage have an irregular aneurysm, additional risk factors for early re-bleeding need to be identified to select patients in whom early clipping or coiling may be needed.
The Biological Markers Associated with Acute Ischemic Stroke (MAGIC) study group (Italy) investigated associations between imaging signs of small-vessel disease on CT-scans and blood biomarkers of endothelial dysfunctions at the acute stage (where they did not find any association), and at 90 days after stroke (where the association was present). A limitation of this study, well discussed by the authors, is the lack of MRI, preventing the evaluation of important imaging markers of small-vessel disease such as brain microbleeds and dilated perivascular spaces.
The ESO, together with SAFE, a patient organisation, conducted an original survey on the availability of secondary prevention services after stroke or transient ischaemic attacks (TIA) in Europe. The originality of this survey is to evaluate how evidence-based data translate into practice. This survey showed that high-income countries do better than less affluent countries, which is not surprising, cost being an important issue in secondary prevention strategies. The most important finding of this survey is that a lot has still to be done as even in high-income countries that had the best results, care if far from optimal: for instance, more than 50% of TIA are not managed within the first 48 h when the risk is the highest, and 20% of those who need carotid surgery have to wait more than two weeks after the clinical event.
The groups of Basel and London investigated whether lesions seen on diffusion-weighted images (DWI) after carotid artery stenting (CAS) or carotid endarterectomy (CEA) can provide a surrogate outcome measure for procedural strokes. A systematic search found 4871 patients with CAS and 2099 with CEA in 85 trials. They found in the whole group of patients who underwent a recanalisation procedure (either CEA or CAS) and in patients with CAS, a significant association between clinical strokes and occurrence of DWI abnormalities. In patients with CEA, this association could not be evaluated because of the lack of statistical power. The authors conclude that occurrence of new DWI lesions can be considered as a surrogate marker in patients who undergo carotid revascularisation.
Our colleagues from London performed a systematic review and meta-analysis to clarify the impact of selective serotonin re-uptake inhibitors (SSRIs) on the risks of intracranial haemorrhages (ICrH) in patients with depression or other indications for SSRI. They identified 24 observational studies and three randomised trials. They found an association between the SSRIs and an increased risk of ICrH, but they showed also that this association is, in part, accounted for by prescription bias and methodological issues. Therefore, there is no sufficient data to advise against SSRIs.
Another systematic review focused on the risk of cognitive impairment no dementia after a stroke. The author analysed 23 studies and performed a meta-analysis of 21 of them. The prevalence of cognitive impairment no dementia was 38%. However, study quality emerged as one source of heterogeneity between these studies. This review confirms the burden of cognitive impairment after stroke, 4 out of 10 patients with stroke experiencing cognitive decline in the first year, on top of those who develop dementia.
Two protocols of on-going studies are published in this issue. The Nordic atrial fibrillation and stroke study is an international, multicentre, prospective, observational study that evaluates predictors of occult atrial fibrillation in patients with cryptogenic ischaemic stroke or TIA who consented to have a 12-month ECG monitoring with an insertable device. The results of this study are expected at the end of 2020. The results of the first two ESUS trials will make the search for atrial fibrillation necessary and the results of this study of major importance. The other protocol is that of the Registry of acute stroke under novel oral anticoagulant (RASUNOA-prime). This study conducted in Germany is designed to describe current patterns of emergency management, and of outcome of patients with atrial fibrillation who have an acute stroke (ischaemic or haemorrhagic) under direct oral anticoagulants. This will help physicians for emergency management of these patients.
This issue of the European Stroke Journal will be released approximately at the moment of the 5th European Stroke Organisation Conference, held in Milan, 21–24 May. We hope to meet you there and that you will submit the best of your research to the Journal.
Didier Leys, Vice Editor
Karin Klijn, Associate Editor
Bo Norrving, Chief-Editor