Abstract
We are pleased to present to you the third issue of the European Stroke Journal. You will find yet another European Stroke Organisation (ESO) guideline, advise from the ESO Trials Alliance (ESOTA) on the building of stroke clinical trials networks, a report on the position of women in the ESO, the results of a European multicentre randomised controlled trial, two original studies on ICH and SAH, a systematic review and a study protocol.
An international working group summarised the evidence on antithrombotic treatment for secondary prevention of stroke and other thromboembolic events in patients with stroke or transient ischaemic attack and non-valvular atrial fibrillation. In this guideline, you will find information that you can use in your clinical practice regarding specific topics including the timing and bridging of medical treatment, restarting of medical treatment after intracerebral haemorrhage and information about medical treatment in the elderly, in patients with cognitive deficits, with renal impairment and in those with small vessel disease.
ESOTA is a voluntary partnership of national networks, which will foster investigator-led clinical trials in European countries. The authors report their first year activities, including the identification of and collaboration among five networks, comprising around 200 hospitals, in England, Ireland, Netherlands, Spain and Switzerland. ESOTA aims to gradually grow into a network of networks to facilitate randomised controlled trials of new stroke treatments.
In a systematic review by colleagues from the UK and Norway, the accuracy of the Heads Impulse-Nystagmus-Test of Skew (HINTS) for the identification of posterior circulation stroke was investigated in patients with acute vestibular syndrome. They found that a positive HINTS increases the risk of having a posterior circulation stroke 15-fold. A negative HINTS is very helpful to exclude posterior circulation stroke, whereas a positive HINTS is less accurate in predicting a posterior circulation stroke.
A Dutch-Swedish collaboration studied the proportion of aneurysmal SAH patients with poor outcome from early in-hospital rebleeding that can be prevented by emergency aneurysm occlusion. In a period of 10 years, they found 16 patients out of a total of 923 (1.7%) who were in good clinical condition on admission who had a rebleed. Of these, nine rebleeds could have been prevented by emergency treatment within 1 h during daytime shifts and four by treatment within 4 h during daytime shifts. Based on their data and on disparate results on the risk of ultra-early treatment of ruptured aneurysms in the literature, they do not recommend 24/7 < 1 h treatment regimens for ruptured aneurysms.
As illustrated by this year’s The Lancet’s February 9 issue, dedicated to advancing women in science, medicine and global health, a gender gap remains widely prevalent in the field of medicine; this is not different for stroke. ESO’s Women’s Initiative for Stroke in Europe reports on the results of the efforts within ESO to close this gender gap within the organisation. Although there was a significant increase in the proportion of female members of ESO and in women faculty at ESOC between 2014 and 2017, the proportion of women holding positions of seniority and leadership is still significantly lower than the proportion of women attending educational activities. So, we are making progress but a lot of work remains to be done.
The results of Euro-HYP-1, an investigator-initiated, international, multicentre, randomised, open-label, blinded outcome, clinical trial illustrate how difficult it can be to demonstrate clinical benefit of a treatment of acute stroke that appeared safe and feasible in phase 2 trials. Euro-HYP-1, similar to the previously published ICTuS 2 trial, was stopped early after inclusion of 98 of the intended 1500 patients. Cooling to a target of 34.0–35.0°C within 6 h of symptom onset and maintaining this for 12–24 h was found not feasible. With the severely underpowered sample size, it was not possible to demonstrate any effect on functional outcome after three months. An important lesson to be learned from this study is that recruitment was significantly hampered by the complexity of the trial design, and regulatory and reporting requirements.
In an international collaboration of three trials in patients with intracerebral haemorrhage, VISTA, Interact1 and MISTIEII, the authors assessed in over 1028 patients baseline predictors of oedema extension distance (EED) and its association with clinical outcome. Increasing EED between 0 and 72 h was independently associated with worse modified Rankin score at 90 days. The authors conclude that EED could be a useful surrogate outcome measure in early phase randomised controlled trials of treatments aimed at secondary injury involving development of oedema in patients with ICH. This study is one of a multitude of increasing efforts in recent years towards finding a treatment for this devastating subtype of stroke that in population-based studies still has a one month mortality of 40%.
Finally, you will find the protocol and rationale of the Treat Stroke to Target trial conducted in France and South Korea comparing two LDL targets in patients with atherothrombotic stroke. Patient inclusion has been completed at the end of 2018 and the answer to the question whether treating to a LDL-c target of less than 70 mg/dL (1.8 mmol/L) leads to less recurrent ischaemic stroke, myocardial infarction, urgent coronary or carotid revascularisation after new symptoms requiring hospitalisation, or vascular death than achieved LDL-c of 100 mg/dL (2.6 mmol/L) is expected soon.
Enjoy reading, and looking forward to the submission of your best research to our journal.