Abstract
We are pleased to present to you the concluding issue of Volume 4 of the European Stroke Journal. 2019 has been a good year for the journal, with entry to PubMed, and an increasing number of submissions.
This issue starts with yet another important ESO Guideline, this time on Reversal of Oral Anticoagulants in Acute Intracerebral Haemorrhage. The benefit of anticoagulants in reducing the risk of ischemic stroke in patients with atrial fibrillation represents a major advance in stroke prevention, and the proportions of patients treated with novel oral anticoagulants (NOACs) are rapidly increasing in most countries and regions. However, the therapy also carries a risk of intracerebral haemorrhage (ICH), although this risk is halved by NOACs compared to warfarin. Anticoagulant-related ICHs now constitute up to a quarter of all ICHs, carry a serious prognosis and pose clinical management dilemmas. The present guidelines provide recommendations for care, even if there is a persisting concern on the lack of adequate randomised trials with hard clinical endpoints in this field.
This issue also includes two consensus statements articles. The Consensus Statements and Recommendations from the ESO Karolinska Stroke Update Conference, Stockholm 11–13 November 2018, were prepared by a large body of leading stroke scientists, with the purpose to provide updates on recent stroke therapy research and to give an opportunity for the participants to discuss how these results may be implemented into clinical routine. Like earlier Karolinska Stroke Update recommendations, the currents topics are broad and represent many areas in which research is currently in progress. In the second consensus statement, the Pneumonia in Stroke ConsEnsuS (PISCUS) group propose a standardised approach to empirical antibiotic therapy in pneumonia complicating stroke, based on likely microbiological aetiology. In their systematic review, no randomised trials to guide treatment were identified, and there was limited evidence available to formulate consensus on choice of specific antibiotic class for pneumonia complicating stroke. These two consensus statements both illustrate the need for further research into many core areas of stroke.
This issue features a second report from the ESO/ESMINT/EAN/SAFE Survey on European stroke services, this time with a focus on planning of stroke care and urgent prehospital care. This study on data from 44 countries shows that there is still a considerable proportion of European countries without an appropriate Stroke Strategy or Plan, something that is unfortunately pointing at the low priority that healthcare decision makers give to stroke in these countries. Like the previous report (published ESJ 4:1), these data further emphasise the importance to implement the European Stroke Action Plan (published ESJ 3:4), a process that has now started and which will be one of the flagship activities of the ESO in cooperation with SAFE for many years ahead. The European Stroke Action Plan emphasises the importance of national quality registers for providing reliable data to monitor quality of care and identify inequalities and gaps. Korea is a country with well-developed stroke registers. Park and colleagues report on the improvement of stroke care in Korea from 2008 to 2014, and that quality of care was higher in centres with a larger volume of stroke or intravenous thrombolysis cases and providing stroke unit care. However, even at the end of the study, there were residual differences between the hospitals, demonstrating that implementation is a long process.
Whereas the risk of stroke increases with age and most strokes occur in the elderly, an important proportion occurs in the young and leads to a large cumulative disability burden with time. There are few comprehensive prospective epidemiological studies on stroke in the young, and the Norwegian NOR-SYS study reported by Nawaz and colleagues is a welcome addition to this literature. Whereas the study found a decreasing incidence trend from 2010 to 2015, the authors cautiously discuss the difficulties in comparing rates and time trends among studies based on small numbers and variations in study methods. The present issue also includes the report by Traenka and colleagues on genetical factors in cervical carotid artery dissection, one of the important causes of stroke in the young. Using whole exome sequencing in patients with a family history, or recurring, carotid dissection, they found that genetic variants were rare and exclusively found in patients with a family history, suggesting differences between the genetic architectures between these subtypes of carotid dissection.
Study protocols is one of the manuscript types published in the ESJ. Criteria for publication are that the protocol article shall provide background and rationale of the study complementary to a general study protocol (which can be browsed in www.clinicaltrials.gov) and be of general interest to the ESJ readership. In the present issue, Kimberley and colleagues describe the VNS-REHAB (VNS-Rehabilitation) trial, which is a pivotal, multi-site, double-blinded, randomised trial designed to evaluate safety and efficacy of vagus nerve stimulation paired with upper limb rehabilitation after ischaemic stroke. The study adds to the growing body of novel rehabilitation approaches in stroke, and we hope some of these trials may be positive and will make their way all through to clinical practice.
The present issue is the last one with Didier Leys as the ESJ vice editor. Starting 1 January 2020, Didier Leys takes up the position as Editor-in-Chief for the European Journal of Neurology, which could not have appointed a more suitable and qualified person for this task. Didier Leys and I worked closely together in setting up the European Stroke Journal from the start, and his knowledge and experience has been instrumental for the success of the ESJ to this date. I take this opportunity to thank Didier warmly for all his dedicated work for our journal. Didier’s ‘shoes’ will be filled by Karin Klijn, who steps up from associate editor to the vice editor position. I am fortunate to have such an experienced and highly qualified scientist on my side in the journal lead – Karin: warmly welcome in your new position!
Bo Norrving
Department of Clinical Sciences, Section of Neurology, Lund University, Skåne University Hospital, Lund, Sweden Email: