Editorial

The year 2020 will certainly be marked in history by the COVID-19 pandemic, which continues to influence not only the health systems but the entire society. Most of us have also, in one way or another, personal encounters with the pandemic from individual patients, families and friends. The current issue includes an obituary of John Norris who sadly passed away from COVID-19. John Norris was one of the pioneers in the modern history of stroke, with a number of landmark contributions, as outlined by his former colleagues Dr Hachinski, Bornstein and Markus. John Norris was a very strong character with his mix of scientific rigor, wit and social skills that created a special legacy.

The present issue features the European Stroke Organisation web-based survey on the provision of stroke care during the pandemic. The survey collected responses from 426 stroke care providers from 55 countries, most of whom worked in Europe. About three quarters of the respondents stated that not all stroke patients were receiving the usual care, and a majority estimated that functional outcomes and recurrence rates of stroke patients would be negatively affected by the organisational changes caused by the pandemic. Dr Aguilar de Sousa and co-authors provided several policy recommendations, one of which stressed the importance to monitor quality of services also during times of constraints in the health care system.

In Europe, Italy was one of the most severely affected countries in the early stages of the COVID-19 pandemic. Dr Zedde and colleagues analysed the stroke pathways before and after the pandemic outbreak of four Italian regions. In the most affected regions, the closure of departments and hospitals led to a complete reorganisation of previously functioning stroke networks. Different organisational models were applied to diminish the negative impact of the stroke care. Sharing of such solutions is very important for other regions, many of which may not yet have seen the full effect of the pandemic.

A few decades ago, the world faced another serious epidemic: HIV/AIDS. With time, the incidence and prevalence patterns of HIV/AIDS have changed. The German study by Schaefer and colleagues reminds us that HIV/AIDS should not be forgotten in the context of acute stroke. In a retrospective, observational study of HIV-positive patients treated at their stroke unit and outpatient clinic in Germany between 2012 and 2018, 0.7% were newly or previously diagnosed as HIV-positive. Compared to a control group, HIV-positive stroke patients more often had large-vessel disease (often in the posterior circulation) and vasculitis. The age spectrum at stroke onset as one of the widest reported with the oldest patient presenting at the age of 67 years, presumably because antiretroviral therapies have increased the life expectancy among patients with HIV.

It is well known that occult brain cancer may mimic stroke, leading to misdiagnosis that may lead to improper treatment and delay in diagnosis. In a large study based on the Danish Stroke Registry and data linkage to the Danish population register and Danish Cancer Registry, Dr Andersen and colleagues characterised strokes associated with occult primary brain cancer. The multivariable stroke risk factor analysis showed that patients with occult primary brain cancer differed significantly from those without, indicating they might have been stroke mimics rather than true strokes. Primary brain cancer was rare in patients with ischemic stroke (1 in 200), whereas it was less rare among patients with haemorrhagic stroke (1 in 66). This is an important point for clinical practice.

Atrial fibrillation is an important risk factor for ischemic stroke and is commonly present in patients treated with endovascular thrombectomy. Dr Smaal and colleagues from the HERMES collaboration used individual patient data from six randomised endovascular trials to investigate whether there was an interaction between atrial fibrillation and treatment effect of thrombectomy, and whether atrial fibrillation was associated with worse outcome in patients with ischemic stroke due to large vessel occlusion. They found no differences in primary and secondary outcomes between patients with and without atrial fibrillation, supporting current clinical practice that presence of atrial fibrillation should not be a determining factor in patient selection for endovascular thrombectomy.

The spectrum of neuropsychological effects after stroke is very broad. Little focus has been directed on deficits of emotion recognition. In their analysis of 230 patients derived from a prospective study of cognitive recovery, Dr Aben and colleagues found that five weeks after ischemic stroke one-third of the patients had impaired emotion recognition, as diagnosed by a neuropsychological assessment including an emotion recognition task. Impaired emotion recognition was associated with cognitive dysfunction but was present in one out of five patients with no cognitive disorder in traditional cognitive domains. Given that impaired emotion recognition negatively impacts social functioning, this suggests that clinicians should systematically ask patients and their caregivers about deficits in emotion recognition, and, if needed, test for these deficits.

Internal carotid artery stenosis is one of the well-established mechanisms for ischemic stroke, but the literature on its prevalence is scarce and heterogeneous. Prevalence may have changed over time due to improved management of cardiovascular risk factors. In a large hospital-based study of patients with recent hemispheric transient ischemic attack or ischemic stroke in the Netherlands, Dr den Brok and colleagues found that 12.5% had 50%–99% ipsilateral internal carotid artery (ICA) stenosis; this proportion appears lower than in earlier studies. They found that higher age, male sex, white ethnicity, retinal ischemia and current smoking were important risk factors for symptomatic ICA stenosis.

The topic of risk factors for intracerebral haemorrhage was revisited by Dr Svensson and colleagues, who used a very large Swedish population-based cohort followed for more than 18 years with data cross-linked to other Swedish hospital registers. They found that blood pressure, smoking, low apolipoprotein B, oral anticoagulants and living alone were associated with lobar as well as non-lobar intracerebral haemorrhage, whereas diabetes was associated with non-lobar intracerebral haemorrhage only.

Another Swedish register-based study, Dr Sennfält and colleagues analysed patterns of hospital readmissions after ischemic stroke. Of the 10,092 patients included, 43.7% had been readmitted within 12 months and 74.0% within 5 years. A small number of patients with a high degree of comorbidity accounted for the majority of hospital readmissions after index stroke. The findings highlight the need for further development of strategies to support high-risk comorbid stroke patients in the community setting.

This issue of the journal also includes two important study protocols. Small vessel disease (SVD) causes a quarter of ischaemic strokes (lacunar subtype), up to 45% of dementia either as vascular or mixed types, cognitive impairment and physical frailty. However, there is no specific treatment to prevent progression of SVD. Dr Wardlaw and colleagues report the design of the LACunar Intervention Trial-2, which aims to test feasibility of a large trial testing cilostazol and/or isosorbide mononitrate by demonstrating adequate participant recruitment and retention in follow-up, drug tolerability, safety and confirm outcome event rates required to power a phase 3 trial.

In the second trial protocol paper, Dr Traenka and colleagues delineate the design of the Biomarkers and Antithrombotic Treatment in Cervical Artery Dissection randomised trial. The type of antithrombotic treatment in cervical artery dissection patients is still a matter of debate. The trial aims to compare aspirin to oral anticoagulants with regard to efficacy and safety by using both clinical and imaging surrogate outcome measures.

We wish you happy reading and hope that you share the editors enthusiasm for the development of the European Stroke Journal. We thank you for your continuing support for the journal.