Abstract
We are pleased to start the sixth volume of the European Stroke Journal with yet another major guideline document from the European Stroke Organisation (ESO): the ESO guidelines on intravenous thrombolysis (IVT) of acute ischaemic stroke. The guideline provides recommendations on IVT with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 hours earlier, who have MRI DWI/FLAIR mismatch, and for whom mechanical thrombectomy is not planned. The document marks important progress in acute stroke management, but also reminds us that several areas need to be further explored in clinical trials. Issuing guidelines is a prioritized task for the ESO, and several more guidelines are in the pipeline for 2021.
The links between stroke and dementia are strong. The current issue includes a review by the Dementia Committee of the European Stroke Organisation (ESO) which proposes a practical clinical approach to cognitive impairments in patients with known cerebrovascular disease. Another review delineates prognostic rules for predicting cognitive syndromes following stroke. In both fields, there is a large need for more solid knowledge on predictors and therapies.
The challenges of making progress in the prevention and treatment of intracerebral haemorrhage (ICH) is a recurring theme in the European Stroke Journal. The present issue features a study by Flaherty and co-workers based on data from the large Ethnic/Racial Variations of ICH (ERICH) study addressing the issue of hypertension, age, ethnicity and risk of ICH. Hypertension was found to be a strong independent risk factor for ICH irrespective of location among persons of younger age, demonstrating the importance of early detection of hypertension in the population. Ornello and co-workers assessed the applicability and utility of the Edinburgh CT criteria for cerebral amyloid angiopathy (CAA) in an unselected cohort of patients with a first-ever lobar ICH. In the third article on ICH in this issue, Bornello and colleagues demonstrated the usefulness of a quality improvement program in Scotland to increase the prescription of blood pressure lowering at discharge, providing a model for such programs in other geographical areas.
The study by Fasth and colleagues reminds us on the prognostic seriousness also of ischaemic events that only a few decades were thought to be quite benign. In a Swedish register-based study on patients with high-risk TIA or minor ischaemic stroke, they reported a substantial use of health-care resources and high mortality rates, showing the need for better preventive efforts also in this milder part of the spectrum of cerebrovascular diseases.
Implementation of evidence practices is also a theme of the study by Pietzsch and colleagues, who analyzed the volumes of PFO closure in patients with cryptogenic ischaemic stroke in four European countries: Germany, England, France, and Italy. After the 2017 announcement of positive trial results of PFO closure, volumes increased but were still substantially different across the countries studied. Many eligible patients at risk for a recurrent cryptogenic event might remain untreated due to regional practice variations.
The benefit of anti-inflammatory therapies in ischaemic stroke is currently uncertain, and the potential usefulness of blood inflammatory markers is under debate. In a systematic review and meta-analysis, McCabe and colleagues found that despite evidence suggesting an association between inflammatory markers and post-stroke vascular recurrence, there was substantial methodological heterogeneity between studies. Further development in methods and standardizations were proposed to improve the design of randomized trials of inflammatory therapies.
Small vessel disease is the topic of one of the protocols published in this issue. Clancy and colleagues delineate the rationale and design of the Mild Stroke Study 3 (MSS-3), a prospective observational cohort study on the role of small vessel dysfunction using advanced serial neuroimaging in a well characterized cohort to increase the understanding of the natural history of small vessel disease. The other study protocol in this issue returns to the vascular cognitive theme; in the Rates, Risks and Routes to Reduce Vascular Dementia (R4VaD) study, Wardlaw and co-workers aim to recruit >2000 stroke patients to be followed longitudinally using a detailed protocol, which in subgroups also includes high-sensitivity inflammatory markers, genetics, blood pressure, and diffusion tensor imaging.
In summary, the first issue of 2021 illustrates the progress and dynamics that we currently see in the stroke field, despite the challenges that the pandemic creates. Awaiting better times, we wish our readers happy reading, and thank you again for your support to the journal.