Paper of the Month

Featuring the Latest in Stroke Research and Care: The Paper of the Month

The Paper of the Month initiative is brought to you by the Council of Fellows to highlight interesting and relevant papers published by ESO members or with special relevance to Europe.

Papers will be suggested by members of the Paper of the Month (PoM) Working Group. All ESO members can nominate a paper by sending it directly to esoinfo@eso-stroke.org. Please note, you cannot nominate a paper in which you are a named author.

January 2026

Thrombectomy for Medium-Sized Cerebral Vessel Occlusion: Size Does Matter

“This single-centre observational study addresses a clinically relevant and underexplored determinant of outcomes in endovascular thrombectomy (EVT) for medium vessel occlusions (MeVO): the mismatch between thrombectomy device size and target vessel diameter. While recent randomised trials have raised concerns about the overall benefit of EVT in MeVO, this analysis provides a mechanistic perspective that may help explain observed neutrality or futility.

The authors demonstrate that using thrombectomy devices substantially larger than the occluded M2 segment (>20% oversizing) is independently associated with higher rates of symptomatic intracranial haemorrhage and futile clinical outcomes. These findings suggest that procedural factors – rather than patient selection alone – may critically influence MeVO EVT safety and effectiveness. The graded increase in harm with increasing device-to-vessel size ratio strengthens the biological plausibility of vessel injury and distal endothelial damage as contributing mechanisms.

Although limited by its retrospective design and single-centre setting, the study highlights the importance of tailoring device choice to vessel anatomy in MeVO thrombectomy. It underscores the need for dedicated MeVO-specific devices, refined procedural strategies, and careful interpretation of trial results where device selection was heterogeneous. Future randomised trials and guideline recommendations should explicitly account for device-to-vessel size matching to optimise outcomes and minimise harm in this patient population.”

Virtanen P, Räty S, Tomppo L, Brandstack N, Peltola E, Kokkonen T, Sillanpää M, Strbian D, Thrombectomy for medium-sized cerebral vessel occlusion: Size does matter, European Stroke Journal, 11, (1), January 2026, doi: 10.1093/esj/23969873251376862

December 2025

Prevalence, Predictors, and Prognosis of Depression After Transient Ischemic Attack: A Population-Based Study.

“The prevalence of depression was investigated 1 and 12 months after TIA in a population-based cohort (OXVASC ) from 2014 to 2020. Depression was related to risk factors (including infarction on brain imaging) and outcome (disability, quality of life, institutionalisation, recurrent events, and mortality) during 5-year follow-up. Of 519 patients (mean age, 70.5 [13.1]; female, 51.1%), 126 (24.3%) had depression after TIA, with a higher rate at 1 versus 12 months (99/20.7% versus 66/14.9%; P=0.022). Depression was independently associated with younger age (adjusted odds ratio/decade, 0.74 [95% CI, 0.60–0.90]), low baseline mood (4.06 [95% CI, 2.31–7.15]), past depression (1.81 [95% CI, 1.09–3.03]), multimorbidity (1.19 [95% CI, 1.02–1.39]), living alone (1.94 [95% CI, 1.14–3.32]), disability (3.53 [95% CI, 1.89–6.59]), and deprivation (1.28 [95% CI, 1.03–1.59]). After adjustment for confounders, depression did not predict risk of recurrent vascular events (adjusted hazard ratio , 1.42 [95% CI, 0.76–2.64]; P=0.27) but did predict increased 5-year all-cause mortality (aHR, 2.27 [95% CI, 1.21–4.27]; P=0.011), independently of acute lesions on brain imaging (aHR, 2.18 [95% CI, 1.09–4.34]; P=0.027), and particularly when persistent (present at 1- and 12-month follow-up; aHR, 4.58 [95% CI, 2.07–10.13]; P<0.001). Persistent depression was also independently associated with disability (adjusted odds ratio, 12.10 [95% CI, 6.18–23.7]; P<0.001) and institutionalisation (aHR, 5.83 [95% CI, 1.84–18.50]; P=0.003) within 5 years and with reduced quality of life (coefficient, −0.245; P<0.001). The authors concluded that depression is common early after TIA, independent of acute ischemia on brain imaging, and persistent depression is also strongly associated with adverse outcomes."

McColl AJ, Luengo-Fernandez R, Vaughan-Fowler ER, Downer MB, Pendlebury ST, Binney LE, Silver LE, Rothwell PM, Oxford Vascular Study. Prevalence, Predictors, and Prognosis of Depression After Transient Ischemic Attack: A Population-Based Study. Stroke; 2025 Dec 12. https://doi.org/10.1161/STROKEAHA.125.052251

November 2025

Optic nerve sheath diameter for prediction of intracranial hypertension after ischemic sTrokE – The ONSITE study.

“Internal optic nerve sheath diameter (ONSDint) via transorbital ultrasound in 65 stroke patients and 30 controls was prospectively measured. ONSD was also measured on the initial CT or MRI. The primary endpoint of IH was a composite of clinical and radiological signs of brain swelling. Seven of 65 stroke patients (11%) developed IH. The initial sonographic ONSDint was significantly increased in patients who developed IH. The multivariable model identified an optimal predictive cut-off of ⩾5.51 mm, which predicted IH with a sensitivity of 85.7% and a specificity of 94.8%. In comparison, ONSD derived from initial neuroimaging was also a strong predictor, with an optimal cut-off of 6.80 mm yielding a sensitivity of 100% and a specificity of 91.1%, and showed superior predictive accuracy in the cross-validation (AUC 0.905 vs 0.687). These results align well with recent stroke literature that used similar standardised measurement techniques. The findings also highlight the distinct roles of different imaging modalities. While the initial CT/MRI provides a static measurement with high predictive power, the unique advantage of sonography is its bedside applicability, allowing for the crucial, non-invasive serial monitoring of ONSD as a dynamic marker of intracranial pressure changes. In conclusion: early ONSD assessment is a valuable predictor of IH after severe stroke. A sonographic ONSDint of ⩾5.51 mm identifies patients at high risk with excellent accuracy. While initial neuroimaging may offer superior predictive power, bedside sonography remains a crucial, repeatable tool for monitoring these critically ill patients.”

Baumgartner P, Zahn M, Handelsmann H-L, et al. Optic nerve sheath diameter for prediction of intracranial hypertension after ischemic sTrokE – The ONSITE study. European Stroke Journal. 2025; 0(0). doi:10.1177/23969873251379985

October 2025

Association between the Edinburgh CT and genetic diagnostic criteria for cerebral amyloid angiopathy-associated lobar intracerebral haemorrhage and recurrent intracerebral haemorrhage: an individual patient data meta-analysis

“The authors aimed to determine whether the Edinburgh CT-only and CT-APOE diagnostic criteria for cerebral amyloid angiopathy-related lobar intracerebral haemorrhage are associated with recurrent intracerebral haemorrhage. They did a meta-analysis of individual patient data from cohort studies identified at the 2018 International cerebral amyloid angiopathy conference in Lille, France. In the primary two-stage meta-analysis of the CT-only criteria (562 patients from three European cohorts, median age 76 years , 282 [50%] female and 280 [50%] male), 69 patients had a recurrent intracerebral haemorrhage over 1381 person-years’ follow-up. The proportion with recurrent intracerebral haemorrhage during 5-year follow-up in the intermediate-risk and high-risk CT-only cerebral amyloid angiopathy criteria group was 48 (16%) of 307 patients compared with 21 (8%) of 255 patients in the low-risk group (adjusted sub-distribution hazard ratio 1·79, 95% CI 1·05–3·05, p=0·032). In the one-stage meta-analysis of the CT-only criteria (1620 patients with lobar intracerebral haemorrhage from eight cohorts, median age 73 years , 763 [47%] female and 857 [53%] male), 171 patients had a recurrent intracerebral haemorrhage over 3208 person-years’ follow-up. Cumulative 5-year incidence of recurrent intracerebral haemorrhage in the low-risk CT-only cerebral amyloid angiopathy criteria group was 45 (12%) of 727 patients compared with 54 (16%) of 513 patients in the intermediate-risk group (adjusted sub-distribution HR 1·68, 95% CI 1·21–2·32; p=0·0018), and 72 (26%) of 380 patients in the high-risk group (adjusted sub-distribution HR 2·97, 1·50–5·89, p=0·0018). They included six cohorts with 1021 eligible patients for the CT-APOE criteria. In the one-stage meta-analysis of the CT-APOE criteria (1006 patients, median age 71 years female and 529 [53%] male), 74 patients had a recurrent intracerebral haemorrhage over 1495 person-years’ follow-up. Cumulative 3-year incidence of recurrent intracerebral haemorrhage was 34 (15%) of 320 patients in the high-risk CT-APOE cerebral amyloid angiopathy criteria group versus 14 (8%) of 322 patients in the low-risk group (adjusted sub-distribution HR 2·22 [95% CI 1·36–3·61], p=0·0014). The authors concluded that the Edinburgh CT-only and CT-APOE diagnostic criteria for cerebral amyloid angiopathy-associated lobar intracerebral haemorrhage were associated with a greater incidence of recurrent intracerebral haemorrhage. These findings could aid personalised prediction and targeted secondary prevention in standard clinical practice where brain CT is available.”

Rodrigues MA, Seiffge D, Samarasekera N, Moullaali TJ, Wardlaw JM, Schreiber S, Behymer TP, Khandwala V, Stanton RJ, Vagal V and Woo D, Association between the Edinburgh CT and genetic diagnostic criteria for cerebral amyloid angiopathy-associated lobar intracerebral haemorrhage and recurrent intracerebral haemorrhage: an individual patient data meta-analysis. The Lancet Neurology. 2025; 24(10), pp. 828-839. https://doi.org/10.1016/S1474-4422(25)00285-6

September 2025

Nationwide extrapolation of economic benefit of therapeutic innovation: a 10-year retrospective budget impact of direct oral anticoagulants introduction in France

“This study evaluated the 10-year budget impact of DOACs in France, focusing on reductions in strokes/SE, MB, and monitoring costs (INRt). A retrospective budget impact model from 2014 to 2023 compared scenarios with and without DOACs, using clinical and cost data from the NAXOS study. Over a 10-year horizon, the introduction of DOACs is estimated to have prevented 73,009 strokes, 97,234 major bleeding, and 19,567 stroke-related deaths among patients with NVAF. DOAC introduction increased treatment costs by €5.15 billion over 10 years, and reduced costs for strokes/SE (-€4.24 billion), MB (-€3.22 billion), and INRt (-€1.14 billion), leading to €3.45 billion of savings for National Insurance over 10 years, with apixaban contributing 55% of savings. The authors concluded that over 10 years, the introduction of DOACs in France has generated substantial savings in AF-related costs, highlighting their clinical and economic benefits and the importance for authorities to valorise the external effects of therapeutic innovations.”

Guilmet C, Lesage H, Cotté FE, Moreau R, Marant Micallef C, Née M, Guitard-Dehoux D, Belhassen M, Danchin N. Nationwide extrapolation of economic benefit of therapeutic innovation: a 10-year retrospective budget impact of direct oral anticoagulants introduction in France. Journal of Medical Economics. 2025 Dec 31;28(1):859-70. https://doi.org/10.1080/13696998.2025.2514381

August 2025

Costs during the first year after stroke by degree of functional disability: A societal perspective.

“The authors performed a descriptive study of the cumulative costs incurred during 1-year follow-up of a cohort of patients with stroke in Catalonia (Spain) participating in a multicentre, population-based, cluster-randomised trial (RACECAT). Of the 567 patients included, 53% had ischaemic large vessel occlusion (LVO) stroke, 24% intracranial haemorrhage and 23% ischaemic non-LVO stroke. Mean cost per patient during the first year after stroke was €29,673 ± 28,632, and increased with degree of disability (mRS 0–2: €18,568 ± 12,244; mRS 3: €38,214 ± 28,172; mRS 4–5: €52,859 ± 36,383). Healthcare costs represented the highest proportion of total costs (63%; €18,724/patient) across all disability levels, with index hospitalisation being the highest (€12,319 ± 17,675); however, community care and patient/family costs represented over 40% of total cost in patients with higher disability levels.

These results are in line with other studies; the costs during the first year after stroke are high and increase with disability.”

Soler-Font M, Ribera A, Aznar-Lou I, Sánchez-Viñas A, Slof J, Vela E, Salvat-Plana M, Villa-García L, Serrano-Blanco A, Perez de la Osa N, Ribo M. Costs during the first year after stroke by degree of functional disability: A societal perspective. European Stroke Journal. 2025 Jun; 10(2): 513-23. doi: 10.1177/23969873241301904

July 2025

Anti-beta2-glycoprotein I IgG antibodies are associated with early-onset cryptogenic ischemic stroke.

“The authors presented the results of the SECRETO multi-center case-control study that enrolled 503 patient-control pairs aged 18–49 years with imaging-positive acute cryptogenic ischemic stroke and 1:1 matched stroke-free controls. Lupus anticoagulant (LA), anticardiolipin (aCL), and anti-beta2-glycoprotein I (aβ2GPI) IgG antibodies were assessed from blood samples taken at two time points (baseline and 12-weeks) from patients and at a single time point from controls.

At either time-point, compared to healthy controls, patients had more frequently positive aβ2GPI (patients 11.9% vs controls 2.0%, p < 0.001). There was no significant difference in the presence of positive LA between patients and controls. In the logistic regression model, at either time-point positive aB2GI and aCL were associated with CIS (odds ratio [OR] 11.22, 95% confidence interval [CI] 4.35–28.95 and OR 20.85, 95% CI 204–213.16, respectively). The frequency of patients with positive aβ2GPI or aCL increased from baseline to 12 weeks (p < 0.001), whereas frequency of positive LA results decreased (p < 0.001).

The authors concluded that positive aβ2GPI and aCL, but not LA, detected either shortly after stroke or after 12 weeks were associated with early-onset CIS. After the acute phase, frequencies of positive aβ2GPI and aCL increased, whereas LA showed a reverse trend.”

Jaakonmäki N, Helin T, Szanto T, Zedde M, Sarkanen T, Martinez-Majander N, Sinisalo J, Junttola U, Redfors P, von Sarnowski B, Waje-Andreassen U. Anti-beta2-glycoprotein I IgG antibodies are associated with early-onset cryptogenic ischemic stroke. European Stroke Journal. 2025 Apr 1. https://doi.org/10.1177/23969873251351207

June 2025

Mechanical Thrombectomy for Large Ischemic Stroke: A Critical Appraisal of Evidence From 6 Randomised Controlled Trials.

“Randomised assessment of EVT in patients with large strokes in 6 clinical trials across 4 continents has yielded strong and consistent results, cementing the utility of reperfusion, even in those with substantial volumes of irreversible ischemia. Most importantly, the benefits of reperfusion outweighed the potential harms of reperfusion-infarcted brain tissue across clinical and imaging characteristics, indicating the safety of the intervention. These results have challenged our fundamental understanding of the utility of neuroimaging in estimating ischemic changes and our dichotomous view of infarcted versus noninfarcted tissue. Further pooled analyses from these trials are planned and should clarify the role of endovascular thrombectomy in subgroups such as the elderly, those with the largest ischemic core in the late time window, and those without significant mismatch assessed by perfusion imaging.”

Sarraj A, Yoshimura S, Thomalla G, Huo X, Arquizan C, Yoo AJ, Morimoto T, Bendszus M, Lapergue B, Nguyen TN, Campbell BC. Mechanical Thrombectomy for Large Ischemic Stroke: A Critical Appraisal of Evidence From 6 Randomised Controlled Trials. Stroke. 2025 Jul. doi.org/10.1161/STROKEAHA.125.050402

May 2025

Optimised medical therapy alone versus optimised medical therapy plus revascularisation for asymptomatic or low-to-intermediate risk symptomatic carotid stenosis (ECST-2): 2-year interim results of a multicentre randomised trial.

“The 2-year interim analysis of ECST-2 found no evidence for a benefit of revascularisation in addition to OMT for patients with symptomatic and asymptomatic carotid stenosis of 50% or greater, with a 5-year predicted stroke risk of less than 20% (as assessed by the CAR score), in the first 2 years following the procedure. The risk of stroke in patients treated with OMT alone was substantially lower than recorded with best medical treatment in previous carotid stenosis trials. Further follow-up of ECST-2 up to 5 years from randomisation, and data from other trials, will be needed to confirm these findings. In the meantime, these results support treating patients with asymptomatic and low or intermediate risk symptomatic carotid stenosis with OMT alone. Applying individualised risk assessment could result in a reduction in revascularisation procedures and substantial cost savings in the future. Identifying patients with carotid stenosis who are at high risk of future stroke, who might benefit from revascularisation, should also be a goal of future research.”

Donners SJ, van Velzen TJ, Cheng SF, Gregson J, Hazewinkel AD, Pizzini FB, Emmer BJ, Simister R, Richards T, Lyrer PA and Maurer M. Optimised medical therapy alone versus optimised medical therapy plus revascularisation for asymptomatic or low-to-intermediate risk symptomatic carotid stenosis (ECST-2): 2-year interim results of a multicentre randomised trial. Lancet Neurol. 2025; 24(5): 389-399. doi.org/10.1016/S1474-4422(25)00107-3

April 2025

Emergent Carotid Stenting During Thrombectomy in Tandem Occlusions Secondary to Dissection: A STOP-CAD Secondary Study.

“The authors concluded that in patients presenting with an anterior circulation tandem occlusion secondary to cervical artery dissection, emergent stenting was associated with a higher likelihood of successful intracranial recanalisation, but not improved functional outcomes or increased symptomatic intracranial haemorrhage. It remains unclear whether emergent stenting led to successful intracranial recanalisation or patients with successful intracranial recanalisation were more likely to be stented.”

Sousa JA, Rodrigo-Gisbert M, Shu L, Luo A, Xiao H, Mahmoud NA, Shah A, Oliveira Santos AL, Moore M, Mandel DM, Heldner MR. Emergent Carotid Stenting During Thrombectomy in Tandem Occlusions Secondary to Dissection: A STOP-CAD Secondary Study. Stroke. 2025 Apr; 56(4): 808-817. doi.org/10.1161/STROKEAHA.124.048295

March 2025

Direct oral anticoagulants versus vitamin K antagonists for cerebral venous thrombosis (DOAC-CVT): an international, prospective, observational cohort study

“The rate of recurrent thrombosis and major bleeding did not differ between patients with CVT treated with DOACs versus VKAs. This study adds to the increasing evidence that DOACs are a reasonable treatment option for CVT alongside VKAs.“

van de Munckhof A, van Kammen MS, Tatlisumak T, Krzywicka K, Aaron S, Antochi F, Arauz A, Barboza MA, Conforto AB, Contreras DG, Heldner MR, Hernández-Pérez M, Hiltunen S, Ji X, Kam W, Kleinig TJ, Kristoffersen ES, Leker RR, Lemmens R, Poli S, Wasay M, Wu T, Yeşilot N, Chen J, Cotelli MS, Demeestere J, Duan J, Ergin N, Freitas TE, Gomes A, den Hertog HM, Lindgren E, Martinez-Majander N, Metanis I, Miraclin A, Rani LJ, Reddy YM, Saleem S, Scutelnic A, Shanmugasundaram S, van den Wijngaard IR, Gençdal IY, van Eekelen R, Vellema J, Arnold M, Neto L, Middeldorp S, de Sousa DA, Jood K, Putaala J, Ferro JM, Coutinho JM; DOAC-CVT investigators. Direct oral anticoagulants versus vitamin K antagonists for cerebral venous thrombosis (DOAC-CVT): an international, prospective, observational cohort study. Lancet Neurol. 2025 Mar; 24(3): 199-207. doi: 10.1016/S1474-4422(24)00519-2. PMID: 39986309.

February 2025

Sex Differences in the Pre-and In-Hospital Setting of Patients With Stroke Are Driven by Higher Age and Stroke Severity

“The authors concluded that although treatment and outcome parameters seem to be in favor of men, most can be explained by older age, poorer prestroke independence, higher stroke severity, and more large vessel occlusion in women. Sex was not independently associated with worse 90-day functional outcome in women.”

Westphal LP, Rüttener L, Gasser T, Luft AR, Held U, Wegener S. Sex Differences in the Pre-and In-Hospital Setting of Patients With Stroke Are Driven by Higher Age and Stroke Severity. Stroke. 2025 Feb; https://doi.org/10.1161/STROKEAHA.124.048303

January 2025

Incidence and predictors of intracranial hemorrhage after intravenous thrombolysis with tenecteplase

“In this large real-life study, authors found that rates of parenchymal haemathoma (PH) and any intracerebral haemorrhage (ICH) after intravenous thrombolysis were 9.5% and 39.4%, respectively. In particular, older age, male gender, history of hypertension, higher baseline NIHSS and higher admission blood glucose levels were significantly associated with an increased risk of PH. These findings can help to identify patients presenting with an increased risk of ICH.”

Marnat G, Gerschenfeld G, Olindo S, Sibon I, Seners P, Clarençon F, Smadja D, Chausson N, Ben Hassen W, Piotin M, Caroff J. Incidence and predictors of intracranial hemorrhage after intravenous thrombolysis with tenecteplase. European Stroke Journal. 2024 May doi/10.1177/23969873241253660

Members of the PoM Working Group

Working Group

Archive

2025

January: Incidence and predictors of intracranial hemorrhage after intravenous thrombolysis with tenecteplase

February: Sex Differences in the Pre-and In-Hospital Setting of Patients With Stroke Are Driven by Higher Age and Stroke Severity

March: Direct oral anticoagulants versus vitamin K antagonists for cerebral venous thrombosis (DOAC-CVT): an international, prospective, observational cohort study

April: Emergent Carotid Stenting During Thrombectomy in Tandem Occlusions Secondary to Dissection: A STOP-CAD Secondary Study.

May: Optimised medical therapy alone versus optimised medical therapy plus revascularisation for asymptomatic or low-to-intermediate risk symptomatic carotid stenosis (ECST-2): 2-year interim results of a multicentre randomised trial.

June: Mechanical Thrombectomy for Large Ischemic Stroke: A Critical Appraisal of Evidence From 6 Randomised Controlled Trials.

July: Anti-beta2-glycoprotein I IgG antibodies are associated with early-onset cryptogenic ischemic stroke.

August: Costs during the first year after stroke by degree of functional disability: A societal perspective.

These results are in line with other studies; the costs during the first year after stroke are high and increase with disability.”

September: Nationwide extrapolation of economic benefit of therapeutic innovation: a 10-year retrospective budget impact of direct oral anticoagulants introduction in France

October: Association between the Edinburgh CT and genetic diagnostic criteria for cerebral amyloid angiopathy-associated lobar intracerebral haemorrhage and recurrent intracerebral haemorrhage: an individual patient data meta-analysis

November: Optic nerve sheath diameter for prediction of intracranial hypertension after ischemic sTrokE – The ONSITE study.

December: Prevalence, Predictors, and Prognosis of Depression After Transient Ischemic Attack: A Population-Based Study.

2024

January: Early neurological deterioration in patients with acute ischemic stroke is linked to unfavorable cerebral venous outflow.

This month’s paper focusses on unexplained early neurological deterioration after successful thrombectomy and examines the role of pre-EVT collateral vessel patterns. Unfavourable venous outflow on admission CT angiogram was highly linked to unexplained poor functional outcome at day 90, whereas no significant difference was found for pial arterial collaterals. This underlines increasing interest for the venous system.

February: Safety and efficacy of factor XIa inhibition with milvexian for secondary stroke prevention (AXIOMATIC-SSP): a phase 2, international, randomised, double-blind, placebo-controlled, dose-finding trial.

Sharma et al demonstrate in this phase 2 RCT that the factor XIa inhibitior milvexian added to dual antiplatelets is safe, but did not significantly reduce the composite of ischaemic stroke or incident covert brain infarct on MRI at 90 days. No need to change practice yet, but a phase 3 study is planned.

March: Safety and efficacy of platelet glycoprotein VI inhibition in acute ischaemic stroke (ACTIMIS): a randomised, double-blind, placebo-controlled, phase 1b/2a trial.

This randomised, double-blind, placebo-controlled study with dose-escalation (1b) and dose-confirmation (2a) phases (ACTIMIS) was done in 26 stroke centres in six European countries. Participants were adults (≥18 years) with disabling acute ischaemic stroke with a National Institutes of Health Stroke Scale score of 6 or higher before alteplase administration. Patients were randomly assigned treatment using a central electronic procedure. Total administered dose at the end of the intravenous administration was 125 mg, 250 mg, 500 mg, and 1000 mg of glenzocimab or placebo in phase 1b and 1000 mg of glenzocimab or placebo in phase 2a. Treatment was initiated 4·5 h or earlier from stroke symptom onset in patients treated with alteplase with or without mechanical thrombectomy. Glenzocimab 1000 mg in addition to alteplase, with or without mechanical thrombectomy, was well tolerated, and might reduce serious adverse events, intracranial haemorrhage, and mortality. These findings support the need for future research into the potential therapeutic inhibition of glycoprotein VI with glenzocimab plus alteplase in patients with acute ischaemic stroke.

April: Microplastics and Nanoplastics in Atheromas and Cardiovascular Events

In this study, patients with carotid artery plaque in which MNPs were detected had a higher risk of a composite of myocardial infarction, stroke, or death from any cause at 34 months of follow-up than those in whom MNPs were not detected.

May: Dysphagia after stroke: research advances in treatment interventions

After a stroke, most patients have dysphagia, which can lead to aspiration pneumonia, malnutrition, and adverse functional outcomes. Protective interventions aimed at reducing these complications remain the cornerstone of treatment. Dietary adjustments and oral hygiene help mitigate the risk of aspiration pneumonia, and nutritional supplementation, including tube feeding, might be needed to prevent malnutrition. Rehabilitative interventions aim to enhance swallowing function, with different behavioural strategies showing promise in small studies. Investigations have explored the use of pharmaceutical agents such as capsaicin and other Transient-Receptor-Potential-Vanilloid-1 (TRPV-1) sensory receptor agonists, which alter sensory perception in the pharynx. Neurostimulation techniques, such as transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and pharyngeal electrical stimulation, might promote neuroplasticity within the sensorimotor swallowing network. Further advancements in the understanding of central and peripheral sensorimotor mechanisms in patients with dysphagia after a stroke, and during their recovery, will contribute to optimising treatment protocols.

June: Decompressive craniectomy plus best medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracerebral haemorrhage: a randomised controlled clinical trial.

Decompressive craniectomy plus best medical treatment might be superior to best medical treatment alone in people with severe deep supratentorial intracerebral haemorrhage, but the evidence is weak. The point estimate of the treatment effect was higher than that seen with any other specific intervention previously tested in people with intracerebral haemorrhage. Based on the 95% CI a null effect is plausible, but harm is unlikely. The results of SWITCH apply to a subgroup of people with severe deep intracerebral haemorrhage and cannot be generalised to people with intracerebral haemorrhage in other locations. Irrespective of treatment, survival was associated with severe disability in both treatment groups.

July: Type 1 Myocardial Infarction in Patients With Acute Ischemic Stroke

This cross-sectional study found that a dynamic change in troponin was not associated with myocardial infarction in patients with ischemic stroke whereas baseline absolute troponin value was independently associated with type 1 myocardial infarction. The best cutoffs for predicting type 1 myocardial infarction were 5 to 10 times the upper limit of normal. In acute ischemic stroke, a dynamic change in troponin values is not helpful in detecting myocardial infarction, emphasizing that dynamic changes do not reveal the underlying pathophysiological mechanism of myocardial injury.

August: Statin Overuse in Cerebral Ischemia Without Indications: Systematic Review and Annual US Burden of Adverse Events.

More than one-fifth of patients with acute cerebral ischemia (ACI) do not have an indication for statins, and statin overuse in these patients could annually lead to over 5600 adverse events each year in the United States, including diabetes, myopathy, and eye disease. These findings emphasize the importance of adhering to guideline indications for the start of statin therapy in ACI.

September: Recurrent Ischemic Stroke in Patients With Atrial Fibrillation While Receiving Oral Anticoagulants

In a cohort study including 8119 patients with AF who started or restarted OAC after an IS, the risks of recurrent IS and mortality were high despite OAC treatment. In a nested case-control analysis, patients with OAC discontinuation had a significantly higher recurrent IS risk compared with patients who continued OAC use. The results suggest that OAC discontinuation is an important risk factor for recurrent IS, and there is a need to improve secondary prevention strategies for patients with AF.

Oktober: Before, during, and after: An Argument for Safety and Improved Outcome of Thrombolysis in Acute Ischemic Stroke with Direct Oral Anticoagulant Treatment

Direct oral anticoagulants are the primary stroke prevention option in patients with atrial fibrillation. Anticoagulant use before stroke, however, might inhibit clinician comfort with thrombolysis if a stroke does occur. Resuming anticoagulants after ischemic stroke is also problematic for fear of hemorrhage. We describe extensive literature showing that thrombolysis is safe after stroke with direct anticoagulant use. Early reinstitution of direct anticoagulant treatment is associated with lower risk of embolic recurrence and lower hemorrhage risk. The use of direct anticoagulants before, during, and after thrombolysis appears to be safe and is likely to promote improved outcomes after ischemic stroke.

November: Tenecteplase versus alteplase for acute stroke within 4· 5 h of onset (ATTEST-2): a randomised, parallel group, open-label trial

Tenecteplase 0·25 mg/kg was non-inferior to 0·9 mg/kg alteplase within 4·5 h of symptom onset in acute ischaemic stroke. Easier administration of tenecteplase, especially in the context of interhospital transfers, indicates that tenecteplase should be preferred to alteplase for thrombolysis in acute ischaemic stroke. The ATTEST-2 population was large and representative of thrombolysis-eligible patients in the UK and, together with findings from other trials, provides robust evidence supporting the introduction of tenecteplase in preference to alteplase.

December: Timing of oral anticoagulants initiation for atrial fibrillation after acute ischemic stroke: A systematic review and meta-analysis.

The authors conducted an updated systematic review and meta-analysis including all available randomized-controlled clinical trials (RCTs) and observational cohort studies that investigated early versus later OAC-initiation for atrial fibrillation after acute ischemic stroke. The primary outcome was defined as the composite of ischemic and hemorrhagic events and mortality at follow-up. Secondary outcomes included the components of the composite outcome (ischemic stroke recurrence, intracranial hemorrhage, major bleeding, and all-cause mortality). Pooled estimates were calculated with random-effects model. They included nine studies (two RCTs and seven observational) were included comprising a total of 4946 patients with early OAC-initiation versus 4573 patients with later OAC-initiation following acute ischemic stroke. Early OAC-initiation was associated with reduced risk of the composite outcome (RR = 0.74; 95% CI:0.56–0.98; I2 = 46%) and ischemic stroke recurrence (RR = 0.64; 95% CI:0.43–0.95; I2 = 60%) compared to late OAC-initiation. Regarding safety outcomes, similar rates of intracranial hemorrhage (RR = 0.98; 95% CI:0.57–1.69; I2 = 21%), major bleeding (RR = 0.78; 95% CI:0.40–1.51; I2 = 0%), and mortality (RR = 0.94; 95% CI:0.61–1.45; I2 = 0%) were observed. There were no subgroup differences, when RCTs and observational studies were separately evaluated.The authors concluded that early OAC-initiation in acute ischemic stroke patients with non-valvular atrial fibrillation appears to have better efficacy and a similar safety profile compared to later OAC-initiation.

2023

January: Risk Factors and Causes of Ischaemic Stroke in 1322 Young Adults

Among young adults aged 18 to 49 years with a cryptogenic ischaemic stroke according to the TOAST classification, risk factors for stroke are highly prevalent. Using a pediatric classification system provides new leads for the possible causes in cryptogenic stroke, and could potentially lead to more tailored treatment for young individuals with stroke.

February: Endovascular therapy outcome in isolated posterior cerebral artery occlusion strokes: A multicenter analysis of the Swiss Stroke Registry

Data from this multicentre registry study suggest that in patients with isolated posterior cerebral artery occlusion intravenous thrombolysis and endovascular treatment achieve similarly good outcomes.

March: European Stroke Organisation (ESO) expedited recommendation on tenecteplase for acute ischaemic stroke

A comprehensive analysis of the studies available with evidence-based and workable recommendations. This will shape practice.

April: Comparison of carotid endarterectomy and repeated carotid angioplasty and stenting for in-stent restenosis (CERCAS trial): a randomised study.

In-stent restenosis is common after carotid angioplasty and it is unclear how best to manage this complication. In this study 31 patients with in-stent stenosis of more than 80% were randomized to re-angioplasty/stenting or carotid endarterectomy and followed for 1 year. While mild restenosis was more common in the angioplasty group, severe restenosis, clinical complications, and recurrent vascular events were similar in both groups. Longer-term data are needed.

May: Endovascular treatment versus no endovascular treatment after 6-24 h in patients with ischaemic stroke and collateral flow on CT angiography (MR CLEAN-LATE) in the Netherlands: a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial

This paper may require a total rethink of provision of endovascular services. It shows benefit for mechanical thrombectomy in patients with an NIHSS>1, occlusion in the anterior circulation as far down ad distal M2 within 6-24 h of onset, as long as collaterals are visible on CTA and endovascular treatment can be done within an hour of the angiogram. No ASPECTS or CT Perfusion needed. There will be few patients who do not fit these criteria.

June: Early versus Later Anticoagulation for Stroke with Atrial Fibrillation

This very recent trial presented at the European Stroke Organisation Conference in Munich showed new evidence that early initiation of DOACs after ischemic stroke caused by atrial fibrillation was not associated with an excessive risk of complications, including haemorrhagic transformation. The trial also showed the power of investigator-initiated collaborations which should be further encouraged.

July: Risk Profile of Patients with Spontaneous Cervical Artery Dissection

This paper focused on the individual risk profile of young patients with spontaneous cervical artery dissection. Patients were selected from the Italian Project on Stroke in Young Adults Cervical Artery Dissection registry and matched with stroke patients with other aetiologies than dissection as well as stroke-free individuals. The key finding was that migraine without aura was associated with a higher risk of spontaneous dissection. This study further confirms the evidence of association between migraine and cervical artery dissection.

August: High posterior cerebral artery flow predicts ischemia recurrence in patients with internal carotid artery occlusion.

Recurrent ischemia in patients with symptomatic internal carotid artery occlusion (ICAO) can be significantly predicted by increased flow in the ipsilateral PCA-P2 as measured by Transcranial Duplex, with an accuracy of 89.2% when combined with clinical parameters like prior transient ischemic attack (TIA) and low NIHSS score. This non-invasive PCA-P2 flow velocity assessment aids in identifying ICAO patients at heightened risk of repeated ischemic events

September: RACECAT Trial Investigators. Effect of Bypassing the Closest Stroke Center in Patients with Intracerebral Hemorrhage: A Secondary Analysis of the RACECAT Randomized Clinical Trial.

This pre-specified secondary analysis of the RACECAT trial conducted in Catalonia to examine the benefits of direct admission to an endovascular centre over admission to the nearest centre shows that such strategies may have unintended consequences.

Oktober: Value of intravenous thrombolysis in endovascular treatment for large-vessel anterior circulation stroke: individual participant data meta-analysis of six randomised trials.

If a patient with ischaemic stroke is admitted directly to a centre capable of endovascular treatment, is iv thrombolyis still of value? The question has been addressed by an individual participant data meta-analysis of 6 randomised trials, with 2313 patients (1153 with et alone, 1160 with iv and et). The median mRS score was 3 and 2 , a difference which was not significant (OR 0.89, CI 0,76-1,04) Mortality and symptomatic intracranial haemorrhage did not differ between the 2 groups. Authors conclude that they were not able to establish non-inferiority of et alone compared to iv+et.

November: Effects of oral anticoagulation in people with atrial fibrillation after spontaneous intracranial haemorrhage (COCROACH): prospective, individual participant data meta-analysis of randomised trials.

It remains uncertain whether oral anticoagulation is safe and effective in preventing major adverse cardiovascular events in individuals with atrial fibrillation who have suffered a spontaneous intracranial hemorrhage. Through a prospective and comprehensive meta-analysis of individual participant data from randomized trials, the “COCROACH” study aims to shed light on the effects of oral anticoagulants on this specific patient group. The results promise to provide valuable insights for the ongoing discourse on treatment strategies for people with atrial fibrillation and spontaneous intracranial hemorrhage.

December: Risk of ischemic stroke in patients recovered from COVID-19 infection: A systematic review and meta-analysis.

In this systematic review Zuin et al demonstrate stroke risk remains increased even after Covid 19 symptoms have resolved.

2022

January – Noncontrast Computed Tomography vs Computed Tomography Perfusion or Magnetic Resonance Imaging Selection in Late Presentation of Stroke With Large-Vessel Occlusion

This study suggests that pain CT is as safe and reliable in predicting good outcomes for thrombectomy in patients presenting late as CT perfusion. These findings could affect the way thrombectomy decisions are made and simplify the pathway. It is sure to generate discussion.

Additional Paper of Interest

International Post Stroke Epilepsy Research Consortium (IPSERC): A consortium to accelerate discoveries in preventing epileptogenesis after stroke

We added this paper to highlight the International Post Stroke Epilepsy Research Consortium (IPSERC). Please contact the lead author if you are interested in joining.

February – Long-Term Follow-up of Enhanced Holter-Electrocardiography Monitoring in Acute Ischemic Stroke

One sometimes wonders whether AF identified with long-term remote monitoring is clinically relevant. The findings of the RCT need confirmation in a larger study, but the trend suggests that monitoring does not only find AF earlier than standard monitoring, but also may prevent both strokes and deaths.

March – European Stroke Organisation (ESO)-European Society for Minimally Invasive Neurological Therapy (ESMINT) expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischemic stroke and anterior circulation large vessel occlusion.

In this paper the ESO guidelines group summarizes the evidence for bridging versus direct thrombolysis with endorsement for bridging unless thrombolysis is contraindicated. Check out this and the other recently published guidelines here.

April – Safety and efficacy of aspirin, unfractionated heparin, both, or neither during endovascular stroke treatment (MR CLEAN-MED): an open-label, multicentre, randomised controlled trial.

Van der Steen et al present the results of an open label 2×3 RCT of iv aspirin/no aspirin, and low dose/moderate dose/no iv heparin in 663 patients undergoing mechanical thrombectomy and found an increased risk of intracranial haemorrhage, and a trend towards worse functional recovery.

May – Association of intraventricular fibrinolysis with clinical outcomes in ICH: an individual participant data meta-analysis

Time is brain for intracerebral haemorrhage in this individual patient metaanalyisis if two RCTs including 1501 patients who had an intraventricular drain placed for post-ICH hydrocephalus and were randomized to intraventricular alteplase or not. Patients included within less than 48 h from symptom onset had better functional outcomes at 6 months. Check out detail and implications in the full paper.

June – Role of Intravenous Thrombolytics Prior to Endovascular Thrombectomy

A timely review of the 6 trials addressing the question. For most of us the best approach will be to lyse first, but direct endovascular treament is not completely out. More information in the full paper.

July – Vitamin K antagonist versus novel oral anticoagulants for management of cervical artery dissection: Interactive systematic review and meta-analysis

Since the CADISS and TREAT-CAD RCTs established that in patients with cervical artery dissection antiplatelets and anticoagulation (with warfarin) were equally safe and effective DOACS have emerged as an alternative, but without RCT evidence. This systematic review compares DOACS with warfarin for patients with CAD. There was no significant difference in safety and efficacy, but a closer look at the paper shows trends which need to be tested in further clinical trials.

September – Cerebellar cognitive affective syndrome after acute cerebellar stroke

The cerebellum modulates both motor and cognitive behaviors, and a cerebellar cognitive affective syndrome (CCAS) was described after a cerebellar stroke in 1998. Yet, a CCAS is seldom sought for, due to a lack of practical screening scales. This paper provides an assessment of both the prevalence of CCAS after cerebellar acute vascular lesion and the yield of the CCAS-Scale (CCAS-S) in an acute stroke setting.

October – European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack.

A timely update. Please check the ESO guidelines section for a video and slides to accompany the guidance.

November – Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial.

Thus far we have depended on observational studies to determine what blood pressure targets to set after thrombecotmy. The Enchanted-2 MT RCT was conducted in 44 tertiary-level hospitals in China and tested whether a blood pressure target of 120 mm Hg systolic or less was better than 140-180 mm Hg. It was terminated early because of safety concerns in the intensive treament group after 821 our of a planned 2257 participants were enrolled, and showed significantly more early neurological deterioration and worse mRS at 90 days in the intensive blood pressure control group.

December – Sex Differences in Carotid Atherosclerosis: A Systematic Review and Meta-Analysis.

In this systematic review and meta-analysis the authors provide an overview on sex differences in atherosclerosis comprising different methods of plaque measurement. A key finding is a clear sex difference with higher prevalence in men for all measures of atherosclerosis including calcification, intraplaque hemorrhage and plaque ulceration. The authors also give an outline how these findings should be addressed in future trials.

2021

January – Carotid Artery Stenting Versus Endarterectomy for Treatment of Carotid Artery Stenosis

CAS can be safely offered as an alternative to CEA in patients with symptomatic carotid stenosis <70 years, provided both treatments are technically feasible. Older patients should be treated with CEA. In patients with asymptomatic carotid stenosis, the amount of evidence currently available is limited and further data from randomized trials are needed. Two large RCTs, ECST-2 and ACST-2, are in follow-up and expected to report in 2021.

February – Treatment and Outcome in Stroke Patients With Acute M2 Occlusion and Minor Neurological Deficits

This study by Dobrocky et al from Bern included 169 consecutive stroke patients with acute occlusion of the M2 segment and a minor stroke (NIHSS ≤5) between 2005 and 2020. The authors explored the efficacy and safety of recanalization therapies and demonstrated a similar effectiveness of intravenous thrombolysis (IVT) only versus endovascular therapy (EVT, including intra-arterial thrombolysis and mechanical thrombectomy), and of IVT only versus mechanical thrombectomy alone (without intra-arterial thrombolysis). Outcomes were best in patients treated after 2015 (Nicolas Martinez-Majander).

March – European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke

This guideline is a welcome summary and assessment of available evidence on thrombolysis after stroke. It gives graded recommendations, where evidence is available and considered expert opinion where it is not. It will be practice changing for many of us. Of particular interest is the recommendation to use tenecteplase for patients considered for thrombectomy, the recommendation to thrombolyse selected patients with pre-stroke disabilities and those with low NIHSS but nevertheless disabling deficits. It is a fitting memory to the late Eivind Berge who contributed greatly to its production.

April –Diagnosis of non-consensus transient ischaemic attacks with focal, negative, and non-progressive symptoms: population-based validation by investigation and prognosis

This paper has the potential to completely change the way we manage our TIA services, but also to improve outcomes.

Maria A. Tuna and the team form the Oxford Vascular Study found that patients with non-consensus TIA, i.e. those who do not fit our diagnostic criteria for TIA, and who are often sent back to their primary care team with no specific treatment, are at high early and long-term risk of stroke and have cardiovascular pathological findings on investigation similar to those of classic TIA. Designation of non-consensus TIAs as definite cerebrovascular events will increase overall TIA diagnoses by about 50%.

May –Stroke 20 20: Implementation goals for intravenous thrombolysis

Based on the IVT analysis in the Czech Republic, authors discuss that thrombolysis can be provided to ≥ 20% of all ischemic strokes nationwide and it is realistic to achieve median door-to-needle time 20 minutes. They propose Stroke 20–20 that could serve as national implementation target for intravenous thrombolysis and country specific implementation policies should be applied to achieve such target.

Guest Paper – Caplan-Fisher Rules

We see this paper as a classic which should be read by every aspiring and practising stroke neurologist.

June –Vagus nerve stimulation paired with rehabilitation for upper limb motor function after ischaemic stroke (VNS-REHAB): A randomised, blinded, pivotal, device trial

The authors tested a potential new approach for rehabilitation after stroke; the preliminary data showed safety and efficacy, i.e. the VNS group improved by 5.0 points on the FMA-UE scale, compared with a 2.4-point improvement in the sham-stimulation group, a significant difference. At 90 days, 47% of VNS patients had a clinically meaningful improvement, compared with 24% of the control group, also a significant difference. Larger trials are needed to show which subroups will have more benefit. Comment by Anita Arsovska

July –Colchicine for prevention of vascular inflammation in Non-CardioEmbolic stroke (CONVINCE) – study protocol for a randomised controlled trial

This month the paper of the month is a trial protocol. CONVINCE is a multi-centre international (in 17 countries) Prospective, Randomised Open-label, Blinded-Endpoint assessment (PROBE) controlled Phase 3 clinical trial in 3154 participants. The intervention is colchicine 0.5 mg/day and usual care versus usual care alone (antiplatelet, lipid-lowering, antihypertensive treatment, lifestyle advice) in patients with non-severe ischaemic stroke or high-risk TIA.The primary outcome is time to first recurrent ischaemic stroke, myocardial infarction, cardiac arrest, or hospitalisation with unstable angina (non-fatal or fatal).CONVINCE will provide high-quality randomised data on the efficacy and safety of anti-inflammatory therapy with colchicine for secondary prevention after stroke.

August- PRESERVE: Randomized Trial of Intensive Versus Standard Blood Pressure Control in Small Vessel Disease

Intensive blood pressure lowering reduces stroke risk, but it is unclear whether it this is safe in patients with severe small vessel disease and impaired cerebral autoregulation. The results of PRESERVE show that blood pressure lowering did not adversely affect white matter microstructure or cognitive function.

September –Sonothrombolysis in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: An Individual Patient Data Meta-Analysis

Sonthrombolysis may enhance the effectiveness of thrombolysis, but could also increase the bleeding risk. Tsivgoulis et al included 7 randomized controlled studies and 1102 patients into this meta-analysis and report that sonothrobolysis significantly improved recanalization with no significant increase in intracranial haemorrhage and no difference in mRS at 90 days.

October – Characteristics and Outcomes of Patients With Cerebral Venous Sinus Thrombosis in SARS-CoV-2 Vaccine-Induced Immune Thrombotic Thrombocytopenia

This study includes 78 patients with thrombotic thrombocytopenic syndrome and cerebral venous thrombosis after Covid-19 vaccination from multiple countries on 4 continents. Most (776/78) received the AstraZeneca vaccine. Mortality was very high initially at 62% but improved to 42% after the syndrome became better known, platelet transfusions were avoided, and non-heparin anticoagulants were given.

November –Female Gender Increases Risk of Stroke and Readmission after CEA and CAS

In this retrospective study of 106,568 patients, the authors found that female gender was associated with significantly increased rates of 30-day postoperative CVA/stroke in asymptomatic and symptomatic patients as well as readmission in asymptomatic patients following CEA or CAS. They conclude that we need adequate representation of female patients in studies to better understand gender-based disparities in carotid intervention.

December –Long-Term Impact of Urgent Secondary Prevention After Transient Ischemic Attack and Minor Stroke: Ten-Year Follow-Up of the EXPRESS Study

Luengo-Fernandez et al report the 10 year results of the Oxford-based EXPRESS study, which established that rapid (within 24 hours of onset) assessment and treatment of TIA saves strokes, reduces death and disability, and is cost-effective. This follow-up study demonstrates that the benefit persists over a 10 year period of follow-up. Time is brain, even for TIAs.

2020

April – Burden of Stroke in Europe: Thirty-Year Projections of Incidence, Prevalence, Deaths, and Disability-Adjusted Life Years

This study gives the current burden of stroke within Europe and modelled predictions, based on Global Burden of Disease data. It will prove valuable for service and research planning.

May – Clinical prognosis of FLAIR hyperintense arteries in ischaemic stroke patients: a systematic review and meta-analysis

This review is of interest as it provides non-radiologists with a new way of looking at MRIs.

June – Safety and efficacy of dual antiplatelet pretreatment in ischemic stroke patients treated with IV thrombolysis: A systematic review and meta-analysis

In this paper, the authors report safety and efficacy of iv alteplase in ischemic stroke patients who were on dual antiplatelets. Antiplatelet pre-treatment is not an exclusion criterion for the use of iv alteplase; however, some concern persists particularly because of conflicting data and recent suggestions from ENCHANTED trial that prior antiplatelets use is associated with increased symptomatic intracerebral haemorrhage risk. This is therefore an important study which tackles an important clinically relevant question. Also, this is a robust meta analysis of almost 70 000 patients. In unadjusted analyses, they noted increased risk of symptomatic intracerebral haemorrhages amongst patients on dual anti platelets who received iv alteplase for acute ischemic stroke; this, however, was not associated with poor functional outcomes. In a adjusted analysis however, prior treatment with dual anti platelets was not associated with increased risk of symptomatic intracerebral haemorrhages. This meta analysis adds to our evidence in favour of the use of iv alteplase in ischemic stroke patients who are on dual anti platelets.

July – Age and Sex Differences in Ischemic Stroke Treatment in a Nationwide Analysis of 1.11 Million Hospitalized Cases

An interesting and methodologically balanced nationwide registry study examining changes of access to stroke units and recanalization therapies (both IVT and MT) over time, age and sex differences. Read this and contemplate why men are more likely to be admitted to a stroke unit, but women are more likely to be treated by mechanical thrombectomy.

August – International translation of Fever, Sugar, Swallow Protocols: The Quality in Acute Stroke Care Europe Project

Sometimes positive results are not enough. In 2011 Middleton et al demonstrated that a nurse-led protocol of managing fever, hyperglycaemia and swallowing dysfunction significantly reduced death and disability. However, there was little impact on practice. In this paper Middleton et al describe how ESO and the Angels initiative worked collaboratively to implement the FeSS protocol across 20 European countries. We hope that this paper is a stimulus for more stroke centres to put this evidence into practice.

September – DNA Content in Ischemic Stroke Thrombi Can Help Identify Cardioembolic Strokes Among Strokes of Undetermined Cause

Nishant Mishra comments: This study examines thrombus composition as a tool to identify stroke mechanism. Cardioembolic thrombi were found to have had significantly increased levels of DNA compared to non-cardioembolic thrombi. The investigators identified a threshold of 44.7 ng DNA/mg thrombus at which 47% of thrombi from undetermined cause could be classified as cardioembolic with a specificity of 90%. We need reliable biomarkers of the stroke mechanism, and this approach appears to identify one. The findings, however, need validation.

October – Early Recanalization in Patients With Cerebral Venous Thrombosis Treated With Anticoagulation

With increasing rates of sinus venous thrombosis in the wake of COVID-19 this observational study is of particular interest. It demonstrates that recanalization starts within the first 8 days of therapeutic anticoagulation and is predictive of good outcome.

November – Sex differences in the association between major risk factors and the risk of stroke in the UK Biobank cohort study

Results from just under half a million people entered in the UK Biobank confirm that men have a higher risk of stroke than women, but also show that Hypertension, smoking and low socioeconomic status are more strongly associated with stroke risk in men than in women.

December – Intravenous alteplase for stroke with unknown time of onset guided by advanced imaging: systematic review and meta-analysis of individual patient data

Evidence supporting the use of thrombolysis for selected stroke patients with unknown time of onset has been strengthened with data from a new individual patient meta-analysis. This meta-analysis combined data from four clinical trials that included a total of 483 patients with stroke of unknown time of onset, using MRI or CT-perfusion imaging to identify patients with salvageable brain tissue.

2019

Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation

This is an individual patient data pooled analysis of 5314 patients, which addresses the question whether patients who have an ischemic stroke while anticoagulated should be changed to a different anticoagulant or not. It is a clinically relevant topic and will help in decision making, but still many questions remain unanswered.

Seiffge DJ, De Marchis GM, Koga M, Paciaroni M, Wilson D, Cappellari M, et al. Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation. Ann Neurol 2020 Feb 12. https://onlinelibrary.wiley.com/doi/10.1002/ana.25700

Outcomes of patients with stroke treated with thrombolysis according to prestroke Rankin Scale scores

“Was the patient independent before this stroke?” The answer to this question is no longer needed to decide whether to give thrombolysis or not t a patient with ischaemic stroke presenting within 4.5 h from the event. Even patients with significant disability (mRS up to 4) may improve and return to their previous level if appropriately treated, according to this paper by Gumbinger et al, published recently in Neurology. The Authors found that intravenous thrombolysis in patients with pre-stroke mRS (pRS) scores of 0 to 4 was associated with a higher chance of returning to their baseline (or a modified Rankin Scale score of 0/1). Only patients with a pre-stroke Rankin of 5 did not benefit from thrombolysis. So another barrier to treatment is disappearing…

Anticoagulation after stroke in patients with atrial fibrillation: to bridge or not with low-molecular-weight heparin?

This month’s paper is of particular interest as it addresses an area of clinical uncertainty which affects daily practice. Should we bridge with full dose heparin/low molecular weight heparin when faced with a patient in AF who has had a minor stroke? Altavilla et al’s large observational study suggests ‘no’. Both ischemic and haemorrhagic strokes were more frequent in the bridged group. However, the study is not randomized, and neither multivariate analysis nor propensity matching can fully exclude biases. However, while we are waiting for results of on-going clinical trials such as ELAN, these results should make us stop and think when considering bridging.