This 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 Group. ESO members can also nominate a paper by sending it directly to esoinfo@eso-stroke.org
Updated May 2020 – COVID Publications Relevant for Stroke Diagnosis and Management
As there is a great need for information about the diagnosis, prognosis and management of stroke during the COVID-19 epidemic the Paper of the Month Task Force have decided to publish all relevant articles rather than select a single paper of the month. We hope you will find this helpful.
Original Research
This observational study suggests better outcomes in hospitalized patients with Covid-19 who are fully anticoagulated.
There was no increased risk of death with ACEIs or ARBs in this observational study including 8910 hospitalized Covid-10 positive patients form 181 countries worldwide. Mortality was 4.9% in patients with and 4.9% in those without risk factors.
This is a large observational study of risk factors for Covid-19 death based on a UK general practice registry including a population of 17,425,445. It puts stroke as a risk factor for Covid-19 mortality into the context of a wide range of other risks.
Clinical studies
Guidance
March 2020
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
February 2020
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.
Malhotra K, Katsanos AH, Goyal N, Ahmed N, Strbian D, Palaiodimou L, Karapanayiotides T, Alexandrov AW, Grotta JC, Alexandrov AV, Tsivgoulis G. Safety and efficacy of dual antiplatelet pretreatment in ischemic stroke patients treated with IV thrombolysis: A systematic review and meta-analysis. Neurology. 2020 Jan 20. pii: 10.1212/WNL.0000000000008961. doi: 10.1212/WNL.0000000000008961.
January 2020
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.
Weber R, Krogias C, Eyding J, Bartig D, Meves SH, Katsanos AH, Caso V, Hacke W. Age and Sex Differences in Ischemic Stroke Treatment in a Nationwide Analysis of 1.11 Million Hospitalized Cases. Stroke 2019 Dec;50(12):3494-3502. https://www.ahajournals.org/doi/10.1161/STROKEAHA.119.026723
December 2019
“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…
Gumbinger C, Ringleb P, Ippen F, Ungerer M, Reuter B, Bruder I, Daffertshofer M, Stock C; Stroke Working Group of Baden-Württemberg. Outcomes of patients with stroke treated with thrombolysis according to prestroke Rankin Scale scores. Neurology. 2019 Nov 12;93(20):e1834-e1843. doi: 10.1212/WNL.0000000000008468.
November 2019
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.
Altavilla R, Caso V, Bandini F, Agnelli G, Tsivgoulis G, Yaghi S, et al.. Anticoagulation after stroke in patients with atrial fibrillation: to bridge or not with low-molecular-weight heparin? Stroke. 2019; 50:2093–2100.