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
December 2020
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.
Source: Thomalla, Götz et al. Intravenous alteplase for stroke with unknown time of onset guided by advanced imaging: systematic review and meta-analysis of individual patient data. The Lancet, Volume 396, Issue 10262, 1574 – 1584
Updated December 2020 – COVID-19 Publications Relevant for Stroke Diagnosis and Management
November 2020
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.
Source: Peters SAE, Carcel C, Woodward M. Sex differences in the association between major risk factors and the risk of stroke in the UK Biobank cohort study. Neurology. 2020 Oct 16:10.1212/WNL.0000000000010982. doi: 10.1212/WNL.0000000000010982.
October 2020
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.
Source: Aguiar de Sousa D, Lucas Neto L, Arauz A, Sousa AL, Gabriel D, Correia M, Gil-Gouveia R, Penas S, Carvalho Dias M, Correia MA, Carvalho M, Canhão P, Ferro JM. Early Recanalization in Patients With Cerebral Venous Thrombosis Treated With Anticoagulation. Stroke. 2020 Apr;51(4):1174-1181. doi: 10.1161/STROKEAHA.119.028532. Epub 2020 Mar 2. PMID: 32114929.
September 2020
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.
Source: DNA Content in Ischemic Stroke Thrombi Can Help Identify Cardioembolic Strokes Among Strokes of Undetermined Cause. Stroke. Di Meglio et al. Stroke 2020;51(9):2810-2816. doi:10.1161/STROKEAHA.120.029134
August 2020
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.
July 2020
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.
June 2020
This review is of interest as it provides non-radiologists with a new way of looking at MRIs.
Zhou Z, Malavera A, Yoshimura S, et al. Clinical prognosis of FLAIR hyperintense arteries in ischaemic stroke patients: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2020;91(5):475‐482. doi:10.1136/jnnp-2019-322625
Archive
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
“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.
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.