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