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
May 2021
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.
Source: Mikulik R, Bar M, Cernik D, et al. Stroke 20 20: Implementation goals for intravenous thrombolysis. European Stroke Journal. April 2021. doi:10.1177/23969873211007684.
Guest Paper
We see this paper as a classic which should be read by every aspiring and practising stroke neurologist.
Source: Caplan L. Caplan-Fisher Rules. Stroke. 2021 May;52(5):e155-e159. doi: 10.1161/STROKEAHA.121.035017. Epub 2021 Apr 12. PMID: 33840226.
April 2021
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%.
Source: Tuna Maria A, Rothwell Peter M, on behalf of the Oxford Vascular Study. Diagnosis of non-consensus transient ischaemic attacks with focal, negative, and non-progressive symptoms: population-based validation by investigation and prognosis. Lancet 2021; 397: 902–12. DOI: https://doi.org/10.1016/S0140-6736(20)31961-9.
Updated May 2021
COVID-19 Vaccination and Cerebrovascular Events
Original Articles/Case Reports - AstraZeneca Vaccine
Original Articles / Case Reports - Johnson and Johnson/Janssen Vaccine
Original Articles / Case Reports - Moderna Vaccine
Original Articles / Case Reports - Pfizer/Biontech Vaccine
Guidance
Comments and Editorials
Venous thromboembolism after vaccination or COVID-19
Post-Discharge Thromboembolic Outcomes and Mortality of Hospitalized COVID-19 Patients: The CORE-19 Registry Giannis et al. Preprint as .pdf
Cerebral venous thrombosis: a retrospective cohort study of 513,284 confirmed COVID-19 cases and a comparison with 489,871 people receiving a COVID-19 mRNA vaccine. Taquet M et al. Preprint
Additional Publications on COVID-19 and Stroke
March 2021
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.
Source: Berge E, Whiteley W, Audebert H, et al. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. European Stroke Journal. February 2021. doi:10.1177/2396987321989865.
February 2021
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).
Source: Dobrocky T, et al. Treatment and Outcome in Stroke Patients With Acute M2 Occlusion and Minor Neurological Deficits. Stroke. 2021 Jan 26:STROKEAHA120031672. doi: 10.1161/STROKEAHA.120.031672. Epub ahead of print. PMID: 33494637.
January 2021
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. Source: Müller MD, et al. Carotid Artery Stenting Versus Endarterectomy for Treatment of Carotid Artery Stenosis. Stroke. 2021 Jan;52(1):e3-e5. doi: 10.1161/STROKEAHA.120.030521. Epub 2020 Dec 28. [/av_textblock] [/av_one_full] [av_one_full first min_height='' vertical_alignment='av-align-top' space='' row_boxshadow_color='' row_boxshadow_width='10' margin='0px' margin_sync='true' mobile_breaking='' border='' border_color='' radius='3px' radius_sync='true' padding='30px' padding_sync='true' column_boxshadow_color='' column_boxshadow_width='10' background='bg_color' background_color='#e2e2e2' background_gradient_color1='' background_gradient_color2='' background_gradient_direction='vertical' src='' attachment='' attachment_size='' background_position='top left' background_repeat='no-repeat' highlight_size='1.1' animation='' link='' linktarget='' link_hover='' title_attr='' alt_attr='' mobile_display='' id='' custom_class='' aria_label='' av_uid='av-k5o14eiw'] [av_textblock size='28' av-medium-font-size='' av-small-font-size='18' av-mini-font-size='22' font_color='custom' color='#ee5d69' id='' custom_class='' av_uid='av-k38ibehb' admin_preview_bg=''] December 2020 [/av_textblock] [av_textblock size='' av-medium-font-size='' av-small-font-size='' av-mini-font-size='' font_color='' color='' id='' custom_class='' av_uid='av-k37g3nqg' admin_preview_bg='']
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
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.
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.