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
November 2021
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.
Source: Goicoechean S et al. Female Gender Increases Risk of Stroke and Readmission after CEA and CAS. Journal of Vascular Surgery. November 01, 2021.
October 2021
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.
Source: Sánchez van Kammen M, Aguiar de Sousa D, Poli S, et al. Characteristics and Outcomes of Patients With Cerebral Venous Sinus Thrombosis in SARS-CoV-2 Vaccine-Induced Immune Thrombotic Thrombocytopenia. JAMA Neurol. 2021 Sep 28.
September 2021
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.
Source: Tsivgoulis G, et al. Sonothrombolysis in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: An Individual Patient Data Meta-Analysis. Stroke. 2021 Aug 25:STROKEAHA120030960. doi: 10.1161/STROKEAHA.120.030960. Epub ahead of print. PMID: 34428930.
August 2021
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.
Source: Markus H.S. et al. PRESERVE: Randomized Trial of Intensive Versus Standard Blood Pressure Control in Small Vessel Disease. Stroke. 2021 Aug;52(8):2484-2493. doi: 10.1161/STROKEAHA.120.032054.
July 2021
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.
Source: Kelly P et al. Colchicine for prevention of vascular inflammation in Non-CardioEmbolic stroke (CONVINCE) – study protocol for a randomised controlled trial. European Stroke Journal. 2021;6(2):222-228. doi:10.1177/2396987320972566
Updated September 2021
COVID-19 Vaccination and Cerebrovascular Events
Original Articles/Case Reports - All Vaccines
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
Additional Publications on COVID-19 and Stroke
June 2021
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
Source: Dawson J et al. Vagus nerve stimulation paired with rehabilitation for upper limb motor function after ischaemic stroke (VNS-REHAB): A randomised, blinded, pivotal, device trial. Lancet 2021 Apr 24; 397:1545. DOI:https://doi.org/10.1016/S0140-6736(21)00475-X
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.
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.