Practicing evidence based medicine means that you initiate statin treatment for the patients with cardiovascular diseases or TIA/Stroke if the level of the total cholesterol is >3.5 mmol/L. The clinical question arise all the time about the duration of the treatment with statin itself and if there is any side effect of this treatment. We might have the answer today from the trial that was published in The Lancet (The Lancet, 378; 9808:2013-2020).

Assessing the long- term efficacy and safety of Lowering LDL cholesterol, the authors of the Heart Protection Study (HPS) allocated 40 mg once a day simvastatin or placebo for 20 536 patients of vascular and non- vascular outcomes. Major vascular event was the primary outcome measure of the trial. A mean total duration of 11 years was yielded from the post-trial follow-up of surviving patients.

It was reported today that during the in-trial period, allocation to simvastatin yielded a proportional decrease in major vascular events of 23%. The trialists concluded that more prolonged LDL- lowering statin treatment produces larger absolute reductions in vascular events. The benefit of this treatment persists after stopping it for at least 5 years without any evidence of adverse reaction to the simvastatin.

The implications of such trials are significant on prevention strategies of stroke and cardiovascular diseases as hyperlipidemia is one of the established risk factors for cardiovascular diseases and stroke.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61125-2/abstract

Dr. Amer Jafar writes:

Stroke can be a devastating disease as it might lead to death in third of the patients and disability in another third. Stroke causes over 4.3 million deaths world-wide annually. The focus on preventing stroke is important in any health care strategy. However; it remains a challenge to meet the standard level of care which is expected for acutely ill patients with ischaemic or haemorrhagic stroke. The recent Royal College of Physicians/London stroke audit¹ and the reports in the media yesterday² regarding stroke care are examples of the variation in the level of care for stroke patients in different regions of the country and even in between different hospitals, trusts or health boards in one area.

The basic standard of stroke care provision includes medical intervention within the first few hours of presentation to the acute medical units in the hospital which should include arranging a CT brain examination within the time window of 0-4.5 hours. Thrombolysing ischaemic stroke patients is vital within this time window. All the recent evidences in medical literature support the notion that the outcome of thrombolysing stroke patients is better than the outcome in otherwise routine conventional medical intervention.

The speed of transferring stroke patients from the general medical assessment units to a specialised stroke unit is another important factor in providing a good standard of care in stroke medicine.

There are different factors which can lead to the variation between different regions in the country with regard of the stroke care.

1. Stroke care can be expensive and not every hospital is expected to provide an immediate access to CT scanning or accessing immediately the stroke units for admitting patients. Some hospitals are lacking such units in the first place. This is in fact one of the major factor that can lead to the big variation between developing and developed countries regarding stroke care on the global level.
2. The issue of leadership and management is important in stroke care. It is a multidisciplinary care which depends on team work. Leaders are expected to practice to the high standard in the field of health in general and in stroke care in particular.
3. Providing an acceptable staffing level of skilful medical and other allied health professionals to stroke units is another important factor in improving the stroke care in any region.

1. http://www.rcplondon.ac.uk/press-releases/stroke-care-audit-results

1. http://www.independent.co.uk/news/uk/politics/variations-in-nhs-stroke-care-shock-mps-2375531.html

The STICH II Trial is a surgical trial in sponatenous lobar Intracerebral Haemorrhage or ICH. The Trial has a target of 600 patients to reach before 31st May 2012. Currently over 100 hospitals worldwide are participating, including 18 in the UK. If you are registered and would like some promotional material to distribute to your colleagues / a member of the STICH II team to visit your site, please do send an email to  stich@ncl.ac.uk

STICH was a prospective randomised trial to compare early surgery with initial conservative treatment for patients with spontaneous supratentorial intracerebral haemorrhage.

The link for the STICH II website is: http://research.ncl.ac.uk/stich/

The US Department of Health and Human Services is palnning to prevent 1 millioon heart attacks and strokes by 2017. The focus of the new startegy is on the ( ABCS) or the aspirin, blood pressure, choelsterol and smoking. The epidemiological studies showed that currently only 46% of people in the USA at increased risk of cardiovascular disease are taking aspirin, only 46% of people with hypertension have adequately controlled blood pressure, 33% of people with high cholesterol have adequately controlled hyperlipidaemia, and only 23% of people who are trying to quit smoking get help to do so. The use of the mutidisciplinary team approach and the medical education facilities is part of the new startegy. The Lancet Journal which published the news today ( 23rd September 2011) did not mention the exact cost of the new initiative.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61490-6/fulltext

In the October issue of the “Lancet Neurology”, Suhaib A et al discussed the potential benefit of augmenting or maintaining the cerebral collateral circulation in case of ischaemic stroke. The article which was published on line today mentioned that “Imaging of the brain and vessels has shown that collateral flow can sustain brain tissue for hours after the occlusion of major arteries to the brain, and the augmentation or maintenance of collateral flow is therefore a potential therapeutic target. Several interventions that might augment collateral blood flow are being investigated”.

http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(11)70195-8/fulltext

The daily TIA clinic in Newport City has managed to cut the waiting list of the patients referred to the clinic for TIA management. The clinic adopted the ABCD2 score to prioritise the referral on daily basis of TIA patients.

Thrombolysing ischaemic stroke patients was another area of development in the region. The team is providing 24/7 thrombolysing stroke service and telestroke medicine is well under way in the region in spite of the financial difficulties.

So far using the aggressive medical treatment to prevent recurrent stroke after atherosclerotic intracranial arterial stenosis, is the best approach to deal with the condition which is causing the ischaemic stroke. In this week New England Journal Of Medicine, a study was published comparing  percutaneous transluminal angioplasty and stenting (PTAS) with the aggressive medical treatment to prevent the recurrence of stroke in patients with stenotic intracrainal arteries. The stucy concluded that in patients with intracranial arterial stenosis, aggressive medical management was superior to PTAS with the use of the Wingspan stent system, both because the risk of early stroke after PTAS was high and because the risk of stroke with aggressive medical therapy alone was lower than expected (NEJM September 7, 2011).

The study of how a neurological disorder can change the artistic activity and behavior of creative people is a largely unexplored field. This publication looks closer at famous painters, writers, composers and philosophers of the 18th to the 20th centuries who suffered from neurological diseases such as stroke, epilepsy, brain trauma and dementia. The diseases of Van Gogh, Ravel, Poe, Kant, Haydn and many more are diagnosed in retrospect and treatment options according to modern medical technologies are discussed. Presenting fascinating insights into the relationship between brain disease and creativity in famous minds, this publication is highly recommended to neurologists, psychiatrists, physicians as well as to everybody interested in art, music and literature.

Editors: J Bogousslavsky and F. Boller

ISBN: 3805579144

PAGES: 192 Hard Back. 38 Fig, 14 in Colour. 2005

For a busy three days of 24-27^th May 2011, the 20^th European stroke conference discussed hundreds of research papers and stroke Trials from almost 3000 delegates worldwide.

Professor Hennerici, the Chairman of the European stroke conference mentioned in his press conference on 24^th May 2011 that the organisers received 1300 abstracts from 64 countries. He considers the conference as representing the international stroke community and not only the Europeans. In his address on the opening ceremony of the Conference, Professor Hennerici, reminded the audience that 20 years ago the stroke in Europe was in different shape. We were at that time starting discussing the best way to treat stroke acutely and put plans of how to engage in further stroke research activities.

Slides demonstrating the number of abstracts submitted and the origin of these papers were presented to the Conference.

The Wepfer Award 2011 was dedicated to Professor W.D. Heiss, Germany for his life- long achievement in stroke research. Prof. Heiss then presented a summary of his work on the ischaemic penumbra: correlates in Imaging and implications for treating ischaemic stroke.

“Strokeupdate” attended the sessions of the conference and when it was possible its editor participated in the discussion as well.

With regards of the meta-analysis and reviews, there was a study about subarachnoid haemorrhage (SAH) and how it is higher in females after age 50 years compared to males. The review of 12 case-control studies concluded that female hormone levels characteristic for reproductive age, are associated with a lower risk of SAH.

Antihypertensives were studied and discussed in the Conference as well in some details. Cochrane and midline database were searched for systematic reviews and randomised controlled trials of antihypertensives. The paper concluded that calcium channel blockers reduced inter-individual variability in systolic blood pressure (SBP) when added to another agent. The effects of antihypertensive drugs on SBP variability are dose-dependent and persist when used in combinations.

Immunotherapy for stroke: A new Hope

The aim of one of the papers presented in the conference is to investigate developing a novel treatment strategy for stroke, relying on antibodies targeting the pro-neurotoxic effects of tPA.

It demonstrates the efficiency of immunotherapy in a complete pre-clinical screen. After a single administration alone or with late tPA-induced thrombolysis, antibodies dramatically reduce ischemic brain injuries. The paper concluded that the Immunotherapy strategy is thus able to limit ischaemic histological and neurological damages in mice, and extends the therapeutic window of tPA-driven thrombolysis.

Intracerebral Haemorrhage

There were few papers in the 20th European stroke conference from Japan, china and India. Regarding the subject of intracerebral haemorrhage, moderately aggressive blood pressure (BP) lowering with target systolic BP (SBP) ≤160 mmHg using IV nicardipine is the major strategy for patients with acute intracerebral haemorrhage (ICH) in Japan.

An interim report of a prospective, observational study from 10 centers SBP lowering (range 120-160 mmHg) using IV nicardipine with tight BP monitoring appears to be safe and feasible for acute ICH. This was discussed in some details in the conference.

Statins and stroke outcome

Medline/Pubmed was searched for relevant articles on stroke, stroke outcome and statins Ten studies met the inclusion criteria. The research team concluded rom their review that pretreatment with statins may decrease in-hospital mortality in stroke-patients who didn’t had tPA treatment.There was no significant difference between statin users and no statin users for functional outcome in patients who had tPA treatment It was found that statins may increase the risk of haemorrhagic transformation in the tPA patient group.

Brain Natriuretic Peptide and TIA diagnosis

Brain Natriuretic Peptide (BNP) may be a biomarker for occult paroxysmal atrial fibrillation (AF) in patients with ischaemic stroke of undetermined aetiology. The research team related baseline BNP levels at the time of a first TIA or ischaemic stroke to aetiology in patients who had a recurrent ischaemic stroke during follow-up. The team studied all patients in the Oxford Vascular Study (2002-2009) with TIA or ischaemic stroke who had a recurrent stroke more than 90-days after the initial event. Blood was drawn at the first event and stored. Patients with TIA or stroke of initially undetermined etiology in whom AF was detected at the time of subsequent recurrent stroke had had high BNP levels at the time of the first event.

The researchers concluded that BNP may be useful in identification of patients with paroxysmal AF and in the etiological classification of TIA and stroke.

Thrombolysis in Cervical Artery Dissection:

The authors used the CADISP-database (Cervical artery dissection) to compare outcomes of CADStroke-patients treated with and without thrombolysis. Among 612 CADStroke-patients, 68 (11.1%) received thrombolysis. Thrombolysed patients had more severe strokes (median NIHSS-score 16 versus 3; p<0.001), and more often occlusions of the dissected artery. As thrombolysis was neither independently associated with unfavourable outcome nor with an excess of symptomatic bleedings, thrombolysis should not be withhold in CADStroke-patients.

The conference concluded that the lack of any trend towards a benefit of thrombolysis indicates the legitimacy to search for more efficient treatment options. As most patients were treated intravenously, endovascular procedures deserve testing in a comparative trial.

The news from the 20th European stroke conference which is due to be open today in Hamburg, Germany is that the European Union has agreed to fund a new study about stroke during sleep.

The objective of the WAKE-UP project is to provide expanded treatment options for acute stroke improving the outcome of stroke patients, thus reducing the burden of stroke. WAKE-UP is an investigator-initiated multicenter randomised double-blind placebo-controlled trial designed to test efficacy and safety of magnetic resonance imaging (MRI)-based intravenous thrombolysis in patients waking up with stroke symptoms or patients with unknown symptom onset.

Up to 20% of acute stroke patients wake up with their stroke symptoms. Currently, these patients are excluded from thrombolysis because this effective treatment can only be applied to patients in whom the time elapsed since symptom onset can be clearly determined.