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

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).

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.

The available care pathways, guidelines and protocols for stroke care make one thinks that there is almost a unity between the European centres in providing the expected level of stroke care in primary or secondary care setup. But the reality is different. Wellwood I. et al in his recent article published in May issue of ‘stroke’ (Stroke. 2011; 42:1207-1211) mentioned that there are significant differences in the provision of care and outcome after stroke across European countries. To address this issue a research team developed and field-tested a quality tool that was delivered by post and later by site visit at 7 centres across Europe. Systematic reviews and stroke care evidences grading were used for this purpose. The tool included 251 items across 11 domains, of which 214 items could be categorized by any level of evidence. The results of this tool implementation showed that in field testing, the proportion of positive responses to evidence-based items ranged from 43% to 79% across populations. The authors concluded that the European Registers of Stroke Quality Assessment Tool has potential to be used as a framework to compare services and promote increased implementation of evidence-based care.

The focus in medical research on the role of diet in preventing cardiovascular diseases and stroke is always welcome. There are few studies recently addressing the subject of consuming red meat and the relation to stroke. This recent study from Sweden is focusing on the consumption of the red meat in Swedish women and the risk of total stroke (Stroke 2011; 42:324-329).

The researchers prospectively followed 34 670 women without cardiovascular disease and cancer at baseline. Participants completed a self-administered questionnaire on diet and other risk factors for cardiovascular diseases in 1997. During a mean follow-up of 10.4 years, the authors ascertained 1680 incident cases of stroke, comprising 1310 cerebral infarction, 154 intracerebral hemorrhage, 79 subarachnoid hemorrhage, and 137 unspecified stroke.

It was found that total red meat and processed meat consumption was associated with a statistically significant increased risk of cerebral infarction, but not of total stroke, intracerebral haemorrhage, or subarachnoid haemorrhage. The study suggested that red and processed meat consumption may increase the risk of cerebral infarction in women.

As part of the academic activity of the Welsh stroke physicians, professor Peter Sandercock was invited to talk about the latest developments regarding the international stroke trial 3 (IST3) via a video link from his centre in Edinburgh. This trial is targeting thrombolysing ischaemic stroke patients up to 6 hours following their presentations with signs and symptoms of stroke. It was confirmed that so far the trial has managed to recruit 2670 patients and the final target is 3000 patients which should b achieved by the end of June 2011 , the date for ending the trial and analysing the data. In his presentation Professor Sandercock confirmed that UK is recruiting the highest number of patients throughout Europe. He mentioned that there are another two trials regarding thrombolysing ischaemic stroke patients. One of these trials is Extend which is looking into the mismatch of DW1/PW1 radiological techniques for thrombolysing stroke patients 9 hours after their presentations with the stroke symptoms. The second   trial is Tepsi which is recruiting patients at the age over 80years after their presentation with stroke up to three hours.  Thrombolysis  is not licensed at present for stroke patients above 80 years of age. In the videoconference link from Edinburgh, Prof. Sandercock reminded the audience about two educational web sites for stroke physicians.  The first one is www.neuroimage.co.uk and the second is www.stroketraining.org.