European Stroke Journal

To assess the adherence of stroke randomised controlled trials to Consolidated Standards Of Reporting Trials reporting guidelines and investigate the factors that are associated with completeness of reporting.

We took a random sample from the Cochrane Stroke Group's Trial Register of transient ischaemic attack or stroke randomised controlled trials, published in English in 1997–2016 inclusive. Two reviewers assessed the published report of the final primary results of stroke randomised controlled trials with a 10-point truncated Consolidated Standards Of Reporting Trials reporting checklist to investigate adherence over time, univariable associations and independent associations with total Consolidated Standards Of Reporting Trials reporting score in a multiple linear regression model.

In this random sample of 177 stroke randomised controlled trials, the mean score on the truncated Consolidated Standards Of Reporting Trials checklist was 5.8 (SD 2.2); reporting improved from 1997–2000 (4.9 SD 2.0) to 2001–2009 (5.8 SD 2.1) and to 2010–2016 (6.8 SD 2.1). A higher Consolidated Standards Of Reporting Trials score was independently associated with publication during epochs following a revision of Consolidated Standards Of Reporting Trials reporting guidelines (p < 0.001), journal endorsement of the Consolidated Standards Of Reporting Trials reporting guideline at the time of randomised controlled trial publication (p < 0.001) and modified journal impact factor using median citation distribution (p = 0.012).

Stroke randomised controlled trial reporting to Consolidated Standards Of Reporting Trials standards has improved over time, but could be better.

Journal endorsement and enforcement of Consolidated Standards Of Reporting Trials reporting guidelines could further improve the reporting of stroke randomised controlled trials.

Systematic review registration: Registered with PROSPERO (CRD42017072193).

There appears to be an association between poor oral hygiene and increased risk of aspiration pneumonia – a leading cause of mortality post-stroke. We aim to synthesise what is known about oral care after stroke, identify knowledge gaps and outline priorities for research that will provide evidence to inform best practice.

A narrative review from a multidisciplinary perspective, drawing on evidence from systematic reviews, literature, expert and lay opinion to scrutinise current practice in oral care after a stroke and seek consensus on research priorities.

Findings: Oral care tends to be of poor quality and delegated to the least qualified members of the caring team. Nursing staff often work in a pressured environment where other aspects of clinical care take priority. Guidelines that exist are based on weak evidence and lack detail about how best to provide oral care.

Oral health after a stroke is important from a social as well as physical health perspective, yet tends to be neglected. Multidisciplinary research is needed to improve understanding of the complexities associated with delivering good oral care for stroke patients. Also to provide the evidence for practice that will improve wellbeing and may reduce risk of aspiration pneumonia and other serious sequelae.

Although there is evidence of an association, there is only weak evidence about whether improving oral care reduces risk of pneumonia or mortality after a stroke. Clinically relevant, feasible, cost-effective, evidence-based oral care interventions to improve patient outcomes in stroke care are urgently needed.

There is uncertainty regarding the optimal timing for initiation of oral anticoagulant treatment in patients with recent ischaemic stroke and atrial fibrillation. We surveyed the current UK practice and assessed clinician’s opinions of when to use oral anticoagulant in recent stroke patients with atrial fibrillation.

An online survey was sent to stroke physicians within the United Kingdom via their national societies.

One hundred and twenty-one clinicians responded to the survey. Ninety-five percent of responders agreed that there was uncertainty regarding timing of oral anticoagulant initiation after atrial fibrillation-related ischaemic stroke. Thirty-six percent of responders followed the ‘1–3–6–12’ European Society of Cardiology guidelines recommendation. Uncertainty was greater in cases of moderate stroke than in cases of transient ischaemic attack (TIA), mild or severe stroke. Eighty-eight percent of responders would be willing to participate in a clinical trial of early versus later initiation of oral anticoagulant after stroke. Direct-acting oral anticoagulants were the preferred oral anticoagulant of choice.

There is a lack of consensus amongst stroke physicians for when to initiate oral anticoagulant to prevent recurrence in stroke patients with atrial fibrillation. There is little uncertainty regarding TIA. A clinical trial assessing the use of early versus later initiation of direct-acting oral anticoagulant in patients with recent ischaemic stroke and atrial fibrillation would be beneficial.

In the nationwide Dutch Acute Stroke Audit (DASA), consecutive patients with acute ischaemic stroke (AIS) and intracranial haemorrhage (ICH) are prospectively registered. Acute stroke care is a rapidly evolving field in which intravenous thrombolysis (IVT) and intra-arterial thrombectomy (IAT) play a crucial role in increasing odds of favourable outcome. The DASA can be used to assess the variation in care between hospitals and develop ‘best practice’ in acute stroke care. Patients and methods: We describe the initiation and design of the DASA as well as the results from 2015 and 2016.

In 2015 and 2016, 55,854 patients with AIS and 7727 patients with ICH were registered in the DASA. Treatment with IVT was administered to 10,637 patients (with an increase of 1.3% in 2016) and 1740 patients underwent IAT (with an increase of 1% in 2016). Median door-to-needle time for IVT and median door-to-groin time for IAT have decreased from 27 to 25 min and 66 to 64 min, respectively. Mortality during admission was 4.9% in patients with AIS, whereas 26% of patients with ICH died. Modified Rankin Scale score at three months was registered in 49% of AIS patients and 45% of ICH patients.

During the nationwide DASA, time to treatment is reduced for IVT as well as IAT. With the rapidly evolving treatment of acute stroke care, the DASA can be used to monitor the quality provided on patient- and hospital level.

Increasing completeness of registration of the outcome, in combination with adjustment for patient-related factors, is necessary to define and further improve the quality of the acute stroke care.

Neuroimaging in older adults commonly reveals signs of cerebral small vessel disease (SVD). SVD is believed to be caused by chronic hypoperfusion based on animal models and longitudinal studies with inter-scan intervals of years. Recent imaging evidence, however, suggests a role for acute ischaemia, as indicated by incidental diffusion-weighted imaging lesions (DWI+ lesions), in the origin of SVD. Furthermore, it becomes increasingly recognised that focal SVD lesions likely affect the structure and function of brain areas remote from the original SVD lesion. However, the temporal dynamics of these events are largely unknown.

(1) To investigate the monthly incidence of DWI+ lesions in subjects with SVD; (2) to assess to which extent these lesions explain progression of SVD imaging markers; (3) to investigate their effects on cortical thickness, structural and functional connectivity and cognitive and motor performance; and (4) to investigate the potential role of the innate immune system in the pathophysiology of SVD.

The RUN DMC – InTENse study is a longitudinal observational study among 54 non-demented RUN DMC survivors with mild to severe SVD and no other presumed cause of ischaemia. We performed MRI assessments monthly during 10 consecutive months (totalling up to 10 scans per subject), complemented with clinical, motor and cognitive examinations.

Our study will provide a better understanding of the role of DWI+ lesions in the pathophysiology of SVD and will further unravel the structural and functional consequences and clinical importance of these lesions, with an unprecedented temporal resolution. Understanding the role of acute, potentially ischaemic, processes in SVD may provide new strategies for therapies.

Compared to healthy individuals, stroke patients have five times the rate of dementia diagnosis within three years. Aerobic exercise may induce neuroprotective mechanisms that help to preserve, and even increase, brain volume and cognition. We seek to determine whether aerobic fitness training helps to protect brain volume and cognitive function after stroke compared to an active, non-aerobic control.

In this Phase IIb, single blind, randomised controlled trial, 100 ischaemic stroke participants, recruited at two months post-stroke, will be randomly allocated to either the intervention (aerobic and strength exercise) or active control (stretching and balance training). Participants will attend one-hour, individualised exercise sessions, three days-per-week for eight weeks. Assessments at two months (baseline), four months (post-intervention), and one year (follow-up) post-stroke will measure brain volume, cognition, mood, cardiorespiratory fitness, physical activity, blood pressure and blood biomarkers.

Study outcome: Our primary outcome measure is hippocampal volume at four months after stroke. We hypothesise that participants who undertake the prescribed intervention will have preserved hippocampal volume at four months compared to the control group. We also hypothesise that this group will have preserved total brain volume and cognition, better mood, fitness, and higher levels of physical activity, than those receiving stretching and balance training.

The promise of exercise training to prevent, or slow, the accelerated rates of brain atrophy and cognitive decline experienced by stroke survivors needs to be tested. Post Ischaemic Stroke Cardiovascular Exercise Study has the potential, if proven efficacious, to identify a new treatment that could be readily translated to the clinic.