news from the european stroke congress
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Asymptomatic carotid surgeryCarotid endarterectomy (CEA) halvedthe 5 year stroke risk in patients withsubstantial carotid artery narrowing,but no recent neurological symptoms,according to data presented by AllisonHalliday and Dafydd Thomas on behalfof the asymptomatic carotid surgerytrialists (ACST; Lancet 2004; 363:1491–502). The researchers randomlyassigned 3120 asymptomaticpatients—who were age under 75 yearsand who had carotid artery diameterreduction of about 70% onultrasound—to immediateCEA or no CEA and trackedtheir progress for up to 5years. For the CEA group, theperioperative stroke riskwithin 30 days of surgery was3·1% and the net 5 yearstroke risk was 6·4%. Bycontrast, patients who werenot operated on had a 5 yearstroke risk of 11·8%. “But,outside trials, inappropriateselection of patients or poorsurgery could obviate suchbenefits”, the investigatorscaution.
FOOD for thoughtMartin Dennis, representingThe FOOD trialcollaboration, presentedthe latest data from thethree FOOD trials, which aim toevaluate different feeding policies forstroke. In FOOD 1, 4023predominantly well-nourishedpatients were randomly assigned toeither normal hospital diet alone ornormal hospital diet in combinationwith 360 mL of supplements daily.There was no significant difference ineither death or Modified RankinScores (MRS) between the groups.FOOD 2 assessed whether tube feedingshould be started early in dysphagicpatients (n=859). The results suggestthat early tube feeding may reduce casefatality, but at the expense ofincreasing the proportion of patientssurviving with poor outcome. Thedifference in mortality between earlyand avoid tube feeding was 5·8%.FOOD 3 was designed to assess
whether dysphagic patients (n=321)should be fed in the first month via anasogastric tube (NG) or apercutaneous endoscopic gastrostomytube (PEG). Outcomes with PEGfeeding were worse than with NGfeeding: only 18 (11·1%) of 162patients fed via PEG had a goodoutcome (MRS of 0 to 3), comparedwith 30 (18·9%) of 159 NG patients.“The actual differences in outcomes intrials 2 and 3 were greater than thoseobserved between stroke unit care and
general wards, although not quitestatistically significant in Trial 2”, saysDennis. “The superiority of NG overPEG has come as a big surprise tomany clinicians”.
A MATCH made in heaven?Addition of aspirin to clopidogrel inhigh-risk patients with stroke or TIAproduced a non-significant trendtowards fewer major vascular events,according to the latest analyses of theMATCH trial that were presented byHans-Christoph Diener. However,patients who received both drugs had asignificantly higher risk of life-threatening bleeding and majorbleeding. The investigators randomlyassigned 7599 high-risk patients withrecent ischaemic stroke or TIA, and atleast one additional vascular risk
factor, between the two groups in a 1:1ratio. 596 (15·7%) of the patients inthe aspirin plus clopidogrel groupreached the primary endpoint—acomposite of ischaemic stroke,myocardial infarction, vascular death,and rehospitalisation for an acuteischaemic event—compared with 636(16·7%) of the patients who receivedclopidogrel alone. 96 patients (2·6%)had a life threatening bleed in thecombination group, compared with 49(1·3%) in the clopidogrel group.
Leukoaraiosis and disabilityThere is a significant correlationbetween the severity of white-matter changes (WMC),detected by MRI, anddisturbances of gait and balance,said Hansjörg Bäzner, who gavea presentation on behalf of theleukoaraiosis and disability inthe elderly (LADIS) studygroup. The investigatorsprospectively followed 629 non-disabled elderly people, aged65–84 years and who hadvarying degrees of leukoaraiosis,to determine whether age-related WMC are predictors ofdeath, dementia, motor and gaitdisturbances, cardiovascularincidents, and depression. Theyfound a significant correlationbetween WMC severity and
disturbances of gait and balance, asmeasured by the short physicalperformance battery (SPPB). Inaddition, they observed a significantassociation of mood disturbances(measured by the geriatric depressionscale) with worsening SPPB scores,and of cognitive speed (measured byvarious neuropsychological tests) withslow walking. “According to cross-sectional data from the LADIS trialboth subcortical vascular dementiaand motor compromise have beenproven as important featuresassociated with severe WMC”, saysBäzner. “The prospective design willgive insight into the natural history ofthe disease and might help to developpreventive strategies for thiscondition.”James Butcher
News from the European Stroke Congress
Mannheim, Germany: the city hosted the ESC (May 12–15)
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Neurology Vol 3 July 2004 http://neurology.thelancet.com
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