news from the european stroke congress

1
386 Newsdesk Asymptomatic carotid surgery Carotid endarterectomy (CEA) halved the 5 year stroke risk in patients with substantial carotid artery narrowing, but no recent neurological symptoms, according to data presented by Allison Halliday and Dafydd Thomas on behalf of the asymptomatic carotid surgery trialists (ACST; Lancet 2004; 363: 1491–502). The researchers randomly assigned 3120 asymptomatic patients—who were age under 75 years and who had carotid artery diameter reduction of about 70% on ultrasound—to immediate CEA or no CEA and tracked their progress for up to 5 years. For the CEA group, the perioperative stroke risk within 30 days of surgery was 3·1% and the net 5 year stroke risk was 6·4%. By contrast, patients who were not operated on had a 5 year stroke risk of 11·8%. “But, outside trials, inappropriate selection of patients or poor surgery could obviate such benefits”, the investigators caution. FOOD for thought Martin Dennis, representing The FOOD trial collaboration, presented the latest data from the three FOOD trials, which aim to evaluate different feeding policies for stroke. In FOOD 1, 4023 predominantly well-nourished patients were randomly assigned to either normal hospital diet alone or normal hospital diet in combination with 360 mL of supplements daily. There was no significant difference in either death or Modified Rankin Scores (MRS) between the groups. FOOD 2 assessed whether tube feeding should be started early in dysphagic patients (n=859). The results suggest that early tube feeding may reduce case fatality, but at the expense of increasing the proportion of patients surviving with poor outcome. The difference in mortality between early and 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 a nasogastric tube (NG) or a percutaneous endoscopic gastrostomy tube (PEG). Outcomes with PEG feeding were worse than with NG feeding: only 18 (11·1%) of 162 patients fed via PEG had a good outcome (MRS of 0 to 3), compared with 30 (18·9%) of 159 NG patients. “The actual differences in outcomes in trials 2 and 3 were greater than those observed between stroke unit care and general wards, although not quite statistically significant in Trial 2”, says Dennis. “The superiority of NG over PEG has come as a big surprise to many clinicians”. A MATCH made in heaven? Addition of aspirin to clopidogrel in high-risk patients with stroke or TIA produced a non-significant trend towards fewer major vascular events, according to the latest analyses of the MATCH trial that were presented by Hans-Christoph Diener. However, patients who received both drugs had a significantly higher risk of life- threatening bleeding and major bleeding. The investigators randomly assigned 7599 high-risk patients with recent ischaemic stroke or TIA, and at least one additional vascular risk factor, between the two groups in a 1:1 ratio. 596 (15·7%) of the patients in the aspirin plus clopidogrel group reached the primary endpoint—a composite of ischaemic stroke, myocardial infarction, vascular death, and rehospitalisation for an acute ischaemic event—compared with 636 (16·7%) of the patients who received clopidogrel alone. 96 patients (2·6%) had a life threatening bleed in the combination group, compared with 49 (1·3%) in the clopidogrel group. Leukoaraiosis and disability There is a significant correlation between the severity of white- matter changes (WMC), detected by MRI, and disturbances of gait and balance, said Hansjörg Bäzner, who gave a presentation on behalf of the leukoaraiosis and disability in the elderly (LADIS) study group. The investigators prospectively followed 629 non- disabled elderly people, aged 65–84 years and who had varying degrees of leukoaraiosis, to determine whether age- related WMC are predictors of death, dementia, motor and gait disturbances, cardiovascular incidents, and depression. They found a significant correlation between WMC severity and disturbances of gait and balance, as measured by the short physical performance battery (SPPB). In addition, they observed a significant association of mood disturbances (measured by the geriatric depression scale) with worsening SPPB scores, and of cognitive speed (measured by various neuropsychological tests) with slow walking. “According to cross- sectional data from the LADIS trial both subcortical vascular dementia and motor compromise have been proven as important features associated with severe WMC”, says Bäzner. “The prospective design will give insight into the natural history of the disease and might help to develop preventive strategies for this condition.” James Butcher News from the European Stroke Congress Mannheim, Germany: the city hosted the ESC (May 12–15) m:con Neurology Vol 3 July 2004 http://neurology.thelancet.com For personal use. Only reproduce with permission from The Lancet.

Upload: james-butcher

Post on 17-Sep-2016

220 views

Category:

Documents


1 download

TRANSCRIPT

386

Newsdesk

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)

m:c

on

Neurology Vol 3 July 2004 http://neurology.thelancet.com

For personal use. Only reproduce with permission from The Lancet.