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Stroke: So much to do, still so poorly resourced!

The impact of the results of the recent endovascular trials is starting to be felt globally by the changing of existing and development of new guidelines. For example, in this edition, we have the interdisciplinary European Recommendations on Organisation of Interventional Care in Acute Stroke. A number of important issues are addressed, concerning the facilities required for thrombectomy, key performance indicators required for effective processes to be in place and adjunctive therapies among others. The interdisciplinary nature of the management of such patients is emphasized by the involvement and endorsement of such organizations as the European Academy of Neurology, the European Association of Neurosurgical Societies, the European Society of Emergency Medicine, the European Society of Minimally Invasive Neurological Therapy, the European Society of Neuroradiology, and the European Stroke Organisation. Hence, there should be a broad acceptance of these guidelines by all Europeans and many other countries. It is interesting that we are still developing new approaches to early and late secondary prevention of acute ischemic stroke. Many of you will have seen the results of SOCRATES trial, which only just failed to reach statistical significance in preventing a range of vascular outcome events when testing the hypothesis that the P2Y 12 receptor inhibitor ticagrelor was superior to aspirin after transient ischemic attack or minor stroke. We are still waiting on the POINT trial results, where aspirin plus clopidogral is being used in the acute phase of a similar population. In this edition, we have a call for a trial using the protease-activated receptor inhibitor vorapaxar to be appropriately trailed as a secondary prevention agent. It is heartening to see we continue to push for improvements in secondary prevention, an area of stroke management that has seen enormous advances over the last 30 years. Of course, it is only natural that data from the acute thrombectomy trials continue to dominate the medical literature given the remarkable outcomes that we have seen. Here, the MR CLEAN investigators show us that those patients with large vessel occlusion and contraindications to alteplase still benefit from thrombectomy. This has significant implications for the design of the next generation of clot retrieval trials in this area where direct catheterization may be used without prior thrombolysis. We also have an interesting review by Rannikmae et al. of the currently used intracerebral hemorrhage classifications and their reliability. Reassuringly, all were found to be reliable but could really only be used in specialist centers, where there are highly trained clinicians. This raises the broader issues of developing greater expertise across the board in familiarity with stroke management, and its necessary clinical classification components to guide appropriate interventions. Finally, this segues onto another poorly studied area, which may appear to be mundane but is of utmost importance to those who have recently experienced a stroke; I refer to predictors of factors influencing return to driving after the event.