World Stroke Organization Proclamation

SAGE to begin publishing the International Journal of Stroke January 2016

Taken from the SAGE website!

http://www.uk.sagepub.com/aboutus/press/2015/apr/9.htm

London (April 9 2015)- SAGE, one of the world’s leading independent and academic publishers, has today announced that it is to publish the International Journal of Stroke,the official journal of the World Stroke Organization (WSO) incorporating the International Stroke Society (ISS) and the World Stroke Federation (WSF).

Focused on the clinical aspects of stroke, the International Journal of Stroke reviews not only current topics and recent advances of global interest, but also those which may be more prevalent to certain regions to help facilitate the international debate and awareness around stroke. The journal accepts leading opinion pieces, topical reviews and original contributions from clinical or basic science researchers, alongside pieces focused on the associated structures to manage protocols within the field. The journal is edited by the internationally recognised stroke expert Professor Geoffrey Donnan, who was awarded the prestigious Bethlehem Griffiths Research Foundation (BGRF) medal in 2008.

Speaking about the new partnership, Karen Phillips, Editorial Director, SAGE, remarked that:

“SAGE has developed a strong medical portfolio over the past decade and to have been selected to publish the International Journal of Stroke is a testament to the dynamic nature and breadth of our titles and an indication of our growing strength across these disciplines. We are delighted to be working closely with the leading editorial board and WSO to continue to support access to cutting edge research on stroke awareness, further developing the reach of the journal and making it an excellent platform for sharing international stroke research.”

The International Journal of Stroke Editor- in- Chief Geoffrey Donnan, further stated:

“We are thrilled to now be publishing with SAGE, a publisher whom we feel not only is closely aligned with both our editorial goals but who has proven itself a leader within the field, now being ranked in the top 4 for publication of medical journals. Their growing medical background and clear vision for our future development is what we are most looking forward to when we begin working together. With SAGE behind us we are confident in the continuation of our key aim: reducing the global burden of stroke through prevention, treatment and long term care.”

WSO President Professor Stephen Davis added:

“SAGE offered everything that we were looking for when finding a new home including: the opportunity for international development and a great understanding of the field in which the journal is situated. We are all excited at WSO about this new partnership with SAGE and delighted with the upward trajectory of our Journal as the truly global medium for stroke research and education.”

The first SAGE issue will publish in January 2016. Please click here for more information on the journal.

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SAGE Founded 50 years ago by Sara Miller McCune to support the dissemination of usable knowledge and educate a global community, SAGE publishes more than 800 journals and over 800 new books each year, spanning a wide range of subject areas. A growing selection of library products includes archives, data, case studies, conference highlights and video. SAGE remains majority owned by our founder and after her lifetime will become owned by a charitable trust that secures the company’s continued independence. Principal offices are located in Los Angeles, London, New Delhi, Singapore, Washington DC and Boston.www.sagepub.com

The International Journal of Stroke is the flagship publication of the World Stroke Organization and publishes high quality research articles, reviews and clinical trial protocols from around the world. IJS is dedicated to building a global stroke community, making it a global voice for stroke research and an excellent platform for sharing international stroke research.

The World Stroke Organization (WSO) is the world’s leading organization in the fight against stroke. It was established in October 2006 through the merger of the International Stroke Society and the World Stroke Federation with the purpose of creating one world voice for stroke. Today, WSO has more than 2000 individual members and over 60 society members from 85 different countries. www.world-stroke.org

What do Emilio Botin (Spanish banker), James Gandolfini (american actor) and my grandpa (argentine journalist) had in common? None should have died when they did….

They all suffered “heart attacks”. No details have been provided on Mr. Botin’s (79) death but according to a media source “it was totally unexpected” and “…it occurred a few hours before he would present a painting by Velázquez that he helped restore…”. Mr Gandolfini (51), well known for his role in the Soprano’s, was on vacation in Rome and planning to attend the closing of the Taormina Film festival in Sicily when his 13 year old son found him unconscious at their hotel’s bathroom. Resuscitation efforts at a hospital were unsuccessful. My grandfather (68) died of acute pulmonary oedema (i.e. acute heart failure) the day after he was planning to join a sports club…

Despite medical supervision (a cardiologist was “seeing” my grandfather), it is an epidemiologic fact common to most people above 40 years of age to have at least an untreated or undertreated vascular risk factor. Among the most common modifiable risk factors are inappropriate nutrition with or without excess weight, a sedentary life, current or recent smoking, high blood pressure (undiagnosed in 1 out of 3 people and uncontrolled in 80% of diagnosed patients in developed countries), abnormal lipid levels or diabetes. Also, Botín, Gandolfini and my grandfather shared a load of un-modifiable risk factors such as male sex, age and, potentially, a spectrum of unfavorable genetic traits. All these factors alter the normal arterial wall structure generating plaques that progressively narrow the vessel’s lumen leading to a decrease in blood flow to the heart, brain and other organs. 

The vascular problem is complex and dynamic. It is definitely not just a matter of clogged pipes. In fact, 80% of myocardial infarctions (MI’s) -with a high mortality rate- occur due to arteries that are not previously “stenotic” (i.e. narrowed). These patients will not be detected with a coronary “stress” test which only identifies arteries that have advanced narrowing and thus cannot supply enough blood to the heart muscle. Only 20% of MI’s occur in patients with previously narrowed arteries and these are the ones that can be detected by warning symptoms or a positive stress test. The concern, then, is that the vast majority of people have “plaques” covering the arterial wall (as dirt may accumulate in the walls of a plumbing system) which do not decrease the vessel’s diameter and are thus difficult to detect with conventional studies. The danger is that the so called “plaque accident” can unexpectedly occur leading to a sudden plaque disruption that generates a clogging cascade ending within minutes with a blocked artery… and an infarcted or dead person. A similar mechanism underlies many strokes. We have all heard people saying: “… how could this happen?… he/she was so healthy….”. In the case of James Gandolfini, the New York Times quoted that, after receiving results of the autopsy, a family member stated that he “…died… of natural causes”. Wrong! These people are sick and the essential -the status of their arteries- was invisible to the eye…

What Botín, Gandolfini and my grandpa did not know is that almost 80% of vascular events occur in people with few risk factors. This is the reason why most people feel that a heart attack or stroke is something that will happen “to others”. Yet, some people get health check-ups with the hope that if “approved” they get a few years’ survival guaranteed. Disappointingly, a Danish study on 180.000 people published recently in the British Medical Journal showed that conventional health check-ups (including a chest Xray, EKG, ultrasounds and blood tests among others) did not decrease total mortality or death secondary to cardiovascular disease or cancer, the very reasons for promoting and performing these evaluations (pap smear, mammogram, colonoscopy and prostate exams were excluded). So, what are we missing?

Could an eye doctor give you the right glass prescription without examining your eyes? The exact same rationale applies to disease of the arteries irrespective of whether they are in the heart, brain, legs or kidneys. Different methods can reliably evaluate arteries but most are expensive and some are invasive such as catheterization and others, like multi slice CT, use high doses of radiation precluding the repeated testing needed for disease follow-up. Ultrasound is fast, reliable, non invasive and affordable. There are ultrasound tests available that allow to objectively measure the atherosclerosis load in the vessel’s wall. Atherosclerotic plaque quantification was originally developed by David Spence in the 90’s and further studied by Valentin Fuster and others more recently. A quantification of arterial “plaque” burden (expressed in square or cubic millimeters depending on the technique) allows to accurately measuring the individual’s risk of having a vascular event. Knowing a person’s vascular risk factor profile (smoker, excess weight, hypertensive, etc) does not provide accurate data on that individual person’s risk of suffering a heart attack, stroke or other vascular event. In concordance with this notion, the latest lipid therapy guidelines recommend treatment according to the person’s vascular risk and not according to a specific cholesterol level. It is impossible to accurately define the best medical treatment based only on a person’s risk factor profile (or using “risk scores” which are derived from risk factor data) without measuring the load of atherosclerosis that affects the arteries. Vascular prevention should be based on a tailor made treatment. Or, again, could the eye doctor give you the right glass prescription just knowing you can’t see well (i.e. that you have vascular risk factors) without examining your eyes (i.e. your arteries)?

From Galileo Galilei to the software metrics guru Tom de Marco, many have stressed that one can only control what is measured. And everything is measurable. We should not only be measuring the conventional risk factors such as blood pressure, cholesterol, glucose, exercise and calories, but also the amount of atherosclerosis in the arteries. Only then we will be able to adjust the treatment of vascular risk factors “individually” according to all findings. The World Health Organization and different research authorities have shown that cardiovascular deaths could decrease by 80% if what we know about vascular disease was applied effectively. Botín, Gandolfini and my grandfather, no matter their wealth, social status or popularity were probably not receiving the medications and other measures (exercise, nutrition) that could have prevented their deadly vascular event. It is also unlikely that they had their “atherosclerosis” burden measured to adjust treatment according to their individual atherosclerosis load. There are millions more like them that every year have fatal MI’s and strokes. Of the approximately 150,000 people that die every day worldwide, almost one third dies of vascular related disease. Most of these deaths are preventable. It is due time to declare “tolerance zero” to unexpected vascular death.   

Conrado J. Estol, M.D., Ph.D.

The impact of MR CLEAN Editorial IJS

The impact of MR CLEAN

This is the first opportunity I've had to comment on the recent presentation of the MR CLEAN results by Dr Diedrick Dippel from the Netherlands at the World Stroke Congress in Istanbul, 2014. As the stroke world now knows, the results of this well conducted randomized control trial of endovascular treatment in acute ischaemic stroke, most of whom had commenced intravenous tPA before randomization, was strongly positive. For the first time in my career I observed a standing ovation following a presentation, such was its impact. To have such a clear-cut result, after years of frustration with trials of neuro protection and even endovascular therapy, we now seem to be at a point where the second definite intervention of acute ischemic stroke is upon us. While it is true that we have two other proven interventions for acute ischaemic stroke vis management in a stroke unit and hemicraniectomy, endovascular therapy promises to be the most significant advance in the area since tPA in 1995–96.

Interestingly, the Data safety monitoring boards of trials such as EXTEND IA, SWIFT–PRIME and ESCAPE, reacting to the MR CLEAN results have suggested suspension of these trials, with steering committees recommending these trials now cease, the final results of many will be presented at the forthcoming ISC in Nashville, USA, this month.

More importantly, if the results of MRCLEAN are confirmed by other studies, a revolution of the delivery of stroke services is likely to occur. Specifically, the demand for interventional services is going to escalate almost exponentially so that centres of excellence will need to be established to cope with the throughput to maintain their high standards of excellence in service delivery. Governments around the world will need to response accordingly.

Taking a look at this edition, Patrick Lydens review Revisiting Cerebral Postischemic Reperfusion Injury: New Insights highlights that there is still much research to do to fully understand this process and offers targets for therapy as yet to be identified, the relevance relating to my earlier comments on endovascular therapy is obvious. Since with both tPA and endovascular therapy reperfusion injury is going to become an increasingly important topic; a review well worth reading. I also mentioned how surgical decompression for space-occupying middle cerebral artery infarction has become one of the proven interventions of definite benefit after acute ischemic strokes, albeit in a minority of patients. Hence, the systematic review of Middelar et al is a welcome supplement to a difficult area of research. Reassuringly, quality of life was reasonable amongst most patients receiving this intervention and severe decompressive symptoms were uncommon. This provides even more evidence to suggest that the procedure be performed much more frequently than it is in most centres around the world.

Our research papers this edition are of their usual high standard, and I'm delighted to have a Panorama telling us about the burden of stroke in Mexico, our protocols section, continues to be extremely popular with trials for Cilistozol, folic acid and b vitamins, among a number of secondary prevention studies.

Looking forward to seeing you at the inaugural European Stroke Organization Conference, which is the official European Stroke Conference.