LAUSR

It is a great pleasure to welcome in 2021 and say goodbye to 2020. When I took over as Editor-inChief of IJS a year ago, none of us could have imagined the dramatic effects that the COVID-19 pandemic would have on all of our lives. It has also had a huge impact on stroke worldwide. We have tried hard at IJS to be at the forefront of promoting knowledge on COVID-19 and stroke by rapidly publishing the latest research and its impact on stroke care globally via our newly implemented Express publication pipeline. We have highlighted the impact on stroke services worldwide and presented international guidelines to protect both the physician and the patient. Continuing this theme, we are pleased to publish an expedited publication by Nannoni et al., who performed a comprehensive systematic review and meta-analysis of the relationship between COVID-19 and stroke. Although causality in many cases is unclear, in some patients affected by COVID19 there appears to be a specific phenotype with large artery occlusion in multiple arterial territories, perhaps related to a hypercoagulable state. It provides an upto-date summary of this rapidly evolving area, and is recommended reading. COVID-19 will remain with us for some time, although hopefully, with the encouraging news on vaccines its impact may be much reduced beyond 2021. However, when the pandemic finally passes, stroke will still remain one of the major global health challenges. In this month’s issue, we address a number of important non-COVID-19 clinical issues facing the stroke clinician. The association between cancer and stroke is well recognized, and some patients presenting with stroke are subsequently discovered to have cancer, which may have been a risk factor contributing to the stroke. A comprehensive systematic review by Bastien et al. from Montreal Canada investigates this association. Newly diagnosed cancer after stroke was higher than in patients without stroke, with a pooled cumulative incidence within 1 year of 13.6 per 1000, and most cases were diagnosed within the first few months after stroke. Interestingly, the incidence was markedly higher in patients with cryptogenic stroke at 62.0 per 1000. Reperfusion therapy has transformed treatment of our stroke patients and two papers in this edition address this topic. Di Maria et al. studied in 1832 patients the first pass effect, defined as a complete or near-complete recanalization after one pass of a mechanical thrombectomy device. Those in whom a first pass successfully opened the artery, had significantly better outcomes, and they also concluded that a strategy combining thrombectomy with thrombo-aspiration was more effective in achieving recanalization on the first pass. Thrombectomy is still not available for many patients both in developed and developing health care systems. Therefore, intravenous thrombolysis remains important, but how far one should extend its indications outside those in the original alteplase trials has been debated, including whether there should be an upper age cut-off. The TESPI trial randomized patients aged above 80 years with acute ischemic stroke seen within 3.5 h to either alteplase or placebo; 191 patients were enrolled. Although the trial did not reach its recruitment target and was therefore underpowered for its primary endpoint, the results suggested a benefit for older patients. The authors combined this in an updated meta-analysis of all of the available data which demonstrated that alteplase is beneficial in patients over 80 years of age particularly if given within 3 h.