Stroke research in 2017: surgical progress and stem-cell advances

To show that progress has been made in stroke intervention, it is possible to cite several substantial advances over the past year. Beginning with a clinical highlight: three randomised trials 1 Mas JL Derumeaux G Guillon B et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med. 2017; 377: 1011-1021 Crossref PubMed Scopus (608) Google Scholar , 2 Sondergaard L Kasner SE Rhodes JF et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med. 2017; 377: 1033-1042 Crossref PubMed Scopus (601) Google Scholar , 3 Saver JL Carroll JD Thaler DE et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med. 2017; 377: 1022-1032 Crossref PubMed Scopus (573) Google Scholar that tested the safety and efficacy of patent foramen ovale (PFO) closure after a cryptogenic stroke reported their results simultaneously. The CLOSE trial 1 Mas JL Derumeaux G Guillon B et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med. 2017; 377: 1011-1021 Crossref PubMed Scopus (608) Google Scholar enrolled patients who had a recent PFO-attributed stroke associated with either an atrial septal aneurysm or a large, right-to-left interatrial shunt. Compared with antiplatelet therapy alone, a lower rate of recurrent stroke was reported after combined PFO closure and antiplatelet therapy (hazard ratio [HR] 0·03, 95% CI 0·00–0·26; p=0·001), to the extent that would, statistically, result in one stroke avoided at 5 years per 20 patients treated with PFO closure-treated. However, PFO closure was also associated with an increased risk of atrial fibrillation (4·6% vs 0·9%, p=0·02). The Gore REDUCE trial 2 Sondergaard L Kasner SE Rhodes JF et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med. 2017; 377: 1033-1042 Crossref PubMed Scopus (601) Google Scholar similarly showed that the risks of new and recurrent stroke were significantly lower with PFO closure combined with antiplatelet therapy than with antiplatelet therapy alone (1·4% vs 5·4%; HR 0·23, 95% CI 0·09–0·62; p=0·002 for recurrent stroke; 5·7% vs 11·3%; relative risk [RR] 0·51, 0·29–0·91; p=0·04 for new stroke). PFO closure was also associated with complications related to devices (1·4%) and, as in the CLOSE trial, with atrial fibrillation (6·6% vs 0·4%, p=0·001). The RESPECT trial 3 Saver JL Carroll JD Thaler DE et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med. 2017; 377: 1022-1032 Crossref PubMed Scopus (573) Google Scholar reported the results of long-term follow up after PFO closure (mean 5·9 years), showing that PFO closure combined with anticoagulant pharmacotherapy was associated with a lower rate of recurrent stroke than pharmacotherapy alone (HR 0·55, 95% CI 0·31–0·999; p=0·046). Taken together, these three trials show that PFO closure combined with pharmacotherapy seems to be superior to pharmacotherapy alone for patients with a cryptogenic stroke attributed to PFO. A neuroethics round upIn every January issue, The Lancet Neurology celebrates the best neurological research of the year that we leave behind. The 2017 Round-up, with comments on the advances on eleven major subspecialties, highlights findings that bear testimony to the remarkable progress of the neurological community in understanding brain function, and improving brain dysfunction. The knowledge on how the human brain works, and how physicians can affect its function, is not purely theoretical, but has very real ethical consequences. Full-Text PDF