The edition · Neurology
A recent stroke need not block thrombolysis, and CHA2DS2-VASc 1 gets its first randomised answer
Pooled individual-patient data on repeated thrombolysis found no symptomatic haemorrhage; a Korean trial randomised intermediate-risk atrial fibrillation to anticoagulation or nothing; and a half-million-person cohort points at carbon monoxide behind the smoking-Parkinson association.
The edition in brief
Five findings for the neurology desk. An individual-patient-data meta-analysis of repeated intravenous thrombolysis within 90 days of a previously thrombolysed stroke gathered 28 reports and 63 patients, with data on 44: 66.7% had a favourable outcome, the pooled odds ratio for functional outcome was 1.52 (95% CI 0.97–2.39, I-squared 0%), and no symptomatic intracranial haemorrhage occurred, though asymptomatic bleeding was reported in 15.9%. SINGLE-AF randomised 1,803 South Korean patients with atrial fibrillation at intermediate stroke risk — CHA2DS2-VASc 1 in men, 2 in women — to a direct oral anticoagulant or none; at 24 months the composite of stroke, systemic embolism, major bleeding or cardiovascular death occurred in 0.5% versus 1.5% (HR 0.31, 95% CI 0.10–0.94, p=0.03), with 4 and 13 events respectively. In the China Kadoorie Biobank, among 512,701 adults followed about 12 years with 1,131 incident Parkinson cases, regular smoking carried an adjusted hazard ratio of 0.70 (95% CI 0.62–0.79) for Parkinson disease alongside the expected excess of lung cancer and stroke; among never-smokers, higher exhaled carbon monoxide tracked lower Parkinson risk in a dose-dependent pattern without any association with smoking-related diseases. A meta-analysis of 20 studies in 4,786 patients found slowly expanding lesions account for 14% of T2 lesions but appear in 78% of patients with multiple sclerosis, overlapping paramagnetic rim lesions only 11% of the time. And in 189 patients after mild ischaemic stroke, lower baseline retinal vessel density on OCT angiography predicted worse cognition at one year.
A stroke in the last three months should not, by itself, exclude thrombolysis
A stroke within 90 days is a factor to weigh, not a reason to withhold thrombolysis from a patient who otherwise qualifies.
Carbon monoxide, not nicotine, may explain why smokers get less Parkinson disease
Note the mechanism as biologically plausible and under trial, and change nothing in clinic — this is aetiology, not therapy.
Slowly expanding lesions are in most MS patients, and are not the same as rim lesions
Treat slowly expanding lesions and paramagnetic rim lesions as separate markers of chronic activity — they overlapped in only about one lesion in nine.
Retinal vessel density after minor stroke tracks small vessel disease and cognition
Treat retinal OCT angiography after minor stroke as a promising research marker of small vessel disease, not as a test to order.
Ask where the weakness was at its worst
Ask what the deficit was at its worst and when — the current examination cannot tell you whether you are watching recovery or progression.
SINGLE-AF: anticoagulation helps at CHA2DS2-VASc 1, on very few events
Offer a DOAC to patients with atrial fibrillation at CHA2DS2-VASc 1 in men or 2 in women, framing it as a modest absolute benefit over two years rather than a necessity.
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