The edition · Neurology
Anticoagulating intermediate-risk atrial fibrillation cut strokes in a randomised trial
SINGLE-AF gives randomised support to a class IIa recommendation; pooled trials back thrombectomy beyond 4.5 hours but leave bridging tenecteplase unproven; and midlife p-tau181 tracked memory decline two decades later.
The edition in brief
SINGLE-AF randomised 1,803 Korean patients with atrial fibrillation and a CHA2DS2-VASc score of 1 (men) or 2 (women) to a DOAC or no anticoagulation. Over two years, the composite of stroke, embolism, major bleeding or cardiovascular death occurred in 0.5% versus 1.5% (HR 0.31, 95% CI 0.10–0.94), and strokes in 0.3% versus 1.1%, with no apparent excess in major bleeding. Event numbers were small and the trial open-label, but it is the first randomised evidence for a recommendation that rested on observational data. A Bayesian network meta-analysis of eight trials in confirmed large-vessel or basilar occlusion treated 4.5 to 24 hours after onset found thrombectomy improved functional independence (OR 2.93) and reduced mortality, while adding tenecteplase before thrombectomy gave imprecise estimates (OR 1.10, credible interval 0.34–3.52). In 1,515 ARIC participants, higher plasma p-tau181 in midlife was associated with faster memory decline 20 years later, and late-life p-tau181, NfL and GFAP all tracked decline. These markers are not ready for use in cognitively normal people. A French population study showed that the tissue-based stroke definition in ICD-11 raises measured incidence by 6.5%, more in people under 55. The pearl covers how to document a transient event with a positive scan.
Late-window large-vessel stroke: thrombectomy carries the benefit
Prioritise rapid thrombectomy for imaging-confirmed large-vessel occlusion in the late window; bridging tenecteplase adds unproven benefit.
Midlife p-tau181 tracked memory decline 20 years later
Reserve Alzheimer blood biomarkers for people with symptoms; the midlife signal is too weak to guide care.
The ICD-11 stroke definition adds younger patients to the count
Code and manage transient symptoms with imaging-confirmed infarction as stroke, particularly in younger patients.
Brief symptoms, positive DWI: treat it as a stroke
Manage transient symptoms with a positive DWI scan as a minor stroke, with urgent secondary prevention.
Intermediate-risk atrial fibrillation: fewer strokes on a DOAC
Discuss DOAC therapy with patients whose atrial fibrillation carries an intermediate stroke risk; the first randomised evidence favours it.
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