[Improving the quality of stroke care in the Netherlands; registration of quality indicators is a joint responsibility]. / Verbetering van de kwaliteit van CVA-zorg; registratie kwaliteitsindicatoren is gezamenlijke verantwoordelijkheid.

An article by the International Consortium of Health Outcomes Measurement, with the title 'An international standard set of patient-centered outcome measures after stroke', was published recently in the journal Stroke. In this article we reflect on this paper and its significance for the Netherlands. The authors report on an international consensus conference to establish recommendations for outcome measurement in stroke care. Indicators, measurement moments and measures were proposed, with a strong focus on patient-reported outcomes. The core measure advocated is use of the recently developed Patient Reported Outcomes Measurement Information System 10-Question Short Form (PROMIS SF v1.1 Global Health; or PROMIS-10). We can appreciate this paper as support for current developments towards benchmarking in stroke rehabilitation in the Netherlands; however, we also have concerns about the administrative burden and the proposed time points and measures. Joining forces to strengthen the current efforts to establish benchmarking should be given priority in the Netherlands.

[Calcified cerebral embolism as a cause of ischemic stroke]. / Een vrouw met linkszijdig krachtsverlies en sufheid.

A 60-year-old woman with a history of hypertension presented with acute onset of left-sided weakness and drowsiness. Non-contrast CT at baseline and follow-up showed a focal high density lesion in the right middle cerebral artery, consistent with a calcified embolus. CT angiography confirmed its location.

[Resumption of antithrombotic treatment after an intracerebral haemorrhage]. / Hervatten van antistolling na een hersenbloeding.

There is no evidence from randomised clinical trials with regard to the question if and when to resume antithrombotic medication in patients who have suffered an intracerebral haemorrhage and in whom medication continues to be indicated. It is unknown whether new oral anticoagulants are more suitable than vitamin K antagonists in this group of patients. Oral anticoagulants should probably not be resumed in patients with a lobar intracerebral haemorrhage caused by cerebral amyloid angiopathy. They can be considered in patients with a haemorrhage in subcortical regions of the brain, the brain stem or the cerebellum, provided that blood pressure levels are under control. Depending on the risk of a cardiac embolus, antithrombotic medication can be resumed from 1 to 10 weeks after the intracerebral haemorrhage. In patients with atrial fibrillation this risk can be calculated using the CHA2DS2-VASc score. In patients with a cardiac indication for antithrombotic medication the decision whether or not to resume medication should be made by a cardiologist and a neurologist in collaboration.

[Closure of patent foramen ovale after a TIA or minor ischaemic stroke; yet another logical, but unnecessary treatment]. / Sluiten van open foramen ovale na een TIA of klein herseninfarct; wéér een logische, maar overbodige behandeling.

Recently, three randomised clinical trials have demonstrated that percutaneous closure of a patent foramen ovale (PFO) should not routinely be recommended for patients with a TIA or a minor ischaemic stroke, which was deemed to be caused by a PFO. Although the procedure is feasible and carries a low complication rate, it should be considered unnecessary in most patients, because of its benign prognosis with respect to future ischaemic stroke during optimal medical therapy. Cardiologists and neurologists have the difficult task of identifying the few patients with a TIA or minor ischaemic stroke who might benefit from closure of a PFO. Possibly, the procedure should be performed only in patients with recurrent cerebral ischaemic events, a large right-to-left shunt and a relatively high risk for deep venous thrombosis.