In arguably no other area within neurology—with the possible exception of demyelinating diseases—has the field evolved and the paradigm shifted more significantly since the last triennial Cerebrovascular Disease issue of Continuum than the topic of management of acute ischemic stroke. To help us navigate these critical changes in acute stroke management and keep us up-to-date on the current diagnosis, treatment, and prevention of stroke and recurrent stroke, I am extremely thankful to this issue’s guest editor, Dr Natalia S. Rost, who has organized a remarkable issue and brought together an outstanding team of experts in cerebrovascular disease to serve as authors.
The issue begins with the concise and up-to-date summary by Dr Karen Furie of the fundamentals of the epidemiology and primary prevention of stroke (ie, lifestyle and medical risk factors involved in the mitigation of stroke risk in patients who have not yet had a clinical episode of cerebral ischemia). The next article, by Dr Alejandro A. Rabinstein, is an update to the treatise on the management of acute ischemic stroke that he originally provided for us in the February 2017 issue on cerebrovascular disease. This updated review, which he so nicely provided upon my request, ensures that readers are kept abreast of the current indications and contraindications to IV recurrent tissue plasminogen activator (rtPA) administration and the current role of mechanical thrombectomy for large vessel occlusions. This article represents an important and practical summary of the state of the art in acute ischemic stroke management and a foundation for the next two articles in the issue. In the following article, Dr Bijoy K. Menon discusses neuroimaging in acute stroke, with particular emphasis on the role of CT, CT angiography, and advanced imaging techniques (including assessment of the ischemic penumbra) that inform accurate and timely decisions in acute stroke management. Drs Gisele S. Silva and Raul G. Nogueira then provide a far-reaching review of the current and cutting-edge aspects of endovascular treatment of acute ischemic stroke, with emphasis on the paradigm shift from the “time window” to the “tissue window” in selecting patients for mechanical thrombectomy up to 24 hours from the onset of symptoms.
In the next article, Dr Rost and Dr Mark Etherton review the most current concepts regarding cerebral small vessel disease and the various disorders associated with it, with emphasis on cerebral small vessel disease as a potentially modifiable risk factor for acute and chronic neurologic disorders. Dr Hooman Kamel then discusses the evolving concept of cryptogenic stroke, including summaries of recent investigations to determine the optimal management of embolic stroke of undetermined source, as well as of management of patients with patent foramen ovale.
The next two articles address stroke in specific populations of our patients. First, Drs Hanne Christensen and Cheryl Bushnell review stroke in women, describing the many risk factors in women that can lead to differences in stroke severity, functional outcomes, and mortality. Next, Dr Jukka Putaala discusses ischemic stroke in young adults, including a review of risk factors that have led to an increase in the incidence of ischemic stroke in this population and a discussion of the long-term adverse outcomes that can occur in young patients.
The following two articles discuss the management of patients after stroke. First, recognizing that even in the present era of remarkable improvement in acute stroke therapies many patients continue to have lifelong disability after stroke, Dr Steven C. Cramer reviews the current and evolving evidence for cutting-edge restorative modalities that it is hoped will improve our patients’ recoveries after stroke in the near future. Next, Dr Anthony S. Kim provides an extensive evidence-based and practical review of the options for medical management for secondary stroke prevention, several of which have been clarified by recent practice-changing trials.
In the following article, Dr Michael F. Waters reviews the various surgical approaches to stroke risk reduction, with emphasis on the evidence currently available with regard to these approaches, including not only a discussion of carotid endarterectomy and stenting but also an analysis of the trials of some less-performed direct and indirect vascularization procedures in highly selected patients. In the final review article of the issue, Dr Ynte M. Ruigrok provides a thorough and very practical discussion of the management of unruptured cerebral aneurysms and arteriovenous malformations, abnormalities (particularly the former) that we not infrequently discover as incidental findings on brain or vascular imaging and for which patients request our informed opinion with regard to treatment versus observation.
I would like to give my sincere thanks to Dr Rost for her guest editorship of this important issue and for enlisting such expert authors to assist us as we attempt to provide the highest level of care throughout the continuum of our patients’ stroke odysseys…
In the Medicolegal Issues article, Dr Joseph S. Kass and Ms Rachel V. Rose discuss the important and practical concepts surrounding legal liability associated with rtPA administration and surrogate decision makers. In the Practice Issues article, Drs Anne W. Alexandrov and Andrei V. Alexandrov discuss the state of the art regarding prehospital stroke management using mobile stroke units.
After reading the issue and taking the Postreading Self-Assessment and CME Test written by Drs Douglas J. Gelb and Allyson R. Zazulia you may earn up to 20 AMA PRA Category 1 CreditsTM toward self-assessment CME or, for Canadian participants, a maximum of 20 hours toward the Accredited Self-Assessment Program (Section 3) as defined by the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada. Additional credit can be obtained by listening to Continuum Audio interviews associated with this and other Continuum issues, available to all subscribers, and completing tests on the Continuum Audio web platform or mobile app. Continuum Audio is also accredited by the Royal College of Physicians and Surgeons of Canada.
I would like to give my sincere thanks to Dr Rost for her guest editorship of this important issue and for enlisting such expert authors to assist us as we attempt to provide the highest level of care throughout the continuum of our patients’ stroke odysseys, beginning from the first recognition of symptoms, to the prehospital environment, the emergency department and endovascular suite, acute hospitalization, stroke rehabilitation, and prevention of recurrence. We can only imagine what further developments for the benefit of our patients with stroke will be highlighted 3 years from now.
—STEVEN L. LEWIS, MD, FAAN