Medical progress over the last few decades has led to increasing understanding of the pathogenesis of cerebrovascular disease. Attention has been focused on interventions to affect the acute stroke process. Neurologists have turned from the non-evidence based, and generally futile, use of heparin to more scientifically sound clinical research that has demonstrated the value of timely administration of thrombolytic agents. Increasingly, neurological investigators seek new and better ways to reverse the neurological deficits associated with the acute stroke. These efforts involve seeking better ways to use existing thrombolytic drugs, developing new medications, and exploring mechanical devices and techniques for clearing clogged arteries. These advances are clearly exciting, and there is no denying the drama of successful reversal of an acute significant neurological deficit. Yet, as with most medical conditions, far more benefit could be achieved with successful prevention of stroke than with efforts to correct its consequences. This is the critical focus of this issue of Continuum.
Although much of the important work in stroke prevention should fall to primary care physicians, nonetheless, neurologists in almost all their patient encounters should reinforce those efforts. Furthermore, it is our obligation to help educate our colleagues, as well as our patients, about the importance of these issues and interventions. All too often, unfortunately, the neurologist enters the picture for the first time after the horse has left the barn. Hopefully, the first vascular event will have spared the patient significant damage, and the neurologist then can have an important role in secondary stroke prevention.
Dr Philip Gorelick, who has concentrated on this important problem throughout much of his career, has gathered a highly capable faculty to address a variety of specific subjects in the area of stroke prevention. Dr Ji Chong and Dr Ralph Sacco, as well as Dr Sean Ruland, in their respective chapters address the subject of stroke risk and ways to alter those that are modifiable. A variety of cardiac conditions predispose patients to stroke or represent significant risk factors. Dr Robert Adams informs us about this subject. Dr Larry Goldstein discusses advances in our understanding of the appropriate selection of patients, both symptomatic and asymptomatic, for carotid endarterectomy. Dr Gorelick himself focuses on antiplatelet agents, and then Dr Michael Sloan updates us about the modern, evidence-based approach to the use of anticoagulants. Effective stroke prevention and treatment today involves more than medical and surgical interventions. It also requires a systems-based approach to medical care, a subject that Dr Ruland confronts in a second contribution. Finally, Dr David Nyenhuis concentrates on one of the potential consequences of stroke, vascular dementia. In addressing this particularly tragic outcome of cerebrovascular disease, he reminds us again of the importance of emphasizing preventive strategies.
After you have completed reading the chapters and working through the patient management problem, I again invite you to reinforce your knowledge by attempting to answer the multiplechoice questions. Dr Julie Hammack and Dr Douglas Gelb have ably worked to provide materials that don't simply test, but more importantly, educate.
Additionally, this issue of Continuum offers you the bonus of Quintessentials, a tool that will help you assess your own clinical practice and thereby help you meet the forthcoming mandate of the American Board of Psychiatry and Neurology that neurologists engage in continual practice improvement. I am grateful to Dr Bradford Worrall and Dr Karen Johnston for their efforts in producing Quintessentials, as well as to Dr Gorelick and his faculty for their contribution to this important issue of Continuum. I am confident that, after reading these materials, you will be much better prepared to help protect your patients from the potentially catastrophic consequences of stroke.
Aaron E. Miller, MD