Stroke has long been part of the "bread and butter" of practicing neurologists. For years, the management of acute ischemic stroke, which accounts for an overwhelming majority of cerebrovascular cases, has been a source of frustration and dismay for patients, families, and physicians alike, as effective treatment to reverse a neurologic deficit was lacking. Now, however, despite the availability of thrombolytic therapy that can potentially lead to recovery or at least significant improvement, the exasperation continues as the percentage of patients receiving such treatment languishes in the single digits. The battlegrounds in the struggle to provide better care for the patient with ischemic stroke now include patient education, logistic organization both before and during hospitalization, economic and legal issues, as well as the continuing quest for more effective therapies. A touchstone for the improvement of stroke therapy lies with the education of physicians involved in the treatment of these patients. Indeed, if neurologists wish to retain acute stroke care as part of their "turf," they must be knowledgeable about current best treatment and make themselves available to provide it. In this issue of CONTINUUM, Dr Steven Levine has assembled his own "stroke team," whose members have worked together throughout this issue to promote your understanding of modern acute ischemic stroke care.
A key to more effective stroke management is its prompt recognition. Accurate, as well as rapid, diagnosis is essential. In the first chapter, Drs Kevin Barrett, Joshua Levine, and Karen Johnston review this critical matter, emphasizing not only the importance of distinguishing ischemic from hemorrhagic stroke, but also the exclusion of a variety of conditions that can mimic ischemic stroke. Clearer understanding of the principles of treating stroke is enhanced in the next chapter in which Drs Tudor Jovin, Andrew Demchuk, and Rishi Gupta provide a lucid discussion of the pathophysiology of acute ischemic stroke. Recognition of the importance of the so-called ischemic penumbra should drive home the message that for many stroke patients salvation of critical brain tissues is possible.
With these fundamentals under your belt, you will be better equipped to tackle the next three chapters, which address treatment directly, focusing primarily on thrombolytic therapy. First, Drs Pooja Khatri, Joshua Levine, and Jovin address "Intravenous Thrombolytic Therapy for Acute Ischemic Stroke," and then Dr Barrett teams with Drs Khatri and Jovin to examine the very important subject of the prevention and management of the complications of acute ischemic stroke and its treatment. Time is brain has become an appropriate mantra for the delivery of better acute stroke care, and the earlier chapters have emphasized its importance. Yet, no matter what we do, many patients will fail to reach the hospital within the short timeframe currently recommended for administration of IV thrombolytic therapy. In the next chapter, Drs Demchuk, Gupta, and Khatri combine to discuss emerging therapies not only for hyperacute patients, but also for those whose treatment must be delayed beyond 6 hours.
Contemporary effective stroke care is complex, and its optimization requires the cooperation and efforts of many individuals with different training and skills. Regulatory agencies, including the federal and local governments, have gotten into the act; and reimbursement conditions make it attractive for a hospital to be able to deliver topnotch stroke treatment. In the next chapter, Drs Steven Levine, David Adamowicz, and Johnston address many issues under the rubric of "Primary Stroke Center Certification." In order for the development of more effective stroke therapy, much clinical research remains to be done. This will best be accomplished through the participation not only of "academic" neurologists, but also of those working in the trenches as "community" neurologists. In the final didactic chapter of this issue, Drs Steven Levine, Adamowicz, and Johnston partner in providing a "'How To' Guide for Clinicians Interested in Becoming Involved in Clinical Stroke Research."
The physician dealing with stroke patients is often confronted with knotty ethical dilemmas. Drs O. O. Zaidat, Junaid Kalia, and John R. Lynch discuss the care of a patient with locked-in-syndrome in the Ethical Perspectives in Neurology section. Although this is a very unusual outcome of stroke, the principles discussed are generalizable. In this issue, we also reintroduce a section on Practice Issues in Neurology, and I am very pleased that Dr Larry Goldstein, himself a well-recognized stroke specialist at Duke University, has agreed to serve as CONTINUUM's Associate Editor for Practice. Drs Lawrence Wechsler and Syed Zaidi discuss some issues related to consent for thrombolytic therapy.
As usual, a series of exercises that follow the didactic portions of CONTINUUM will help you fortify your knowledge of acute ischemic stroke and recognize those areas in which you might still need to "bone up." Drs Ronnie Bergen and Eduardo Benarroch will challenge you with their multiple-choice questions, and Drs Gupta and Joshua Levine will help you apply the information on current therapy as you work through the patient management problem.
Accompanying this issue is another edition of Quintessentials. If you have not yet tried the new streamlined version of QE-or even if you have-I invite you to engage in this highly clinical exercise that will help you test your knowledge of the subject of acute ischemic stroke management. You will work through a couple of case vignettes, and then a month later you will have the opportunity to repeat the process with new, but similar, cases to see whether you have acquired and maintained the recommended management principles.
Many of our subscribers may not yet have realized that you now have the option to access CONTINUUM online. Now would be a great time to try this service, which has several recent enhancements. Not only can you access the full text of CONTINUUM, but you can answer the multiple-choice questions and receive instant feedback as well as CME credits within two business days. In addition, you can now perform a keyword search of CONTINUUM, access and download key points for each chapter and for each issue as whole, and obtain PowerPoint slides of the figures and tables for your own use as teaching tools. The AAN and the CONTINUUM staff are very pleased to offer these improvements to our online capabilities and welcome your feedback and suggestions.
I am grateful to Dr Steven Levine for using the team approach to which he is accustomed as a provider of stroke care to build a collaborative group of experts who have provided an outstanding CONTINUUM issue. I am confident that utilization of the didactic material, as well as the many other educational opportunities provided, will enable you to deliver the best stroke care possible and help to reduce the huge number of severely affected patients that currently makes this condition the leading cause of long-term disability in the United States.
-Aaron E. Miller, MD