This issue of Continuum is devoted to the diagnosis, management, and counseling of patients with stroke or who are at risk for stroke.
This issue of Continuum is devoted to the diagnosis, management, and counseling of patients with stroke or who are at risk for stroke. To achieve this goal, Guest Editor Dr Kevin M. Barrett, associate professor and vice chair of the department of neurology at Mayo Clinic Florida, has assembled an impressive group of experts to update us on the cerebrovascular diseases, including current information to guide our diagnosis and management of patients with acute ischemic stroke, for which rapid assessment, adherence to protocols, and an effective multidisciplinary system of care are essential for optimal outcomes.
The issue begins with the article by Drs Amy Guzik and Cheryl Bushnell, who provide an overview of stroke epidemiology and risk factor management to inform the preventive management of patients at risk for stroke or recurrent stroke. Next, Dr Andrew M. Southerland provides an underpinning for the rest of the issue with regard to the bedside clinical evaluation of patients with acute stroke, advising us to “Be quick, but don’t hurry,” while also reminding us of relevant neurovascular anatomy and clinical stroke syndromes. Dr Alejandro A. Rabinstein then reviews the current state of the art in the emergency treatment of acute ischemic stroke, with particular emphasis on IV thrombolysis and the decision-making process with regard to mechanical thrombectomy. Dr Shelagh B. Coutts next discusses the diagnosis and management of transient ischemic attacks and the need for, and specifics of, urgent assessment for etiologic investigation to inform the optimal preventive therapy in an individual patient with transient ischemic attack.
Dr Josephine F. Huang provides us with a review of the immediate and delayed medical complications that can occur after a stroke, emphasizing prevention and management of these complications. Drs Cumara B. O’Carroll and Kevin M. Barrett next discuss cardioembolic stroke, an important potentially preventable cause of ischemic stroke, highlight the diverse underlying mechanisms and their assessment, and summarize the current options for prevention based on the defined mechanism. Dr John W. Cole then reviews large artery atherosclerotic occlusive disease (including asymptomatic and symptomatic extracranial carotid stenosis, intracranial atherosclerosis, and extracranial vertebral artery atherosclerotic disease) and the current roles of medical, surgical, and endovascular therapy in each of these scenarios.
Drs Warren D. Lo and Riten Kumar review the risk factors, recurrence risk, and evaluation and management of arterial ischemic stroke in children and young adults, emphasizing the importance of clinicians recognizing that patients of these age groups may have particular and potentially remediable impairments in cognition and mood as sequelae of their strokes. Drs Kelly D. Flemming and Giuseppe Lanzino next summarize the epidemiology, natural history, and various management strategies for unruptured intracranial aneurysms, arteriovenous malformations, cavernous malformations, developmental venous anomalies, and capillary telangiectasias, information that is critical for us to use as we counsel our patients when these lesions are discovered, often incidentally.
Dr Jennifer Juhl Majersik reviews many of the inherited monogenic disorders that may cause stroke that clinicians need to be aware of and discusses the diagnosis and management of other important but relatively uncommon causes of stroke, including moyamoya disease, cerebral amyloid angiopathy, and pregnancy-associated stroke. In the final review article of the issue, Dr Samir R. Belagaje reviews the principles of neurorehabilitation that inform the optimal poststroke outcomes of our patients.
In this issue’s Ethical and Medicolegal Issues section, Dr David Y. Hwang uses the case example of a patient with a devastating posterior circulation infarction to discuss the ethical issues involved when surrogate decision makers request life-prolonging treatment that members of the care team may believe to be futile. In the Practice Issues article, Dr Bart M. Demaerschalk provides his state-of-the art review of the history, principles, and practice of telestroke for the remote evaluation of the patient with acute stroke. In the Coding article (accessible online and on the Continuum apps), Drs Pearce J. Korb and William Jones use an illustrative example of a patient presenting with acute ischemic stroke to illustrate the issues involved in diagnostic and evaluation and management coding of patients with stroke.
As with every issue of Continuum, several opportunities exist for CME. After reading the issue and taking the Postreading Self-Assessment and CME Test written by Drs Douglas J. Gelb and Adam G. Kelly, you may earn up to 12 AMA PRA Category 1 CreditsTM toward self-assessment and CME. Readers will note a new format in this issue’s CME section, where the questions are no longer repeated in the Preferred Responses section, a move that will keep our print issues a bit more environmentally friendly. We welcome readers’ opinions about this new format for presenting the answers to the multiple-choice questions. The Patient Management Problem, written by Dr Barrett, describes the case of a 78-year-old man who presents with an acute left hemiplegia. By following this patient’s case and answering multiple-choice questions corresponding to diagnostic and management decision points along his course, you will have the opportunity to earn up to 2 AMA PRA Category 1 CME Credits.
I am indebted to Dr Barrett for his insightful leadership and extreme dedication to this issue throughout the process, and I would also like to thank him and each of the expert contributors to this issue for providing us with such well-written articles that share their experience and expertise, which we can all use to inform the timely and accurate diagnosis and management of our patients with acute stroke and other cerebrovascular diseases to optimize outcomes.
—Steven L. Lewis, MD, FAAN