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03-17-2005

Among all the neurologic diseases of adult life, the cerebrovascular ones clearly rank rst in frequency and importance At least 50 percent of the neurologic disorders in a general hospital are of this type At some time or other, every physician will be required to examine patients with cerebrovascular disease and should at least know something of the common types particularly those in which there is a reasonable prospect of successful medical or surgical intervention or the prevention of recurrence There is another advantage to be gained from the study of this group of diseases namely, that they have traditionally provided one of the most instructive approaches to neurology As our colleague C M Fisher has aptly remarked, house of cers and students learn neurology literally stroke by stroke Moreover, the focal ischemic lesion has divulged some of our most important ideas about the function of the human brain It must also be noted that, in the last two decades, new and extraordinary types of imaging technology have been introduced that allow the physician to make physiologic distinctions between normal, ischemic, and infarcted brain tissue This biopathologic approach to stroke will likely guide the next generation of treatments and has already had a pronounced impact on the direction of research in the eld Salvageable brain tissue to be protected in the acute phase of stroke can be delineated by these methods To identify this ischemic but not yet infarcted tissue virtually de nes the goal of modern stroke treatment Which of the sophisticated imaging techniques will contribute to improved clinical outcome is still to be determined, but certain ones, such as diffusionweighted imaging, have already proved invaluable in stroke work Despite these valuable advances in stroke neurology, three points should be made First, all physicians have a role to play in the prevention of stroke by encouraging the reduction in risk factors such as hypertension and the identi cation of signs of potential stroke, such as transient ischemic attacks, atrial brillation, and carotid artery stenosis Second, careful bedside clinical evaluation integrated with the newer testing methods mentioned above still provide the most promising approach to this category of disease Finally, the last decade or two have witnessed a departure from the methodical clinicopathologic studies that have been the foundation of our understanding of cerebrovascular disease Increasingly, randomized studies involving several hundred and even thousands of patients and conducted simultaneously in dozens of institutions have come to dominate investigative activity in this eld These multicenter trials have yielded highly valuable information about the natural history of a variety of cerebrovascular disorders, both symptomatic and asymptomatic However, this approach suffers from a number of inherent weaknesses, the most important of which is that the homogenized data derived from an aggregate of patients may not be applicable to a speci c case at hand Moreover, many large studies show only marginal differences between treated and control groups Each of these multicenter studies will therefore be critically appraised at appropriate points in the ensuing discussion.