Now is an exciting time to care for stroke patients. .

Statistics are impressive, but even more important for me is the effect of stroke on the individual. What could be worse than suddenly to become unable to talk; stand; walk; use a hand, arm, or leg; see; read; feel; understand spoken language; write; or remember? Loss of function is often sudden and totally unanticipated, and it may be transient or permanent, slight or devastating. Most individuals who are asked which health problems they fear the most reply cancer leading to a painful death and the loss of physical capacity as a result of stroke or dementia. In the United States each year, nearly 750,000 individuals have strokes and 150,000 (90,000 women and 60,000 men) die as a result of stroke.(1) Stroke kills more women than breast cancer does. Stroke is a worldwide problem. In China, approximately 1 1/2 million people die each year as a result of stroke. For a long time, stroke has been the third leading cause of death in most countries in the world, surpassed as a killer only by heart disease and cancer . Strokes are an even more important cause of prolonged disability than heart disease or cancer. Survivors of strokes are often unable to return to work or to assume their former effectiveness as citizens, spouses, friends, and parents. The economic, social, and psychological costs of stroke are enormous, and the problem is growing as the population ages.

Now Is the Time

If teachers in medical schools were resurrected from their graves and returned to the hospitals where they worked while alive, which aspect of contemporary medical care would be most surprising to them? Clearly, the tremendous advances in technology. In patients with strokes and vascular disease, clinicians are able to obtain--quickly and safely--imaging studies of the brain and the structures that relate to the brain circulation, including the heart, the aorta, and the major neck and cranial arteries and veins. When I was a trainee in internal medicine and neurology in the 1960s, we had available only cranial x-rays and techniques that were relatively hazardous and unpleasant to perform, such as air encephalography and invasive angiography by direct arterial puncture. Even these studies showed only what was happening in the air spaces within the cranium and the arteries, not what was happening in the brain.

Today, we not only can define the stroke type (eg, ischemia, hemorrhage) more precisely but also can quantitate and localize the region of vascular damage and define the nature, location, and severity of the causative cardiovascular disease. We also know much more than in the past about the blood and its coagulability. In addition to the great advances in diagnostic capability, there now is a much broader therapeutic armamentarium. There are many more different strategies than in the past that can be used to prevent and minimize stroke damage, such as more feasible surgery on arteries in the neck and head, interventional strategies with regard to angioplasty and stenting of arterial lesions, newer agents that alter platelet functions, newer heparins and other anticoagulants, better methods of monitoring anticoagulation, and newer ways to make the brain less vulnerable to ischemic damage.

The newest, and in many ways the most exciting, advance in stroke therapeutics is the study of recovery from stroke. The advent of functional magnetic resonance imaging has provided a window onto the qualitative, quantitative, and temporal aspects of how individuals recover from brain infarction and hemorrhage. It is now possible to study the effect of a number of novel treatments, such as pharmaceutical agents; physical, speech, and occupational therapy; and so-called restraint therapy, in which the therapist forces the patient to use the impaired limbs and impaired functions such as speech, magnetic stimulation, and even cell and growth factor implants. We also know that some substances (eg, haloperidol) substantially impair or delay recovery.(2) The window is now open to provide substantial help for a large group of patients who already have had cerebrovasculature-related brain injuries--a prospect not seriously considered in the past.

Caring for Stroke Patients Is Appealing for Physicians

Stroke is an acute condition with lots of action. Time equals brain, and diagnosis and treatment must proceed quickly and efficiently. A great deal of good can be done, and brain tissue and lives can be saved. Neurology and stroke are undoubtedly complex subjects. Knowledge of the anatomy and pathology of the brain and its supply vessels is the key to diagnosis and treatment. Care is intellectually challenging and extremely rewarding for the physician when a patient with a potentially severe disabling deficit is able to recover as a result of the physician's wisdom and actions.

Strokes involve the brain--arguably the most distinct, complex, and important of all organs in the body. Surely, the brain is wholly responsible for intelligence, capability, character, wit, humor, personality, and most of the characteristics that make people recognizable as human and as individuals. The loss of brain function can be dehumanizing and often makes individuals dependent on others. Everyone would like to exit life with their capabilities and mind intact, despite the inevitable effects of aging on the body.

Some of the Present Problems in Stroke Care

1. The public and most potential patients and families are woefully ignorant about the brain. They know much less about stroke and its symptoms than about other conditions such as cancer and heart attacks. As a result, they do not seek appropriate care in time to receive acute treatment.

2. Individuals involved in emergency services, such as dispatchers and ambulance workers, are not sufficiently educated about stroke and its management.

3. It has been extremely difficult for emergency physicians, primary care doctors and internists (nonneurologists and even nonstroke neurologists) to keep up with the rapid changes in technology and treatment. All too often, stroke patients are not handled well in hospital emergency rooms even when they do arrive quickly. Most hospitals do not have the necessary personnel, technology, and systems to manage acute stroke patients effectively.

4. The economics of managed care have not served stroke patients well. The system needs to be altered so that patients are taken to stroke centers that have the requisite technology and experienced stroke physicians at hand 24 hours per day, 7 days per week as well as the necessary systems to guarantee rapid and effective throughput. The brain is the Rolls Royce of the human body. Would you take your Rolls Royce into the local gas station if it had a problem, especially a potentially serious one? We need to designate qualifications for stroke centers just as we have done for trauma centers, and must find ways to get the patients there. The reward systems do not facilitate emergent stroke care by experts. Most neurologists are office-based. For them to leave crowded offices to rush to the hospital and spend hours with acute stroke patients, there must be sufficient compensation. Even hospital-based physicians are not adequately compensated for acute stroke care and the delivery of thrombolytic agents. More str oke units and more stroke specialists are desperately needed.

5. There is a mismatch between what technology can show us about the cause and the extent of strokes and cerebrovascular disease in individual patients, and what so-called evidence-based medicine can tell us about specific treatments in individual patients on the basis of randomized trials. Nearly all trials lump diverse stroke subtypes in patients in whom the pathology and pathophysiology and vascular lesions have not been studied or reported. There are a few exceptions, such as trials of warfarin prophylaxis in patients with nonvalvular atrial fibrillation, extracranial to intracranial arterial bypass in patients with occlusive carotid and middle cerebral artery disease, and carotid endarterectomy in symptomatic and asymptomatic persons. Unfortunately, the general results of most trials performed to date are not directly applicable to the choice of treatment in patients with well-defined vascular lesions. (3)

How Physicians Should Care for Stroke Patients Today

To care for stroke patients today, the first step is to find out what is wrong with each individual stroke patient as best as you can. Specific, precise diagnosis has great intrinsic value, even when there is no recognized effective present treatment. Knowing what is wrong with the patient tells you what is not wrong. Prognosis is aided greatly. One can choose from different strategies known to be applicable to the individual patient's pathology and pathophysiology with some likelihood of success.

The Disease Process and the Brain and Vascular Lesions

A careful and thorough history of the recent symptoms and past conditions, the family history of the patient, and thorough general and neurologic examinations provide important information about the disease process, the brain, and vascular lesions. Computed tomographic or magnetic resonance imaging studies showing the presence, the nature, and the extent of any brain injury must be obtained. Vascular testing is also essential. Stroke is a cerebrovascular disease. To treat it effectively, it is important to know the nature, the location, and the severity of any vascular lesions. Vascular in the broadest sense encompasses the heart, the aorta, and the major feeding arteries in the neck and the head. The blood also must be analyzed for its cellular constituents and screened for coagulability. The good news is that individuals with training and experience in caring for stroke patients can navigate this complex process safely and quickly. Nothing quite matches the satisfaction of knowing that you have saved someon e from a lifetime of disability.

Accepted November 7, 2002.

References

(1.) Caplan LR. Caplan 's Stroke. A Clinical Approach. Boston, Butterworth-Heinemann, 2000, ed 3.

(2.) Feeney DM, Gonzalez A, Law WA. Amphetamine, haloperidol, and experience interact to affect rate of recovery after motor cortex injury. Science 1982;217:855-857.

(3.) Caplan LR. Evidence based medicine: Concerns of a clinical neurologist. J Neural Neurosurg Psychiatry 2001;711:569-574.

From the Department of Neurology, Beth Israel-Deaconess Medical Center, Boston, MA.

Reprint requests to Louis R. Caplan, MD, Department of Neurology, Beth Israel-Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215-5400. Email: [e-mail]

Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9604-0329