Stroke Historical Perspectives And Future Directions

Magdy Selim

Recent years have witnessed increasing recognition and interest in stroke as a major public health problem. However, stroke is an ancient disease. Imhotep, the founder of Egyptian medicine, described stroke in one of the world's earliest medical documents, the Edwin Smith papyrus, around 3000 BC. More detailed description of this condition followed in AD 1600s when Thomas Willis identified the arterial supply of the brain, "the circle of Willis,'' and used the term "apoplexy" to describe stroke. In the 1800s, anatomists Matthew and Cruveilher illustrated the lesions in stroke; Dechambre described the small cavity that remains after a small stroke and termed it "lacune"; and Virchow introduced the elements of "Virchow's triad'' and reported on thromboembolism as a cause of vascular occlusion, marking the true beginning of the understanding of this condition. In the 1900s, Charles Foix analyzed the distribution of infarcts in various arterial territories and correlated brain lesions with clinical findings, sparking interest in stroke as a clinical entity. Clinical observations by astute physicians, like Foix and Broca, during the nineteenth century provided the basis for clinical anatomical correlates of stroke. The introduction of computerized axial tomography and angiography during the twentieth century made it possible to define the potentially causative vascular lesions.

The modern period in the history of stroke began in the 1960s when C. Miller Fisher described detailed clinical and pathological observations on the features of lacunar strokes, carotid artery disease, transient ischemic attacks, and intracerebral hemorrhage. His student Louis Caplan established one of the first stroke registry

Acute Ischemic Stroke: An Evidence-based Approach, Edited by David M. Greer. Copyright © 2007 John Wiley & Sons, Inc.

databases to collect and analyze important epidemiological, clinical, radiological, and pathological data. Stroke treatment was rudimentary and often nihilistic. Stroke victims might have been treated with maggots or leeches in order to improve blood supply to the brain in hopes of restoring its functions. In 1961, Thomas Dawbe introduced the term ''risk factors'' to describe the contribution of specific conditions to cardiovascular disease. Shortly thereafter, the Framingham heart study highlighted the link between cardiovascular risk factors and stroke. The risk factors were refined and they provided insights into the biology of stroke. The concept of stroke prevention was introduced, and antithrombotics and antihypertensives were used to reduce stroke risk.

Remarkable advances in the field of stroke occurred during the past 50 years. Advances in basic sciences uncovered the intricate pathophysiology of stroke and cerebral ischemia. Various steps in the ischemic cascade were identified, and the concept of neuroprotection evolved, generating several therapeutic agents for clinical investigation. The adoption of organized clinical trials methodology led to the approval of intravenous recombinant tissue-plasminogen activator (rt-PA) as the first proven effective treatment for acute ischemic stroke in 1996. The introduction of new brain-imaging techniques, such as diffusion- and perfusion-weighted magnetic resonance imaging (MRI), enabled the study of the evolution of brain ischemia in vivo. The concept of the ischemic penumbra and its brief duration led to fundamental changes in the way we treat acute stroke patients. The term ''time is brain'' evolved to highlight that there is a small window of opportunity following stroke to intervene. Stroke became a medical emergency, and consensus emerged that thrombolytic and neuroprotective therapies would only be effective if delivered early after stroke onset. Endovascular interventionalists with neurological expertise are increasingly taking a hand in the acute management of stroke patients, marking a new chapter in the history of this challenging condition.

Unfortunately, the management of stroke remains suboptimal despite years of dedicated research and increasing attention. Clinical trials for the evaluation of novel therapies, however, have undergone considerable improvements and have become increasingly sophisticated over the years. Potentially promising investigations of novel neuroprotective compounds, hypothermia, oxygen therapy, brain stimulation, and regenerative therapy are currently underway. The stage is now set to identify new therapies that can significantly improve recovery in stroke patients. This book elucidates the evidence to support our care of acute stroke patients to date, and sets the stage for future areas of study. We have come a long way in our understanding of stroke, and the coming decades are likely to reveal amazing improvements in the care of this devastating condition.

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