Elsevier

The Lancet

Volume 371, Issue 9624, 10–16 May 2008, Pages 1612-1623
The Lancet

Seminar
Stroke

https://doi.org/10.1016/S0140-6736(08)60694-7Get rights and content

Summary

Stroke is the second most common cause of death and major cause of disability worldwide. Because of the ageing population, the burden will increase greatly during the next 20 years, especially in developing countries. Advances have occurred in the prevention and treatment of stroke during the past decade. For patients with acute stroke, management in a stroke care unit, intravenous tissue plasminogen activator within 3 h or aspirin within 48 h of stroke onset, and decompressive surgery for supratentorial malignant hemispheric cerebral infarction are interventions of proven benefit; several other interventions are being assessed. Proven secondary prevention strategies are warfarin for patients with atrial fibrillation, endarterectomy for symptomatic carotid stenosis, antiplatelet agents, and cholesterol reduction. The most important intervention is the management of patients in stroke care units because these provide a framework within which further study might be undertaken. These advances have exposed a worldwide shortage of stroke health-care workers, especially in developing countries.

Section snippets

Epidemiology

Stroke causes 9% of all deaths around the world and is the second most common cause of death after ischaemic heart disease.1 The proportion of deaths caused by stroke is 10–12% in western countries, and 12% of these deaths are in people less than 65 years of age.2 In 2002, stroke-related disability was judged to be the sixth most common cause of reduced disability-adjusted life-years (DALYs—the sum of life-years lost as a result of premature death and years lived with disability adjusted for

Subtypes and pathophysiology

Strokes are either ischaemic or haemorrhagic. Because the management of these subtypes is so different, the clinical distinction between the subtypes is one of the most important and urgent steps in stroke management. This distinction has been revolutionised by the introduction of CT and MRI. Although CT has been the workhorse of stroke diagnosis during the past 20 years, MRI is now as useful as, if not more so than, CT.15

Further systems for stroke classification have been driven by the needs

Stroke prognosis

About a quarter of stroke patients are dead within a month, about a third by 6 months, and a half by 1 year.35, 36 Prognosis is even worse for those with intracerebral and subarachnoid haemorrhage because the 1-month mortality approaches 50%. The major cause of early mortality is neurological deterioration with contributions from other causes such as infections secondary to aspiration (if not managed aggressively), but later deaths are more commonly caused by cardiac disease or complications of

Stroke care units (SCUs)

Remarkable advances in the management of acute stroke seen in the past 10–15 years consist of four proven interventions supported by level 1 evidence and various promising interventions under investigation (table 3). Without doubt the most substantial advance in stroke has been the routine management of patients in SCUs, which is effective and appropriate for all stroke subtypes, and provides a focus for professionals in stroke care. Management of patients within an SCU reduces mortality by

Primary prevention

The steadily reducing mortality from stroke is largely attributable to improved control of risk factors,123 especially for hypertension, in which waves of blood-pressure-lowering agents, each more effective than the previous one, have permeated western societies from the 1950s onward.124 Modification of other risk factors such as socioeconomic status, cholesterol, diabetes, atrial fibrillation, and reduction in smoking rates might also have had some effect.10, 125 Level I evidence for the

Treatments under investigation

Carotid angioplasty with stenting, which is now generally combined with distal protection devices, is a minimally invasive procedure that will probably replace carotid endarterectomy as the treatment of choice in most patients. Initial trials suggested that the perioperative risks associated with the procedure are similar to carotid endarterectomy,153, 154 but the risks might be increased in less skilled hands;120 further randomised controlled trials are underway to explore the procedural risks

Conclusions

Although there have been advances in our understanding of the epidemiology and pathophysiology of stroke during the past decade, the most striking changes have been in the increasing array of therapeutic interventions. The greatest advance is the recognition that SCU management reduces mortality and improves clinical outcomes. The importance of this finding is emphasised as networks of SCUs become established across many countries and form a framework for the propagation of knowledge of stroke

Search strategy and selection criteria

We searched Medline for English language manuscripts. We used the search terms “stroke prognosis”, “secondary prevention”, “primary prevention”, “intracerebral haemorrhage”, and “acute stroke therapies” in combination with the term “review”. We largely selected publications in the past 5 years, but did not exclude commonly referenced and highly regarded older publications. We also searched the reference lists of articles identified by the search strategy and selected those we judged

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