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
SeminarStroke
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
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