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Among all the neurologic diseases of adult life, stroke clearly ranks first in frequency and importance—at least half of the neurologic disorders in a general hospital are of this type. This group of diseases has also provided the most instructive approach to localization in neurology. As our colleague C.M. Fisher aptly remarked, house officers and students learn neurology “stroke by stroke.” The focal ischemic lesion has divulged some of our most important ideas about the function of the human brain.

In the last two decades, extraordinary imaging technology has been introduced that allows 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 field. Salvageable brain tissue in the acute phase of stroke can be delineated by these methods. To identify such ischemic but not yet infarcted tissue virtually defines the goal of modern acute stroke treatment. Which of the sophisticated imaging techniques will contribute to improved clinical outcome is still to be determined but certain ones, such as diffusion-weighted magnetic resonance 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 of risk factors, such as hypertension, smoking, and hyperlipidemia and the identification of signs of potential impending stroke, such as transient ischemic attacks, atrial fibrillation, and carotid artery stenosis. Second, careful clinical evaluation integrated with the newer testing methods still provide the most promising approach to this category of disease. Finally, the last decades have witnessed a departure from the methodical clinicopathologic studies that have been the foundation of our understanding of cerebrovascular disease. Increasingly, randomized trials involving several hundred and even thousands of patients and conducted simultaneously in dozens of institutions have come to dominate investigative activity in this field. These multicenter trials have yielded highly valuable information about the treatment 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 specific case at hand. Most large studies show only modest or marginal differences between treated and control groups and correspondingly give guidance in large populations but not necessarily for an individual. These multicenter studies will be critically appraised at appropriate points in the ensuing discussion.

Incidence of Cerebrovascular Diseases

Stroke, after heart disease and cancer, is the third most common cause of death in the United States. Every year there are in the United States approximately 700,000 cases of stroke—roughly 600,000 ischemic lesions and 100,000 hemorrhages, intracerebral or subarachnoid—with 175,000 fatalities from these causes combined. Since 1950, coincident with the introduction ...

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