(Stroke. 2001;32:1051.)
© 2001 American Heart Association, Inc.
Editorial |
Stroke: 30 Years of Progress
1982–1987
From Robarts Research Institute, London, Ontario, Canada.
Correspondence to Dr Henry Barnett, Robarts Research Institute, 100 Perth Dr, London, Ontario, Canada. E-mail fern{at}rri.on.ca
Key Words: editorial • stroke
The invitation to reflect on the progress in stroke and the contributions of this journal to developments during the years 1982 to 1987 arouses many memories.
In committee report format, it is to be noted that in 1982 the 6 bimonthly issues totaled 942 pages, including the index, the news from the AHA, the literature abstracts, and the program of the Stroke Council Conference. By 1987 there were 1406 pages. Permission was granted to go monthly. Behind the dull statistics, the expansion of Stroke reveals that a critical mass of professionals were dedicating their careers to the study of this common cause of death and dreadful disability. This increased enthusiasm occurred in countries on both sides of the Atlantic, in Japan, Taiwan, and "down under." The internationalization of the journal is reflected in all successive issues and was a factor determining expansion.
Descriptive stroke neurology was still ongoing during this half-decade. The further delineation of the lacunar stroke as a clinically identifiable entity was a feature of one issue. Classic descriptions of "pure sensory stroke" came from the pen of the master of this subject, C. Miller Fisher. He was allowed an unprecedented 13 pages for his report. His Discussion portion occupied only 1 page. There were 7 references, all referring, appropriately, to his past communications about lacunar disease, dating back to 1965. Motor strokes of presumed lacunar origin were the subject of a smaller series reported from Toulouse, France. What has become a classic review on the concept of lacunes came from the pen of Fisher’s pupil and the deputy editor of Stroke, J.P. Mohr.
Stroke was privileged later in this era to publish another lengthy article describing the observations of Fisher on the subject of "Late-Life Migraine Accompaniments." This persuasive case-series report was accompanied by a discussion of only 22 lines and 7 references. The emphasis on case detail was testimony to Fisher’s conviction that progress in understanding the management of patients with any disorder, including vascular disease, begins with a painstaking study of each individual patient.
Cardioembolic causes of stroke were still in the descriptive phase, including the validation of the importance of nonvalvular atrial fibrillation. Most notable among Stroke’s coverage of this subject was the 30-year follow-up from Framingham by Wolf and colleagues. They pointed to the imminence of stroke after the onset of this arrhythmia. All stroke neurologists remain grateful to the scrupulousness of the Framingham study design, follow-up, and ongoing analyses. The investigators have stayed the course with reports of enduring importance. Hard clinical facts from Framingham and other sources set the stage for the rationale behind disciplined management of established stroke risk factors. With others, Framingham prepared the ground for randomized trials in patients with nonvalvular atrial fibrillation.
Additional issues linking the brain and the heart were covered by Stroke in this time period. Led by Robert Hart and his colleagues, the Cerebral Embolism Study Group reported on the value of anticoagulants given immediately after myocardial infarction. Some feel that this task is not yet complete. This team ultimately led the successful SPAF trials. On the other side of the coin, the effect of cerebral lesions on heart muscle and heart regulation were reported in a series of articles written by Norris, Hachinski, and colleagues.
Among the other subjects submitted to clinical description were important articles elaborating on stroke occurring due to the entities of fibromuscular dysplasia, moyamoya disease, arterial dissection, and cerebral amyloid angiopathy. Descriptive neurology continues as an essential ongoing source of pertinent information.
Convincing evidence that stroke could be prevented gradually became more of an exciting reality. The small Italian trial of aspirin with sulfinpyrazone, led by Candelise, was published in Stroke. Later, the editor recalls coveting the opportunity of publishing the results of the second large aspirin trial for transient ischemic attack and stroke. He arranged to meet Bousser, the principal investigator of this trial, in the Charles de Gaulle airport, and flew off with the exciting report of the multicenter Paris study. Bousser eventually became the first editor for foreign submissions to Stroke. The 1985 issue reported the negative American-Canadian study, led by Fields, on the combined use of dipyridamole and aspirin in transient ischemic attack patients. The reader will know that much has happened since then: 2 new platelet-inhibiting agents are being marketed and an attempt made at rehabilitation of combined therapy with dipyridamole, using one twentieth of the aspirin dose given in the early trials. It seems improbable that the last word on platelet inhibition in stroke prevention has been written. Hopefully, the pages of Stroke will continue to reflect the progress as it develops.
Surgical intervention to prevent stroke began before this time frame. Enthusiasm for possible benefit of revascularization procedures continued within these volumes, including increasing numbers of articles on experimental and clinical studies of blood flow and perfusion. The penultimate issue of this editorial regime contained the detailed description of the EC/IC Bypass Study, about to be completed. Later that year, when the negative results appeared, nobody was happy. Physicians had a putative preventive measure snatched from their armamentaria against stroke. Surgeons were disappointed after perfecting a difficult but elegant procedure. Some were angry, and some cried foul. The greatest impetus to pursue regional blood flow studies lost much of its horsepower. The best result from this trial may have been the further blow dealt to reliance on anecdote and experience as a method of evaluating treatment strategies.
During this period, the journal played a key role in stimulating investigators to perform definitive trials seeking the appropriate use of carotid endarterectomy. The last issue of 1984 contained a series of observational studies and several expressions of opinion concerning the appropriateness and safety of carotid endarterectomy for symptomatic and asymptomatic disease. Reflecting on what was known at the time about the risk of stroke for individuals with neck bruits and asymptomatic stenosis, Kuller and Sutton wrote a critical paper entitled, "Carotid Artery Bruit: Is it Safe and Effective to Auscultate the Neck?" Their concluding comments were: "The auscultation of the neck could put the unwary patient at unusual risk in terms of both health and cost. Perhaps the patient should be advised and required to sign informed consent prior to auscultation of the neck." Chambers and Norris entitled an accompanying paper of concern: "The Case Against Surgery for Asymptomatic Carotid Stenosis." A paper by Taylor, Sackett, and Haynes explored sample-size needs in stroke prevention trials. Dyken and Pokras identified the growing enthusiasm for endarterectomy but reported that of 85 000 procedures performed in 1982 in the United States, 2.8% of the patients were discharged dead. Warlow published his now-famous survey under the title, "Carotid Endarterectomy: Does It Work?" From Cincinnati, Allentown, and Helsinki came manuscripts reporting on multi-institutional complication rates, indicating that benefit from endarterectomy was less certain than medical management. Since then, 9000 symptomatic patients and approximately 4000 asymptomatic subjects have been randomized in the major trials. Answers are clearer now.
Still lurking in the shadows during these years was any credible agent to alter stroke once it had occurred. Along with other journals, Stroke carried experimental studies on ischemic lesions with the suggestion that some tissue which was injured might be salvageable provided the cascading ischemic process could be interrupted. The late Julio Garcia, in the first issue of 1984, presented an extensive and scholarly summary of knowledge to that date and touched on the possibility of future agents designed to take existing knowledge to the bedside. Zivin and colleagues were beginning their tissue plasminogen activator studies. Just as importantly, Yatsu, among others, cautioned in Stroke’s pages that any decision about the worth of strategies benefiting the patient with cerebral ischemia would require meticulous research. All the inviolate principles governing clinical research would have to be employed or credibility would soon flounder. In Yatsu’s editorial, entitled "Pharmacologic Protection Against Ischemic Brain Damage: Need for Prospective Human Studies," the following eloquent phrases appear: "Like putting a torch to a masterpiece painting, anoxia/ischemia of brain brutally consumes the highest expression of evolutionary development and atavistic urges to undertake—brain resuscitation represent noble strategies of the life-force." While cautious optimism on the potential benefits of pharmacological protection might be concluded from anecdotal reports, the data cannot yet be construed as license for the indiscriminate use of a therapy under the banner of "saving lives."
In conclusion, a few thoughts about the challenges and the rewards of being the editor-in-chief of Stroke. The biggest challenge is to ensure that no good work in the field goes unrecognized and that its final delivery to the medical reader is in its most accurate, readable, and even exciting form. Good ideas, including technical ones, need not be written to be unintelligible to the average reader or to be without any passion. The sine qua non to effect this readability is the combination of a good Stroke staff working with a cadre of dedicated reviewers. Twice only during my tenure did the authors seek to overturn the reviewers’ opinions. Provoked in both instances by industrial considerations, appeals were sent to the publisher of the journal. In the end, our reviewers held their ground, and the disputed papers never reached our pages. The court of appeal for a rejected manuscript need only be the reviewers examining the resubmission of an improved one.
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