This editorial completes the 5-part history of the first 30 years of the journal Stroke from the perspective of the editors. For this segment, the task is even more intimidating, because the time covered is most recent and most of the readers have personal recollections of the events and changes that have occurred during the years from 1992 through 2000. It is comforting to know that appropriate letters to the editor will correct any inadvertent major omissions. So much has happened during this time that some certainly will be submitted.
In the spring of 1991, after repeatedly refusing to accept nominations to be a candidate for editor of Stroke, I received a call from a distinguished, close personal and professional friend. It was during this conversation that the excitement of being intimately involved with Stroke during times of major change was generated. In addition, the possibility of appointing an associate editor for basic science conceptually solved one of my major concerns. This generated other ideas, I became a candidate, the new ideas were supported, and I was appointed for an initial 5-year term beginning January 1, 1992. Later, for the first time, a 3-year reappointment was made for 1997 through 1999, and an additional year extension for 2000 at the special request of the editor-designee, Vladimir Hachinski.
On October 1, 1991, 3 months early, with only an academic secretary but with considerable support from the previous managing editor and editor-in-chief, Nancy Lynch and O.M. Reinmuth, respectively, my office unofficially took over the editorial duties for Stroke. On November 1, 1991, Marilyn Yurk, who had been appointed managing editor, officially joined us. She soon developed an editorial office that ultimately resulted in the addition of Norma Pahl as associate managing editor and an outstanding support staff.
After discussion with many of the previous editors and associate editors and with their support, a number of changes were initiated. The positions of basic science and foreign associate editors and, later, clinical associate editor were established, with increased responsibilities and authority. Some basic scientists perceived a bias against papers not involving humans, and some clinicians complained about too many “rat” studies. To address these perceptions, the basic science associate editor was delegated the authority to accept or reject submissions within general guidelines independent of the clinical papers, and editorial comments were added to basic science papers to place them into clinical perspective. Similar misconceptions were held concerning work received from outside North America, primarily from Europe. Thus, for the same reasons, the associate editor for foreign publications, primarily Europe, was appointed with the same authority. Fortunately, 2 outstanding scientists agreed to accept these positions, Hermes Kontos for basic science and Marie-Germaine Bousser as foreign editor (Europe). Each is universally respected for scientific and personal abilities, which resulted in these new positions working seamlessly and effectively. Despite very heavy workloads, each agreed to continue on with the editor-in-chief after each extension of the original term. Later, the position of clinical associate editor was added and accepted by José Biller, another outstanding clinical scientist. Without these 3 superb associate editors, the accomplishments during these 9 years would not have been possible.
In addition to the editorial board, the category of consulting editors was reinstated to include those who had served in senior editorial positions in the past. Their purpose was to serve as special advisors to the editor. Despite being required to agree to review manuscripts within 7 working days, an excellent group of outstanding experts in all areas of stroke agreed to serve on the editorial board. Only 2 individuals declined because of the requirement for rapid review.
At this time, many in the field were concerned about the effect on the future of Stroke by 2 new clinical stroke journals and, later, a short-lived third. Because the purpose of a journal is to disseminate knowledge pertaining to a field and not to compete, we welcomed additional journals dedicated to stroke. Meetings with Julien Bogousslavsky and Michael G. Hennerici, editors of the European journal Cerebrovascular Diseases, and Clark Millikan, editor of the Journal of Stroke and Cerebrovascular Disease and founding editor of Stroke, were reassuring. Our early impressions that these journals would be constructively supportive rather than negatively competitive were later proved to be true, as will be documented.
During the ensuing 9 years, other changes and additions were made. Probably the most controversial of the changes was the blinding of reviewers to the identity of authors and their institutions. This policy was precipitated by comments from many young investigators that acceptance of papers was influenced by an “old boys clubs” mentality and from studies presented at the Council of Biology Editors. Initially, some of the senior members of the editorial board were opposed. Their argument that a reviewer needed to know the “quality” of the investigators to properly evaluate a manuscript appeared to support the impressions of the younger group. Some pointed out that the blinding process was not always effective, particularly when authors cited their own work. Studies of blinding indicate that it is successful in 59% to 79% of cases but is never perfect. The editors chose only to remove identification of authors and institutions from the title sheets and not to alter the text. Thus, if an investigator was concerned about reviewer bias, the paper could be written so that it was not identifiable. Nevertheless, blinding has been widely supported, particularly by young and midcareer investigators⇓.
The distinguished Willis and Feinberg lecturers have been encouraged to publish their presentations in Stroke. Most have. Unfortunately, some have not. Every year these 2 international authorities in stroke have been honored at the International Stroke Conferences because of their outstanding contributions to the field. These presentations are pivotal in describing where we have been, where we are, and where we are going.
During the first year of our term, the titles of the contents were removed from the cover by a decision of the Scientific Publishing Committee of the American Heart Association (AHA). The editor of Stroke joined all of the other editors of the AHA journals in convincing the committee that these titles are extremely important to the readers. They were returned to the cover in 1993 and, despite design changes over the years, have remained.
In 1998, the Scientific Publishing Committee of the AHA mandated that an illustration, in addition to the titles, be on the cover of all AHA journals. It immediately became apparent that in addition to focusing on material in the issue, this illustration also could be used to emphasize important issues in stroke. For example, the March 1988 issue illustrated in graphic form the appalling disparity between research dollars spent per death for stroke ($750 in 1996) compared with heart disease ($1270), cancer ($4723), diabetes ($4856), and AIDS ($43 207). This table has been used to justify requests for increased funding for stroke. Unfortunately, the first cover sent the shocking news of William Feinberg’s tragic, premature death.
At the recommendation of members of the editorial board, a special section on major ongoing stroke trials was established in February 1993 and has been published in every February, June, and October issue since then. Although readership surveys cite this as one of the more valuable features of Stroke, it is not complete because it depends on the submission of a brief description to Stroke from the trial investigators. Although we believe most are included, we do know of major trials that are not.
The December of 1998 issue cover of Stroke had the logo “American Heart Association: Fighting Heart Disease and Stroke” on its cover for the last time. The logo was changed in the next issue, January 1999, to “American Stroke Association: A Division of American Heart Association.” For many years, members of the Stroke Council had been requesting some type of name change to identify the many activities and commitment of the AHA to stroke and also to give more emphasis to stroke, the number 3 cause of death and the first cause of major disability in adults. On January 1, 1999, the American Stroke Association was established, and Stroke was permitted to bear its logo.
In 1999 at an international stroke meeting, an investigator of an industry-funded clinical trial announced from the podium that he was not permitted by the sponsor to present the results of the study. Because an estimated 54% of randomized trials are commercially sponsored, this emphasized the danger that the literature could be biased by commercial control. If many studies were performed and negative ones not published, a very few positive studies would lead to acceptance of potentially ineffective therapy. This precipitated an invited editorial and a cover illustration, “Weighing the Evidence: The Scales Are Unbalanced.” Concluding that authors as individuals should not enter into agreements that interfere with their control over decision to publish, Stroke established a formal policy requiring investigators to document the control by sponsors over study design, data collection, analysis and interpretation, and writing of the report.
Advances in Science
During these 9 years, major advancements occurred in the basic and clinical science of stroke. Each of the 108 issues of Stroke added new knowledge. To review all the important changes documented in the thousands of articles published during this time would require a book, not a brief editorial review. Knowing that the most important work for the future will probably be overlooked, I asked our associate editors and Dr Hachinski to independently list what they considered to be the most important advances in knowledge during our tenure. Everyone’s list included thrombolysis in acute stroke, genetics (human genome, location of disease sites, and gene transfer), further clarification of value of carotid endarterectomy, new platelet antiaggregating agents, nitric oxide synthase and its role in vascular and neural regulation, and advances in neuroimaging. Also mentioned were the effects of statins on stroke, the identification and awareness of the gap between the results of randomized trials and clinical practice, recognition of stroke as a problem in women, and increasing awareness of importance of stroke.
Appropriately, the positive results of major therapeutic trials and basic science breakthroughs are usually not published in disease or organ-system-oriented journals. Because they are important across specialty lines and for huge audiences, they tend to be accepted by journals such as the New England Journal of Medicine, Lancet, and the Journal of the American Medical Association. But, these studies are based on the development of basic science concepts and clinical background studies. Even after the publication of the results concerning the primary hypotheses, further studies clarify and further define their application. For example, the results of the controlled trials of endarterectomy for symptomatic and asymptomatic carotid artery disease were published in the New England Journal of Medicine, Lancet, and the Journal of the American Medical Association. Yet, the necessity and the design of these studies were developed from material published in journals like Stroke. After the initial studies are published, further analyses, spin-off studies, and substudies continue to define them. Stroke has made significant contributions to each of the major advances listed by our editors. Large numbers of articles pointed out the need for appropriate studies and guided the way. Before and after the publication of the original trials, Stroke published many papers that have defined how to use the results in clinical practice. Examples of inappropriate use of many therapeutic modalities in practice have been published in Stroke. These include the inadequate use of anticoagulants in nonvalvular atrial fibrillation and widespread violations in following the protocol of the endarterectomy, thrombolytic, atrial fibrillation, and other studies.
During these years, Stroke has performed exceptionally by every standard measurable criterion. We hope that this was, at least partially, due to the contributions of the editorial team. We also believe that the 2 excellent competing journals helped focus on the importance of stroke and further identified Stroke as the premier journal. Of course, the most important factor was the dramatic increase in knowledge and work in the field.
Women and minority membership on the editorial board increased to 42%. The number of submissions increased every year, from 563 in 1991 to 1476 in 2000. Despite these increases, the mean time from submission to first decision has decreased from around 6 to about 4.5 weeks. On a scale of 1 to 6 (best 1), the mean priority score of published manuscripts was between 2.2 and 2.3.
The establishment of associate editors for basic science and foreign editor for Europe has been well received by basic scientists and Europeans. Many clinicians particularly appreciate the editorial comments for basic science articles that place the basic science in clinical perspective.
Stroke is truly an international journal. By 1999, 68% of its submissions were from outside North America. We wish the percentage were the same for subscriptions. Only 42% are from outside the United States. A selected version of Stroke is published in Spanish in South America. As might be expected, most (72%) of the physician subscribers are neurologists, but 28% represent other specialties. Since 1999, all AHA journals have been published online.
The Institute for Scientific Information (ISI) citation index has improved remarkably for Stroke. This citation frequency measurement for journal articles has progressively increased over the last 9 years to 6.008 in 2000 (the number of citations during 2000 for articles published during 1998 to 1999 divided by the number articles published during those years). By these criteria, Stroke is the leading subspecialty journal in clinical neurology (137 journals) and ranks near the top when compared with clinical neurology and peripheral vascular disease journals. Among the major, much broader clinical neurological journals, only the Annals of Neurology and Brain were cited more frequently than Stroke.
In conclusion, Drs Kontos, Bousser, Biller, and I already look back over the past 9 years with nostalgia. In balance, the times were exciting, and our ability to participate in all the major changes and advancements in cerebrovascular disease through the journal Stroke has been most rewarding and worth the efforts required. One of our few regrets is that in these times of major change for stroke, we were not allowed to publish more pages and were required to hold to a very low acceptance rate (31.5% in 1999), based strictly on priority scores given by the referees. For this reason, a number of excellent papers had to be rejected. Fortunately, many of the best ones have ultimately been published in one of the other cerebrovascular disease journals.
Regrets are few, and overall, by most measures, the changes that have occurred in Stroke during our tenure have been positive. As one reviews the history of Stroke, these evolved from the outstanding stewardship of each of the previous 5 editors. Clark Millikan (1970 to 1976) gave birth and carefully nurtured the journal through his term. Each succeeding editor, Fletcher McDowell (1977 to 1981), H.J.M. (Barney) Barnett (1982 to 1986), and O.M. (Mack) Reinmuth (1987 to 1991), maintained the advances of the predecessors and added to them. We are extremely grateful to them for making our task much easier. History, we hope, is prologue to the future. Certainly, if it depends on the quality of its leadership, the future of Stroke is very bright. Vladimir Hachinski is an outstanding scientist, author, clinician, person, and now editor-in-chief. He has taken over during difficult times and will face many external changes that are new and different from those we faced during the last 30 years. During his brief tenure, he has already instituted many exciting changes and has faced and overcome difficult challenges. We look to the future with the greatest confidence and to reading the sixth chapter of this ongoing saga in 5 to 9 years.