Four Decades of Stroke Prevention Trials
Medical students in the 1940s observed that stroke victims were regarded as in a hopeless situation. Severely disabled patients with stroke and those in coma from intracerebral clots were confined to Observation Units. What was learned in my early days allowed us to replace this Medical Bedlam with Stroke Prevention and Treatment Units. Stroke neurologists, specialized nurses, and imaging technicians became available to give expert care in these new units. The hopeless era of stroke disappeared. With a growing number of colleagues I was privileged to contribute to this change or watch from the sidelines, as others were involved.
The biggest differences have resulted from epidemiological observations, dramatic scientific breakthroughs, including microbiology, treating infectious disease, pharmacology, and technology, coupled with the advent of rigid clinical trials. The most important may be listed as follows:
Fleming’s discovery of penicillin eliminated brain abscess and much pneumonia and strokes because of pneumococcal and syphilitic meningo-vascular changes. Streptomycin could cure tuberculous meningitis. Endocarditis with embolic brain infarction was becoming uncommon. I can recall in the mid-1940s, discharging home to their young families, 2 well individuals, 1 recovered from coma because of tuberculous meningitis, the other cured of strep viridans endocarditis. These were pioneering events that before those days were fatal but today we take the cure for granted.
Confirmation of the risk factors emerged from a combination of research strategies. One of the keys to affirmation of many was the collecting of life-time records of populations as in the Framingham Study1 and the Oxfordshire Stroke Project.2
The Four Horsemen of the Stroke Apocalypse are hypertension, tobacco, diabetes mellitus, and cholesterol excess. Control of all of these has been shown clearly to reduce stroke occurrence. Some important factors cannot be changed (eg, old age, male sex, and heredity) but with these in the …