The crux of stroke management is still prevention.

Abstract

A number of times I have commented on the remarkable advances we have made in acute stroke therapy and secondary prevention over the last 30 years. For acute stroke, we now have a series of proven interventions, which include management in a stroke unit, aspirin administered within 48 h, thrombolysis, hemicraniectomy, and more recently endovascular thrombectomy. Likely to be added to the list is the aggressive lowering of blood pressure as per the INTERACT II trial, which if supported by other trials will certainly provide level one evidence. For secondary prevention, we have the categories of antiplatelet agents, blood pressure and lipid lowering agents, oral anticoagulants, and carotid stenting/angioplasty for symptomatic carotid stenosis. This dazzling array of proven interventions, the first of which appeared in 1978, with the Canadian aspirin trial, should not blind us to the even greater need to prevent stroke all together. That is, a continuing emphasis on primary prevention since this is what we and society would generally regard as the most laudable aim. A massive task lies ahead, as developing countries transition from infectious to chronic diseases as the most important causes of morbidity and mortality. Concurrently, western societies face epidemics of obesity and an alarming rise in metabolic disorders such as diabetes. Through agencies such as the World Health Organization and campaigns promoted by the World Stroke Organization, we should continue our attack on modifiable primary prevention risk factors such as hypertension, smoking, therapy for AF, diet and lifestyle, and even air pollution. Protocols are important in our current edition, with some interesting ones including the HeadPoST study in which the long-standing conundrum of whether to manage patients flat or in the sitting position poststroke is addressed. ECASS-4: ExTEND is also presented, which is the sister study to ExTEND, both aiming to determine whether the time window for thrombolysis can be extended out to 9 h, including wake-up stroke. Finally, this is going to be a busy year, with our usual early International Stroke Conference, followed by the European Stroke Organisation Conference in Barcelona, and leading into the World Stroke Congress (WSC) in Hyderabad, India. You will recall that the first positive endovascular trial, Mr Clean was presented at the last WSC in Istanbul, in 2014; we look forward to a similar standard in Hyderabad, see you there!