The future of stroke treatment: bringing evaluation of behavior back to stroke neurology.

Abstract

Acute stoke interventions and stroke rehabilitation are aimed at salvaging or restoring brain function. How do we know if we have accomplished this goal? We examine the patient. One neurological historian asserted, “Most of the modern neurological examination evolved in a short time span, between 1850 and 1914 …”1. This quote is telling; it implies that the examination itself has not changed much since about 1900. For generations of medical students, residents, and other trainees in neurology, the neurological examination has achieved almost sacred, untouchable status, while at the same time becoming less important, as diagnostic technologies have become ever more sophisticated. Indeed, many of the examination's components have become almost empty ritual. Ask a resident what modern neuroscience has revealed about the mechanisms of, for example, increased tone, neglect, apraxia, and alexia, and how this new knowledge relates to the components of the neurological examination, or how the examination might be updated; you will likely be met with a blank stare. So ironically, even as cognitive neuroscience has advanced, the interest of neurologists in behavior in the broadest sense, and its underlying physiology and anatomy has waned. Thus, current stroke neurologists have largely failed to emphasize the evaluation of the effects of our interventions on brain function.