What Lessons Have We Learned in the Past 40 Years?

Abstract

Before 1970, there was no journal devoted to cerebral vascular disease. Only hypertension had been identified as a potentially treatable risk factor for stroke, and there were no established specific therapies for preventing or treating stroke. Imaging was limited to x-ray or x-ray with contrast (angiography, pneumoencephalography, or ventriculography) and very primitive ultrasound. In 1970, the journal Stroke was born and during the next 40 years many advancements occurred. CT, MRI, positron emission tomography, and ultrasound were introduced and further perfected as extremely effective diagnostic instruments. For the first time, we could visualize the nervous system and measure its function in vivo. The major risk factors were identified, and the significant effectiveness of preventive treatment was established for hypertension, tobacco use, lipidemia, and other potentially treatable risk factors. The value and the indications have been defined for platelet antiaggregating agents, thrombolytic therapy, statins, anticoagulant therapy for atrial fibrillation, carotid endarterectomy, and coiling for aneurysm and arteriovenous malformations. Genetics became a major tool in the investigation of cerebrovascular disease. Vascular dementia and its relationship to other dementias have been better identified. The lack of effectiveness of extracranial–intracranial bypass procedures in most ischemic vascular disease has been shown. Steady progress is being made in the understanding of the mechanisms of brain injury, repair, and plasticity. All these and more have been added to our knowledge. These are not the lessons, but they are the results of the lessons we have learned. To address these lessons, we need to go back even further than the past 40 years. Although I cannot equal Dr Barnett’s 65 years, my 56 years as a physician have led to similar conclusions. So, forgive us if we overlap. Like most of the older people in the field, our acceptance and crusade for the “lessons” were initiated and reinforced …