There is no doubt that the best outcomes from stroke are achieved with the utilization of a coordinated interdisciplinary approach. This starts from the moment a stroke victim is identified. There is some evidence that a coordinated approach to pre-admission care--i.e. public education, centralized intake to facilitate thrombolysis, availability of neuroradiology, etc.--has a favourable effect on subsequent stroke morbidity. There can also be no doubt that the proper experienced care of a stroke team in the acute hospital is vital to the final outcome. First, the team ensures that an accurate diagnosis is made, and that proper supportive care (nutrition, including swallowing assessment if necessary, early mobilization, attention to skin and continence issues, etc.) and secondary prevention measures (anticoagulation, aspirin, etc.) are commenced.

Some patients can be discharged from hospital directly to their homes, and rely on either outpatient or home rehabilitation programs (if appropriate outpatient diagnostic and follow-up services are available, acute hospital admission is sometimes not necessary in the first place). These are generally patients with minor or no residual deficits. I include education as part of the rehabilitation model, so no patient would be discharged without some form of rehabilitation, even if no traditional speech, physical or occupational therapy is required. Other patients have such severe strokes that, almost immediately, the prognosis is known to be dismal. These patients are usually referred directly to long-term care programs.

However, there is a large number of intermediary patients who benefit from a formal inpatient rehabilitation program. Almost all of these patients are older, which begs the question, 'Should they be admitted to a geriatric rehab program or a stroke program?' Despite being the director of a large and excellent geriatric rehab program, I feel that the bulk of stroke patients should be handled in dedicated stroke units. The reasons for this are straightforward. Geriatric units are, by definition, generalist units. We have to care for patients with multiple problems and multiple medical diagnoses. This is our strength, but also our weakness. Like most skills, stroke rehabilitation is made better by larger volumes and more focus. Geriatric units do well on the motor problems associated with stroke, as these are not that different from those of patients with falls, fractures and deconditioning, who are our bread and butter. However, complex perceptual deficits require a degree of expertise that often overwhelms non-specialized units. However, for selected cases, there is a place for geriatric units in stroke rehabilitation. These are elderly patients who already had functional problems, and then have a stroke, which serves as 'the straw that breaks the camel's back.' These cases usually require attention to multiple problems, not just the stroke, and are better suited to the generalist nature of geriatric rehab. If stroke rehab and geriatric rehab programs are physically close, back and forth consultations are facilitated (even well selected stroke rehab patients can develop geriatric-type syndromes).

In my institution, there is reasonable consensus on most patients. However, one group falls through the cracks. This is previously healthy patients who have had a severe stroke, but who do have the potential to benefit from rehab. These patients often have stroke syndromes that would challenge the most experienced of stroke rehab professionals, and are often beyond the skill set available in geriatric rehab. Unfortunately, the tyranny of length of stay (LOS) is the enemy of these patients. Too specialized for geriatric rehab, they require too many resources from stroke units. I feel that this represents the failure of proper population-based planning. We need to have enough 'long-stay' stroke rehab beds to accommodate these patients. It does not make sense to prevent the most skilled professionals from caring for the most difficult strokes.

This issue has numerous articles on stroke, contributed by an international line-up of authors. Drs. Kennedy and Buchan discuss acute therapy in ischemic stroke, while Dr. Patten gives us information on some of the psychosocial issues involved. There are also articles on tests (reaction time) that predict recovery from acute stroke (Loranger and Doyon), gender issues in stroke (Clark), and the management of dysphagia in patients post-stroke (Perry). Several authors review the use of medications for primary and secondary stroke prophylaxis, including an article on the treatment of hyperlipidemia (Aronow), thrombolysis in elderly patients (O'Mahony), antithrombotic drugs for secondary stroke prophylaxis (Bennett and Bennett) and new frontiers in the treatment of stroke (Gladstone et al).

As well, we have our usual potpourri of geriatric articles. The topic of our ethics column this month is the ethics of receiving our flu vaccination (Sheehan and Gordon). The mental health column focuses on an atypical psychotic disorder, Capgras Syndrome (Sloan). In the Biology of Aging column, Dr. Mattson provides information on neuroplasticity and how the brain adapts to aging. The cancer column examines quality surgical cancer care in Ontario (Gagliardi)--a topic that has recently been much in the news--and for our Dementia column, Drs. Tong and Corey-Bloom from the University of California San Diego, review galantamine, a new medication for the treatment of Alzheimer disease.

Enjoy this issue.

David J. Gladstone, BSc, MD
Stroke Fellow, Sunnybrook and
Women's College Health Sciences Centre,
University of Toronto,
Toronto, ON.

Cynthia Danells, BScPT
Physiotherapist and Research
Associate,
Sunnybrook and Women's College Health Sciences Centre,
University of Toronto,
Toronto, ON.

Sandra E. Black, MD, FRCPC
Head, Division of Neurology,
Sunnybrook and Women's College Health Sciences Centre, and
Professor of Medicine (Neurology),
University of Toronto,
Toronto, ON.

Delaina Walker-Batson, PhD
The Stroke Center-Dallas,
Professor,
Texas Woman's University, and
Associate Clinical Professor,
Departments of Neurology and Radiology,
The University of Texas Southwestern Medical Center,
Dallas, Texas, USA.

Stroke is a Treatable Condition
Together with advances in the prevention and acute treatment of stroke, the field of stroke rehabilitation is becoming an increasingly exciting frontier for basic science and clinical development (see Table 1). The scientific basis of stroke recovery is becoming better understood, and the post-stroke period is being viewed as an important target for improved therapeutic intervention.

Wilbert S. Aronow, MD, CMD
Department of Medicine,
New York, Medical College
Department of Geriatrics and Adult Development,
Mount Sinai School of Medicine,
New York, NY, USA.

There are conflicting data regarding the association of abnormal serum lipids with stroke in older men and women.^1-4 Despite these conflicting data, simvastatin and pravastatin have been demonstrated to cause a significant reduction in the incidence of stroke in older men and women with coronary artery disease (CAD) in the Scandinavian Simvastatin Survival Study,⁵ in the Cholesterol and Recurrent Events Trial,^6-10 and in the Long-Term Intervention With Pravastatin in Ischaemic Disease Study (Table 1).^11,12

Scandinavian Simvastatin Survival Study
The Scandinavian Simvastatin Survival Study was a prospective double-blind, placebo-controlled trial which randomized 4,444 men and women (2,282 of whom were 60 to 70 years of age) with CAD and hypercholesterolemia to treatment with either 20 mg to 40 mg of simvastatin daily or placebo.⁵ Simvastatin significantly reduced serum total cholesterol by 25% from 261 mg/dL to 196 mg/dL, serum low-density lipoprotein (LDL) cholesterol by 35% from 188 mg/dL to 122 mg/dL, and serum triglycerides by 10% from 133 mg/dL to 120 mg/dL. It significantly increased serum high-density lipoprotein (HDL) cholesterol by 8% from 48 mg/dL to 52 mg/dL.⁵ At 5.

James Kennedy, MB, MRCP(UK)
Clinical Stroke Fellow,
University of Calgary, Calgary, AB.

Alastair M Buchan, MB, FRCP
Professor of Stroke Neurology,
University of Calgary, Calgary, AB.

"It is in the nature of stroke to partly take away the use of a man's limbs and to throw him on the parish if he had no children to look to."¹

While treatments have changed since George Eliot's time, attitudes to the consequences of stroke have not. Stroke, when mild, is viewed by the elderly as a devastating event; when severe it is viewed as being worse than death itself.²

Stroke is the third most common cause of death and the leading cause of disability in most of the developed world.³ It is one of the most common causes for the elderly to be admitted to a chronic care facility, such as a nursing home. Ischemic stroke increases in incidence as people age, rising from 2.1 per 1000 for men aged 55 to 64 to 9.4 per 1000 for men aged 75 to 84.⁴ Age is also one of the major determinants of outcome from stroke. Older patients are less likely to recover than are younger patients with similar sized infarcts and, following a stroke, are more likely to decline physically than to recover.

Despite new diagnosing and treatment modalities, stroke continues to be the third largest cause of mortality in Canada and the leading cause of disability. A recent study shows that a novel therapy may be able to alleviate some of the disability that accompanies stroke. A group of scientists have reported that Constraint-Induced Therapy (CIT), increases the use and function of upper extremities in patients who have suffered a stroke. CIT is intensive in that it is administered 5-7 hours a day for two weeks and emphasizes forced use of the paretic limb while constraining the other, functional limb. The researchers used focal transcranial magnetic stimulation to map the cortical motor output area of a hand muscle, on both sides of the body, in 13 stroke patients in the chronic stage of their illness both before and after a 12-day-period of CIT. After treatment, the size of the muscle output area in the affected hemisphere was significantly enlarged, corresponding to a greatly improved motor performance of the paretic limb. The researchers hypo-thesize that the shift in the centre of the output map in the affected hemisphere spurrs the recruitment of adjacent brain areas. This improvement was still evident in follow-up examinations up to 6 months after treatment, demonstrating the possibility of a long-term alteration in brain function.

Sources

1. Liepert J, Bauder H, Miltner WHR, TaubE, Weiller C. Stroke 2000 31: 1210-1216.
2. Brickner, Elizabeth M.. American Journal of Medicine. April 1996; 100(4): 465-474.
3. Statistics Canada, Health Canada, Heart and Stroke Foundation of Canada. Heart disease and stroke in Canada. Toronto: Heart and Stroke Foundation of Canada; 1997.

Alejandro Floh, BSc

Echocardiography has long been recognized as one of the most valuable non-invasive methods of investigating the heart. With recently-acquired understanding of the importance of cardiac disease in the pathogenesis of stroke, the role of echocardiography, whether transthoracic or transesophageal, in the management of stroke patients has become an area of extensive study. The Canadian Task Force on Preventive Health Care has therefore released their recommendations for the use of this imaging technique in newly diagnosed stroke patients.

Cerebral ischemia, a form of cerebral vascular disease, is caused by the reduction of blood supply to the nervous tissue of the brain. The result is often a rapid onset of focal neurological deficit or global impairment; this is commonly referred to as a stroke or cerebral vascular accident (CVA).¹ Despite similar presentations, the etiology of ischemic strokes vary considerably, and must be differentiated rapidly in order to provide appropriate care.

Despite new diagnostic and treatment modalities, stroke continues to be the third largest cause of mortality in Canada and the leading cause of disability.^2,3 Currently, approximately 50,000 new cases of strokes emerge annually, leading to an overall prevalence of 200,000 cases.³ Furthermore, strokes continue to be a leading cause of hospital admissions, even higher than acute myocardial infarctions, costing the Canadian health care system $2.

Joyce So, BSc

While thrombolytic therapy has become an established part of treatment for acute ischemic heart disease, the controversy continues regarding its potential and practical use in acute ischemic stroke. In a situation where time is of the essence, is thrombolysis the best available solution?

Acute ischemic stroke (AIS), or "brain infarction", is most commonly a result of intracerebral artery occlusion due to embolism from proximal sites such as the internal carotid arteries, heart or aorta. Unlike cardiac arrest, where brain viability is measured in minutes, AIS presents with a mixture of salvageable tissue, allowing for a therapeutic window that can last several hours. While the definitive time frame has yet to be pinned down, the generally accepted mantra "Time is Brain" reflects the notion that prognosis is improved by early intervention. The question now is whether there is a role for thrombolytic therapy in the management of AIS.

The two most prominent candidates for use in thrombolytic AIS therapy are streptokinase and recombinant tissue plasminogen activator (rtPA), both serine proteases that catalyze the conversion of plasminogen to plasmin, which digests fibrin clots.

D'Arcy L. Little, MD, CCFP
York Community Services, Toronto, ON

Introduction
Every year there are approximately 50,000 strokes in Canada. Currently, close to 300,000 Canadians are stroke survivors. As stroke is an age-related condition, the number of strokes is predicted to increase as the Canadian population ages. The resultant national cost, which is estimated at 2.7 billion annually, will also increase unless improvements are made to prevention and treatment.¹ Approximately 1 in 6 survivors of a first stroke experiences a recurrent stroke over the next 5 years, of which 25% are fatal within 28 days.² The above statistics suggest that attention to secondary stroke prevention would be important in reducing the morbidity, mortality and cost to society of stroke. The purpose of this article is to review the role of anti-platelet and anticoagulant agents in the secondary prevention of stroke.

Goals of Therapy
Therapeutic measures in secondary stroke prevention aim to prevent recurrent stroke or transient ischemic attacks, with the aim of preventing morbidity and mortality from incremental neurological deficits, as well as preventing associated cardiac ischemic events.

Lilia Malkin, BSc

A global decline in stroke-related mortality occurred over the last two decades. Canada boasts one of the lowest rates in the developed world: "only" seven percent of its citizens' deaths are attributed to cerebrovascular disease (CVD). Advances in the medical management of stroke combined with health promotion and risk factor modification are being credited with dropping CVD death rates by decreasing stroke severity and incidence.¹ However, CVD-related morbidity remains an important issue for Canadian seniors, with CVD-related hospital admissions creeping upwards as this country's population ages.¹

Preventing the occurrence of the first stroke would not only contribute to decreasing CVD-related deaths, but would alleviate a tremendous burden of suffering by diminishing the stroke-associated morbidity. This article will focus on risk factors associated with CVD and strategies for primary stroke prevention.