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Stroke: the way things really are
1Department of Neurology, University of Miami School of Medicine, Mount Sinai Hospital, Miami Beach, FL 33140.
Insights
Distinguishing scientifically proven stroke prevention and management from anecdotal claims is crucial. Evidence-based therapies, supported by controlled trials, define the standard of care, not physician usage alone.
Area of Science:
- Neurology
- Evidence-Based Medicine
- Clinical Trials
Background:
- Governmental regulations necessitate distinguishing scientifically validated therapeutic modalities from anecdotal information for stroke prevention and management.
- Medico-legal considerations require a clear demarcation between proven and unproven stroke treatments.
Purpose of the Study:
- To review evidence for established stroke prevention modalities in high-risk patients.
- To discuss controversial or unproven therapies lacking scientific validation.
- To emphasize the importance of evidence-based medicine in defining the standard of care for stroke.
Main Methods:
- Systematic review of controlled clinical trials and scientific literature.
- Analysis of evidence supporting antiplatelet drugs, anticoagulants, and endarterectomy for stroke prevention.
- Discussion of therapeutic modalities lacking scientific proof.
Main Results:
- Evidence for antiplatelet drugs, anticoagulants, and endarterectomy in stroke prevention is summarized, along with their limitations.
- Therapeutic modalities without scientific proof, such as anticoagulation for progressing stroke, are critically examined.
- Current treatments for acute stroke remain disappointing despite promising preclinical findings, possibly due to narrow therapeutic windows.
Conclusions:
- Controlled, randomized, multiple-center clinical trials are effective in determining the efficacy of stroke therapies.
- Anecdotal data in stroke treatment can be misleading and potentially harmful.
- Awareness of established scientific knowledge versus unknowns is essential in stroke care.
Background:
To comply with governmental requirements regarding the validity of therapeutic modalities and for medico-legal purposes, it is important to distinguish between what has been scientifically proven and what is anecdotal in the prevention and management of stroke.
Summary Of Review:
This review summarizes the evidence for many of the modalities used to prevent stroke in high-risk patients, including antiplatelet drugs, anticoagulants, and endarterectomy, and the limitations of each. Controversial therapeutic modalities for which no scientific proof exists, such as anticoagulation of progressing stroke, are also discussed. The term "standard of care" should apply to modalities proven to be effective by scientifically controlled studies, not because they are used by many physicians. Treatment of acute stroke is still disappointing despite the development of many promising pharmacological strategies in experimental animals. An important part of the reason may be that the window of therapeutic opportunity is much shorter than the usual entry time of patients in most clinical trials. This logistic problem merits serious attention.
Conclusions:
Numerous controlled, randomized, multiple-center clinical trials have demonstrated that the efficacy or lack thereof of various therapies directed at preventing or treating stroke can be determined and that anecdotal data may be misleading and harmful. At the least we should be aware of what we know and what we do not.