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Should stroke medicine be a separate subspecialty?

BMJ 1997; 315 doi: (Published 01 November 1997) Cite this as: BMJ 1997;315:1167
  1. Philip Bath, Wolfson senior lecturer in stroke medicine,
  2. Kennedy Lees, medicine,
  3. Martin Dennis, senior lecturer,
  4. David Smithard, consultant physician,
  5. Ian Bone, professor in neurology,
  6. Donald Grosset, consultant neurologist,
  7. Jonathon Macdonald, consultant geriatrician,
  8. Stephen Pollock, consultant neurologist
  1. London
  2. Glasgow
  3. Edinburgh
  4. Sidcup
  5. Glasgow
  6. Glasgow
  7. Glasgow
  8. London

    The three facets of the management of cerebrovascular disease—prevention, acute care, and rehabilitation—have in the past been poorly coordinated. Stroke was regarded less as a preventable disorder than a predictable and often terminal consequence of old age. During the past 20 years, however, active management strategies have been shown to influence outcome. Half of all strokes need never happen with better identification and management of risk factors. Effective secondary prevention strategies include warfarin (in patients with atrial fibrillation) or aspirin (in others), and carotid endarterectomy (in patients with severe ipsilateral carotid stenosis) for patients with ischaemic stroke.

    Acute stroke management is changing: early thrombolysis and aspirin may improve outcome while most patients should have computed tomography to differentiate ischaemic stroke from primary haemorrhage and to identify other intracranial pathologies. Early complications are reduced by swallowing assessment to prevent aspiration and graduated compression stockings to prevent thromboembolism. Patients with expanding infratentorial haemorrhage may require immediate surgical evacuation.

    Although there remains a need for domiciliary care, most patients should be admitted to hospital, and ideally to an acute stroke unit offering resuscitation and stabilisation, investigation and diagnosis, initial treatment, and prevention of complications. Patients should then be rehabilitated, preferably in a stroke rehabilitation unit; such units have been shown to reduce mortality and morbidity, and probably length of stay in hospital, through interdisciplinary rehabilitation, and also promote secondary prevention and provide a …

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