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Controversies in the management of cerebral vascular disease

In the past 30 years, enormous progress has been made in the understanding of the pathophysiology of cerebral vascular disease, identification of types and etiologies of strokes, recognition of stroke risk factors, cerebral imaging, and refinement of vascular surgery techniques. Nevertheless, there are still many differences of opinion as to the interpretation of many important studies and extant data, as well as controversies over methods of stroke prophylaxis and management. A part of the reason for this unsettled state is that the studies necessary to decide these issues are difficult to accomplish and expensive. Even state-of-the-art statistical and epidemiologic planning is no guarantee of universal acceptance of Another reason for the continuing uncertainty is that many published studies pertaining to all the above factors are uncontrolled or inadequately controlled, with little regard for even basic statistical techniques. The standards of statistical proof required for publication of animal experimental data have not been applied to many clinical studies involving human beings, and some of these studies have been patently protagonistic. Acceptance of such studies, particularly as they apply to therapy, either medical or surgical, may be partially a reflection of wishful thinking on the part of clinicians eager to treat these disorders successfully and partially because of an unwillingness or inability to evaluate such studies critically. The purpose of this presentation is to address some of the differences of opinion concerning stroke-its incidence, risk factors, prevention, and treatment-with the objective of discouraging unproven concepts and modalities and provoking thoughtful appraisal of our existing views.