Warlow's Stroke

Practical Management

Graeme J. Hankey, Malcolm Macleod, Philip B. Gorelick, Christopher Chen, Fan Z. Caprio, Heinrich Mattle, Graeme J. Hankey, Malcolm Macleod, Philip B. Gorelick, Christopher Chen, Fan Z. Caprio, Heinrich Mattle

• Publisher: Wiley-Blackwell
• Year: 2019
• Print ISBN: 9781118492222
• eBook ISBN: 9781118492413
• Edition: 4
• Topic: Medicine
• Subtopic: Neurology

A practical textbook, based on a problem-oriented workflow, that will improve patients' likelihood of full recovery from stroke and prevent future strokes from occurring

Stroke is the leading cause of adult disability and is in the top five causes of death globally. Warlow's Stroke: Practical Management, 4th Edition takes a problem-oriented approach and addresses the questions posed by a stroke patient in the order they are likely to present in clinical practice, for instance, 'Is it a stroke?', 'What sort of stroke?', 'What caused it?', and 'What can be done about it?'.

Beginning with chapters phrased as questions, the book walks the reader through a standard clinical workflow, exploring the practical skills and assessment required at each stage of patient management. Early chapters cover: locating the vascular lesion, identifying the involved arterial territory, the role imaging should play, and the application thereof.

Subsequent chapters look at what causes a transient or persistent ischemic event, an intracerebral hemorrhage and a subarachnoid hemorrhage. Unusual causes of ischemic stroke and transient ischemic attack are also covered. The book then presents a practical approach to the management of stroke and transient ischemic attack; offers specific treatments for acute ischemic stroke and aneurysmal subarachnoid hemorrhage; provides ways for professionals to prevent first or recurrent stroke; and more.

Final chapters of the book discuss rehabilitation after stroke, how patients and carers can be supported in the short term and long term, prevention of recurrent stroke, and the organization of stroke services.

Warlow's Stroke: Practical Management, 4th Edition

• Follows clinical workflow for stroke analysis
• Features evidence-based approach throughout
• Offers practical application aimed at improving patient outcomes
• Written and edited by internationally renowned experts in the field

An essential resource for all practitioners involved in the care of patients who suffer from cerebrovascular disease, but particularly suitable for neurologists, residents, geriatricians, stroke physicians, radiologists and primary care physicians.

1
Introduction

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CHAPTER MENU

• 1.1 Introduction to the first edition
• 1.2 Introduction to the second edition
• 1.3 Introduction to the third edition
• 1.4 Introduction to the fourth edition

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1.1 Introduction to the first edition

1.1.1 Aims and scope of the book

We, the authors of this book, regard ourselves as practising – and practical – doctors who look after stroke patients in very routine day‐to‐day practice. The book is for people like us: neurologists, geriatricians, stroke physicians, radiologists and general internal physicians. But it is not just for doctors. It is also for nurses, therapists, managers and anyone else who wants practical guidance about all and any of the problems to do with stroke – from aetiology to organization of services, from prevention to occupational therapy, and from any facet of cure to any facet of care. In other words, it is for anyone who has to deal with stroke in clinical practice. It is not a book for armchair theoreticians, who usually have no sense of proportion as well as difficulty in seeing the wood from the trees. Or, maybe, it is particularly for them so that they can be led back into the real world.

The book takes what is known as a problem‐orientated approach. The problems posed by stroke patients are discussed in the sort of order that they are likely to present themselves. Is it a stroke? What sort of stroke is it? What caused it? What can be done about it? How can the patient and carer be supported in the short term and long term? How can any recurrence be prevented? How can stroke services be better organized? Unlike traditional textbooks, which linger on dusty shelves, there are no ‘‐ology’ chapters. Aetiology, epidemiology, pathology and the rest represent just the tools to solve the problems – so they are used when they are needed, and not discussed in isolation. For example, to prevent strokes one needs to know how frequent they are (epidemiology), what types of stroke there are (pathology), what causes them (aetiology) and what evidence there is to support therapeutic intervention (randomized controlled trials). Clinicians mostly operate on a need‐to‐know basis, and so when a problem arises they need the information to solve it at that moment, from inside their head, from a colleague – and we hope from a book like this.

1.1.2 General principles

To solve a problem one obviously needs relevant information. Clinicians, and others, should not be making decisions based on whim, dogma or the last case, although most do, at least some of the time – ourselves included. It is better to search out the reliable information based on some reasonable criterion for what is meant by reliable, get it into a sensible order, review it and make a summary that can be used at the bedside. If one does not have the time to do this – and who does for every problem? – then one has to search out someone else’s systematic review. Or find the answer in this book. Good clinicians have always done all this intuitively, although recently the process has been blessed with the title of ‘evidence‐based medicine’, and now even ‘evidence‐based patient‐focused medicine’! In this book we have used the evidence‐based approach, at least where it is possible to do so. Therefore, where a systematic review of a risk factor or a treatment is available we have cited it, and not just emphasized single studies done by us or our friends and with results to suit our prejudices. But so often there is no good evidence or even any evidence at all available, and certainly no systematic reviews. What to do then? Certainly not what most doctors are trained to do: ‘Never be wrong, and if you are, never admit it!’ If we do not know something, we will say so. But, like other clinicians, we may have to make decisions even when we do not know what to do, and when nobody else does either. One cannot always adopt the policy of ‘if you don’t know what to do, don’t do it’. Throughout the book we will try to indicate where there is no evidence, or feeble evidence, and describe what we do and will continue to do until better evidence becomes available; after all, it is these murky areas of practice that need to be flagged up as requiring further research. Moreover, in clinical practice, all of us ask respected colleagues for advice, not because they may know something that we do not but because we want to know what they would do in a difficult situation.

1.1.3 Methods

We were all taught to look at the ‘methods’ section of a scientific paper before anything else. If the methods are no good, then there is no point in wasting time and reading further. In passing, we do regard it as most peculiar that some medical journals still print the methods section in smaller letters than the rest of the paper. Therefore, before anyone reads further, perhaps we should describe the methods we have adopted.

It is now impossible for any single person to write a comprehensive book about stroke that has the feel of having been written by someone with hands‐on experience of the whole subject. The range of problems is far too wide. Therefore, the sort of stroke book that we as practitioners want – and we hope others do too – has to be written by a group of people. Rather than putting together a huge multi‐author book, we thought it would be better and more informative, for ourselves as well as readers, to write a book together that would take a particular approach (evidence‐based, if you will) and end up with a coherent message. After all, we have all worked together over many years, our views on stroke are more convergent than divergent, and so it should not be too terribly difficult to write a book together.

Like many things in medicine, and in life, this book started over a few drinks to provide the initial momentum to get going, on the occasion of a stroke conference in Geneva in 1993. At that time, we decided that the book was to be comprehensive (but not to the extent of citing every known reference), that all areas of stroke must be covered, and who was going to start writing which section. A few months later, the first drafts were then commented on in writing and in detail by all the authors before we got back together for a general discussion – again over a few drinks, but on this occasion at the Stockholm stroke conference in 1994. Momentum restored, we went home to improve what we had written, and the second draft was sent round to everyone for comments in an attempt to improve the clarity, remove duplication, fill in gaps and expunge as much remaining neurodogma, neurofantasy and neuroastrology as possible. Our final discussion was held at the Bordeaux stroke meeting in 1995, and the drinks that time were more in relief and celebration that the end was in sight. Home we all went to update the manuscript and make final improvements before handing over the whole lot to the publisher in January 1996.

This process may well have taken longer than a conventional multi‐author book in which all the sections are written in isolation. But it was surely more fun, and hopefully the result will provide a uniform and coherent view of the subject. It is, we hope, a ‘how to do it’ book, or at least a ‘how we do it’ book.

1.1.4 Using the book

This is not a stroke encyclopaedia. Many very much more comprehensive books and monographs are available now, or soon will be. Nor is this really a book to be read from cover to cover. Rather, it is a book that we would like to be used on stroke units and in clinics to help illuminate stroke management at various different stages, both at the level of the individual patient and for patients in general. So we would like it to be kept handy and referred to when a problem crops up: how should swallowing difficulties be identified and managed? Should an angiogram be done? Is raised plasma fibrinogen a cause of stroke? How many beds should a stroke unit have? And so on. If a question is not addressed at all, then we would like to know about it so that it can be dealt with in the next edition, if there is to be one, which will clearly depend on sales, the publisher, and enough congenial European stroke conferences to keep us going.

It should be fairly easy to find one’s way around the book from the chapter headings and the contents list at the beginning of each chapter. If that fails, then the index will do instead. We have used a lot of cross‐referencing to guide the reader from any starting point and so avoid constant reference to the index.

As mentioned earlier, we have tried to be as selective as possible with the referencing. On the one hand, we want to allow readers access to the relevant literature, but on the other hand we do not want the text to be overwhelmed by references – particularly by references to unsound work. To be selective, we have tried to cite recent evidence‐based systematic reviews and classic papers describing important work. Other references can probably mostly be found by those who want to dig deeper in the reference lists of the references we have cited.

Finally, we have liberally scattered what some would call practice points and other maxims throughout the book. These we are all prepared to sign up to, at least in early 1996. Of course, as more evidence becomes available, some of these practice points will become out of date.

1.1.5 Why a stroke book now?

Stroke has been somewhat of a Cinderella area of medicine, at least with respect to the other two of the three most common fatal disorders in the developed world – coronary heart disease and cancer. But times are gradually changing, particularly in the last decade when stroke has been moving up the political agenda, when research has been expanding perhaps in the slipstream of coronary heart disease research, when treatments to prevent, if not treat, stroke have become available and when the pharmaceutical industry has taken more notice. It seems that there is so much information about stroke that many practitioners are beginning to be overwhelmed. Therefore, now is a good time to try to capture all this information, digest it and then write down a practical approach to stroke management based on the best available evidence and research. This is our excuse for putting together what we know and what we do not know, what we do and why we do it.

1.2 Introduction to the second edition

Whether we enjoyed our annual ‘stroke book’ dinners at the European stroke conferences too much to abandon them, or whether we thought there really was a lot of updating to do, we found ourselves working on this second edition four short years after the first. It has certainly helped to have been so much encouraged by the many people who seemed to like the book, and find it useful. We have kept to the same format, authors, and principles outlined above in the introduction to the first edition. The first step was for all of us to read the whole book again and collect together any new comments and criticisms for each of the other authors. We then rewrote our respective sections and circulated them to all the other authors for their further comments (and they were not shy in giving them). We prepared our final words in early 2000.

A huge technical advance since writing the first edition has been the widespread availability of e‐mail and the use of the Internet. Even more than before, we have genuinely been able to write material together; one author does a first draft, sends it as an attachment across the world in seconds, the other author appends ideas and e‐mails the whole attachment back to the first author, copying to other authors for comments perhaps, and so on until it is perfect. Of course, we still do not all agree about absolutely everything all of the time. After all, we want readers to have a feel for the rough and ragged growing edge of stroke research, where there is bound to be disagreement. If we all knew what to do for stroke patients there would be no need for randomized controlled trials to help us do better – an unrealistic scenario if ever there was one. So where there is uncertainty, and where we disagree, we have tried to make that plain. But, on the whole, we are all still prepared to sign up to the practice points.

In this second edition, we have been able to correct the surprising number of minor typographical errors and hope not to have introduced any more, get all the X‐rays the right way up, improve on some of the figures, remove some dupl...

Table of contents

• Cover
• Table of Contents
• Contributors
• Acknowledgments
• Abbreviations
• 1 Introduction
• 2 Development of knowledge about cerebrovascular disease
• 3 Is it a vascular event and where is the lesion?
• 4 Which arterial territory is involved?
• 5 What is the role of imaging in acute stroke?
• 5A Neuroimaging
• 5B Ultrasound of the extra‐ and intracranial arteries
• 5C Cardioembolic stroke
• 6 What caused this transient or persisting ischemic event?
• 7 Unusual causes of ischemic stroke and transient ischemic attack
• 8 What caused this intracerebral hemorrhage?
• 9 What caused this subarachnoid hemorrhage?
• 10 A practical approach to the management of stroke and transient ischemic attack
• 11 What are this patient’s problems? A problem‐based approach to the general management of stroke
• 12 Have the patient’s cognitive abilities been affected?
• 13 Specific treatment of acute ischemic stroke
• 14 Specific treatment of intracerebral hemorrhage
• 15 Specific treatment of aneurysmal subarachnoid hemorrhage
• 16 Specific interventions to prevent intracranial hemorrhage
• 17 Preventing recurrent stroke and other serious vascular events
• 18 Rehabilitation after stroke
• 19 The organization of stroke services
• 20 Reducing the impact of stroke and improving public health
• Index
• End User License Agreement