The American Heart Association’s 2014 update to its annual statistical report estimates that ∼795 000 individuals experience a new or recurrent stroke in the USA every year. In China, a country where stroke incidence is reputed to be amongst the highest, there are almost 2·5 million new cases per year. If these numbers were not somber enough, the World Health Organization estimates that, worldwide, about 15 million individuals suffer from stroke every year where one-third of cases result in permanent disability and an additional one-third end in fatality. Clearly, this is not just a global issue, it is every inch a global epidemic. Greater focus and renewed vigor from scientists, clinicians, and public health advocates is justified — let alone an occasional special issue journal put together by concerned editors and researchers whose work lies herein.
Research, thus far, into treatments for such a rampant and debilitating disease has not made great clinical strides since the landmark NINDS study in 1996 detailing the efficacy of recombinant tissue plasminogen activator (rt-PA) for use in acute ischemic stroke. As effective and undoubtedly life-saving as rt-PA has been in the past 18 years, its clinical usefulness has long been attenuated by its many limitations. The appropriate selection of patients for rt-PA treatment is difficult, due largely to a narrow therapeutic window of only 3·5–4 hours. This alone sheds light on one of the most pressing concerns related to modern-day stroke protocols, which is the need for faster and more accurate diagnoses. This special issue begins with a comprehensive overview provided by Dr Zhang that provides as detailed of a synopsis as possible on current guidelines regarding the early management of acute ischemic stroke — appropriately setting the stage for treatments that lie on the horizon. With the continuing maturation of the computer and internet age, it is about time to harness new technologies in order to overcome the time constraints related to rt-PA eligibility. To that end, Dr Chen’s group in Shanghai has designed and has already begun testing a computer-based algorithm dubbed a ‘diagnostic expert system’ that integrates informational databases and objective clinical findings.
Looking ahead, it is not enough to simply increase the number of stroke-related studies. Future undertakings should pay greater heed to existing study designs so as to maximize the efficient use of time and resources. Dr Liebeskind realizes this point in his review article where he scrutinizes how data are used and presented in trial studies of ischemic stroke. In a second article provided by Dr Liebeskind, he expands further on his stance that existing trials deserve a second look. The review article, aptly titled ‘collateral lessons’, discusses the overlooked role that collateral circulation plays in reperfusion and the possible salvaging of ischemic tissue. Future stroke studies will undoubtedly make use of animal models in the natural progression of concept to clinical trial. With this in mind, Tim Kwiecien’s review article analyzes the historical gains as well as the shortcomings garnered from use of rodent models, which is the prevalent model in use today. By looking back at what has been accomplished so far, he is able to look forward and propose the potential benefits of increasing the utilization of non-human primate models in future trials.
As much value and efficiency as analyzing past studies affords, simultaneous innovations on the frontier of cerebrovascular treatments is what ultimately provides the backbone of ongoing progress. Xiao-Feng Jiang et al. show the potential of targeting physical exercise treatments toward undamaged cerebral hemispheres contralateral to an infarct in a rat model; raising important implications for modern rehabilitation protocols. Yongan Chen’s group from Shandong University, meanwhile, presents their latest data regarding the use of stent-assisted coiling for cerebral aneurysms.
Because of the growing trend of utilizing small interfering RNA constructs to selectively modulate specific metabolic pathways in ischemia/reperfusion injury, this special issue also includes the promising findings from Zhao’s group that demonstrate how selective inhibition of CTMP and the subsequent activation of the Akt pathway led to improved outcomes in a mouse traumatic brain injury model.
With improvements to existing treatments and the advent of brand new approaches comes the natural need to predict and track clinical outcomes in order to vindicate continued efforts. As such, Dr Wang presents interesting cross-sectional data showing the strong correlation between stratified levels of impaired fasting glucose and the severity of arterial stiffness in Chinese adults. The argument for strict blood glucose control in at-risk patients is magnified even more in light of a study from Dr Wu showing how a patient’s HbA1c can be used to prognosticate all-cause mortality in the first year following a stroke. Dr Ai, meanwhile, details the usefulness of advanced imaging, specifically the use of 3D-FLAIR, in detecting white matter lesions and how these lesions correspond to subcortical cognitive impairments in affected individuals. In the spirit of Dr Liebeskind, Dr Yang’s group re-evaluates existing practices by questioning the use of specific qEEG parameters in the prognosis of patients suffering from post-anoxic comas.
Lastly, we have in this issue two studies that take a look at two unique clinical situations which deserve attention no less than what has already been discussed. Dr Chung out of Cedars-Sinai in Los Angeles, CA, USA, provides an overview and his expertise in regards to seizure management within the acute stroke setting. From Seoul National University in South Korea, we also have Dr Kim, who brings us the latest in regards to the diagnosis and treatment of adult Moyamoya disease.
It goes without saying that this special issue covers a wide breadth of topics with the hope that it is both informative and motivating. With that said, a special thanks must be given to Professor Ben Roitberg, the Editor-in-Chief, for the wisdom and encouragement he has given throughout the process of putting this issue together.