From The Editor's Desk

Over the past 10 years acute therapy and prevention have enabled us to make great strides in the war against cerebrovascular disease. Previous nihilism is being replaced with new protocols designed to aggressively manage ischemic strokes with the goal of performing thrombolysis on every qualifying patient. Polypharmacy approaches addressing atherosclerosis from multiple directions, including statins, ACE inhibitors, homocysteine reduction, and high-intenstity antiplatelet therapy, have the potential to reduce recurrent vascular events by 60%–70%.

Although a stroke is usually placed in the realm of neurological disease, a multidisciplinary approach has been vital to the success of the Ochsner Stroke team. We are fortunate to have strong representation from primary prevention specialists, emergency medicine, prehospital services, radiology, interventional cardiology, neurosurgery, and vascular surgery. This group dynamic and “critical mass” is well represented in this issue of The Ochsner Journal.

Dr. Andrew Naidech and I address the evidence-based approach to acute stroke therapy. Besides considering the thought process behind thrombolysis, we also try to present rational arguments regarding anticoagulation. My mentors taught me that brevity is wit, and I hope that the “Five P” approach will help treating clinicians in an emergency room situation.

Even in the best medical environment, there will always be patients who do not qualify for thrombolysis. However, every patient can benefit from primary and secondary prevention. Drs. Lavie and Milani report the very exciting work accomplished in the last 5–10 years applying the molecular knowledge gained through bench research to clinical situations in order to reduce vascular events.

Carotid disease remains a controversial subject. Although most specialists will agree that symptomatic 50% or greater internal carotid artery disease or 70%–80% nonsymptomatic disease responds better to intervention plus medical therapy versus medical therapy alone, the debate still continues on the best selection of patients and the best technique. This debate occurs in the pages of this journal as well. Drs. Sternbergh and Money of Ochsner's Vascular Surgery Section present compelling, albeit retrospective data that high-risk carotid endarterectomy (CEA) patients have excellent morbidity and mortality rates in their experience. Dr. White, Chairman of Ochsner's Cardiology Department, presents results from a multicenter trial suggesting that stenting is superior to CEA for the same high-risk patients. How are we to interpret this evidence? Clearly, the outcome of either CEA or stenting is highly operator-dependent. Although national rates may suggest a certain outcome trend, like politics, all treatment is local. We are fortunate to have local vascular surgeons who have a markedly superior skill set than the national average. We also have pioneers in interventional (stenting) approaches in carotid disease. Although the final risk/benefit ratio of both procedures remain to be answered by a currently ongoing NIH sponsored trial (the CREST trial), I currently feel comfortable recommending both procedures to high and normal risk patients.

Ochsner interventional cardiologists Drs. Jenkins and Subramanian, neurosurgeon Dr. Smith, and neurologist Dr. Strub describe advances in difficult vascular diseases and the pioneering work to address these situations. The role of extracranial-intracranial bypass and intervention of vertebral and intracranial vessels is an advancing field that will give hope for an effective therapy to many previously untreatable patients. On the other hand, the stroke can result in changes in cognition resulting in vascular dementia. Dr. Strub presents guidelines to the diagnosis and management of this disabling condition.

Finally, a case presentation is included that shows what can happen when all of these diverse elements are brought together to help a patient suffering from a massive ischemic stroke. With advances in bench and clinical research, cases such as the one presented will become commonplace. I am confident that the Ochsner stroke service will be in the forefront of this progress.