1105
Editorial
Nihilism and Stroke Therapy
Jos6 Biller, MD, and Betsy B. Love, MD
I
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n spite of recent advances in supportive management and prevention of stroke, it is not uncommon to hear nonneurologists as well as neurologists express the opinion that "nothing can be done
for a patient with a stroke." These individuals are
expressing an attitude of therapeutic nihilism. The
word nihilism is derived from the Latin nihil, meaning "nothing."1 A therapeutic nihilist is one who
shows skepticism regarding the therapeutic value of
drugs. Since ancient times, therapeutic nihilism has
been accepted in relation to diseases of the nervous
system, particularly stroke.
To trace the roots of nihilistic attitudes toward
stroke, one must begin by analyzing the definition of
apoplexy or stroke. Apoplexy means "struck with
violence" in Greek and "being thunderstruck" in
Latin. Stroke was not seen as an affliction from
within the body, but the result of a force from outside
the body, perhaps even celestial. This view is reflected best by the definition of stroke in the 1599
Oxford English Dictionary as a "stroke of God's
hands."2 The logical deduction was that if the disease
were caused by divine intervention, no human intervention such as drug therapy could possibly alter the
outcome. Often, stroke has been referred to as a
"cerebrovasoilar accident," a term that supports the
concept of stroke as a random, unpreventable catastrophe. The term "cerebrovascular accident" should
be banished from our vocabulary.
Historical writings about stroke provide some insight into the evaluation of therapeutic nihilism. Hippocrates wrote that "to get over a strong attack of
apoplexy is impossible, over a weak one, not easy." An
indication of early thoughts about the prognosis of
stroke is contained in the writings of Aretaeus of
Cappadocia during the second century AD. He wrote
that "should indeed the apoplexy be severe, they
cannot survive the greatness of the illness combined
with the misery of advanced life." Paul of Aegina
expressed that, "in some patients, the power of speech
was lost and if it did not return in 14 days, the
physician should do something about it."3 In 1892,
Osier4 stated that in cases of hemiplegja "the friends
From the Division of Cerebrovascular Diseases, Department of
Neurology, University of Iowa College of Medicine, Iowa City,
Iowa.
Address for correspondence: Jos6 Biller, MD, Stroke Program,
Department of Neurology, Northwestern University Medical
School, 233 East Erie, Suite 614, Chicago, IL 60611.
Received May 8, 1991; accepted May 28, 1991.
should at the outset be frankly told that the chances of
full recovery are slight." He also wrote that "when
hemiplegia has persisted for more than 3 months and
contractures have developed, it is the duty of the
physician to explain to the patient or to his friends,
that the condition is past relief, that medicines and
electricity will do no good, and that there is no
possible hope of cure." The lack of urgency for
intervention after a stroke has been a theme for many
years. Attempts to alter the course of cerebral infarction have led to the development of some peculiar
remedies, some of which continue to be used in some
locales. These unusual treatments include purgatives,
bleeding with leeches, and "opening of the bowels."4-5
From this historical perspective, one senses that a
recurring theme in stroke therapy has been an attitude of hopelessness, with a tendency to view stroke
as a disease rather than as a disorder with many
different etiologies. The lack of urgency in the diagnosis and management of stroke on the part of
physicians has fostered a nihilistic attitude, and many
of the misconceptions of our predecessors have been
carried into the present age of stroke therapy. The
nihilistic attitudes of physicians have resulted in an
equally misinformed public.
Although there have been no definitive breakthroughs in the treatment of stroke, striking progress
in that direction has been made during the past
several decades. We are much more knowledgeable
about stroke epidemiology and prevention, diagnosis
of stroke, and pharmacological therapy after stroke.
Until the early 1980s, a decline in the incidence of
stroke over the preceding 30 years had been observed. This decline was attributed primarily to better management of hypertension. The exact cause for
the recent reversal of this trend is not known. Recent
estimates of the incidence of acute cerebrovascular
disease indicate that 150 such events occur per
100,000 population per year.6 Close follow-up of
these trends provides important information about
therapeutic efforts.
Diagnosis of stroke continues to rely primarily on
clinical features. However, advances in neuroimaging
techniques allow early documentation of stroke and
differentiation between hemorrhagic and bland infarcts. More detailed information about cerebral
arterial thromboembolism can be obtained with visualization of a hyperdense cerebral artery on noncontrast computed tomography or with the absence of a
flow-void phenomenon on magnetic resonance imag-
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Stroke Vol 22, No 9 September 1991
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ing (MRI). Exciting breakthroughs have been made
in the technique of MRI angiography, which provides
a noninvasive method of visualizing the cerebral
circulation. Progress has been made in diagnosing
hematological and cardiac sources of stroke. These
advances have made "garden-variety" stroke a repugnant term. On the contrary, stroke is a heterogeneous
condition with varied etiologies. There is no place for
investigative nihilism.
Over the last three decades, medical and surgical
therapy for cerebrovascular disease has undergone
intense evaluation. While modernists think that anticoagulation is a relatively new intervention, this
therapy has been used since ancient times. Leeches
were used for their anticoagulant properties due to
the presence of hirudin in their heads.7 Beginning in
the 1930s, the use of anticoagulants such as heparin
and warfarin was gaining popularity for the treatment of cerebrovascular disease. In spite of little
definitive evidence to support their use, anticoagulants became widely used.
There have been few trials evaluating the efficacy
of anticoagulants and, as a result, their use is governed in many instances by emotions. One area
where there is more conclusive evidence for the use
of anticoagulants is for the primary prevention of
cardiogenic cerebral embolism. Three important primary prevention studies — the Copenhagen AFASAK
Study, the Stroke Prevention in Atrial Fibrillation
(SPAF) Study, and the Boston Area Anticoagulation
Trial for Atrial Fibrillation — have supported the
efficacy of warfarin in nonvalvular atrial fibrillation.8-10 The efficacy of warfarin compared to aspirin
for that indication is being investigated in SPAF II.
Surgical therapy for carotid artery disease emerged
in the mid-1950s. At the peak of its popularity, more
than 100,000 carotid endarterectomies were performed
annually. During the past few years, several new advances have been made in the understanding of cerebral revascularization in the treatment of selected
patients with cerebral ischemia. The Extracranial-toIntracranial Bypass Study demonstrated that the addition of surgery to medical therapy did not improve
outcome for symptomatic patients with distal internal
carotid artery stenosis, internal carotid artery occlusion,
or middle cerebral artery stenosis or occlusion.11 The
North American Symptomatic Carotid Endarterectomy
Trial recently reported that carotid endarterectomy is
more beneficial than the best medical care, including
antiplatelet therapy, for patients with carotid artery
territory transient ischemic attacks or nondisabling
strokes and ipsilateral 70-99% narrowing of the carotid luminal diameter.12 Likewise, the European Carotid Surgery Trial (ECST) demonstrated that the
operation was effective in preventing fatal and disabling
strokes among high-risk patients who had recent ischemic symptoms and ^70% carotid artery stenosis. In
contrast, the ECST demonstrated that surgery did not
provide additional benefit among patients with <30%
carotid artery stenosis.13 Studies are under way to
evaluate the possible benefits of carotid endarterec-
tomy for symptomatic patients with moderate (3069%) stenosis.
Intense research is under way for the medical
management of acute cerebral ischemia. Evidence
from several studies favors the use of platelet antiaggregants (aspirin and ticlopidine) as first-line agents
for patients with threatened stroke,1415 and other
antithrombotic agents such as low-molecular-weight
heparinoids are being investigated. Novel approaches
to the alteration of cellular events after stroke are
receiving focused attention. Cerebral protection with
calcium channel blockers and excitatory amino acid
antagonists are currently under intense investigation.
The safety and potential efficacy of therapy with
tissue plasminogen activator is being evaluated in
cerebral infarction, subarachnoid hemorrhage, and
intracerebral hemorrhage. The advent of thrombolysis has brought about an awareness of the potential
importance of hyperacute therapy for stroke. Finally,
while hemorrheological therapy in general has not
been successful, trials evaluating the efficacy of ancrod are in progress.
As these and other therapies are being tested,
several important concepts about stroke management are emerging. First, it is likely that there is a
narrow therapeutic window for pharmacological intervention after stroke, probably less than 6-12 hours
for most agents. This will place further emphasis on
the importance of viewing stroke as a neurological
emergency in order to preserve vulnerable brain
tissue. Second, it has become clear that the best way
to evaluate therapies is with randomized, doubleblind, placebo-controlled, multicenter studies. This
mechanism of critical evaluation provides many important advantages for the assessment of stroke
prevention and treatment.16 Finally, it may be that a
combination of drugs, each affecting a different cellular mechanism or process, initiated acutely after
stroke will be the therapy of choice.
This review of recent advances in the evaluation of
stroke-prone patients and therapeutic strategies to
alter cellular mechanisms early after stroke elevates
us from an age of therapeutic nihilism to one of
cautious optimism. It is hoped that a successful drug
therapy for stroke will emerge that will reverse the
trend of nihilism. This feeling of optimism should be
conveyed to the public, especially in light of the
importance of early therapy. The symptoms of stroke
should be as well known to the nonphysician as are
the symptoms of myocardial infarction, and the treatment of stroke should be considered just as urgent.
References
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Biller and Love Nihilism and Stroke Therapy
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KEY WORDS • cerebrovascular disorders • stroke management
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Nihilism and stroke therapy.
J Biller and B B Love
Stroke. 1991;22:1105-1107
doi: 10.1161/01.STR.22.9.1105
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