Stroke: Insights into Thromboembolism Treatment and Prevention through the Decades

With the availability of back issues online for Thrombosis & Haemostasis ever since the original first published issue in 1957 (then under the name Thrombosis et Diasthesis Haemorrhagica), we felt that stroke could be an initial special focus, given the publication on this topic in Volume 1, Issue 1 of this journal.[1]

Way back in 1957, the era that ‘the treatment for all cerebral vascular diseases was futile’[1] and ‘the physician's choice lay between masterly inactivity and skilful neglect [2]’, was slowly giving its place to a period of progress in stroke prevention and treatment. At that time, physicians were beginning to feel optimistic that they had started climbing up the learning curve, although it was still clear that they ‘did not consider present treatment entirely satisfactory’.[1]

Let's take a hypothetical patient, Michael, in the 1950s. If only Michael could share his optimism this evening. For the last 2 hours, he was lying on a bed in the emergency department of the hospital waiting for a physician to examine him and help him talk and move his right leg and hand again. It was easy for him to guess that he was having a “brain attack”—many of his friends had suffered something similar, and many of them did not make it through. Next day, although dizzy, Michael could listen to the doctor talking to his daughter:

• ‘We took some fluid from his spinal cord for examination and we tend to conclude that this is probably a non-haemorrhagic infarction (1). We don’t really know why it happened, for most of our patients we don't.[1] I won't fool you, the management of this entity is discouragingly inadequate.[3] We tried all our weapons: we blocked his stellate ganglion to increase the collateral vessels around the dead zone,[3] we administered intravenous procaine[4] and histamine[5] , carbon dioxide[2] , nicotine and whiskey,[3] ephedrine and ritalin[6] , cortisol,[6] we tried everything… I am sorry, no improvement'.

• ‘Will you do an arteriogram to my father, doctor?’, she asked.

• ‘Of course not, there are no indications for this,[6] it is only experimental [1]’, the doctor responded decisively.

• ‘Will you treat him with anticoagulants, doctor?’, she asked again looking desperately for a glimpse of hope.

• ‘No’, he said avoiding looking her in the eyes. ‘We are rather reluctant with this form of treatment. In our own hospital we have been impressed by the dangers of using anticoagulants in the severely hypertensive patient and by the incidence of haemorrhagic problems that occur when long-term anticoagulation is undertaken. It certainly should not be considered a benign procedure but rather one which presents definite risks’.[6]

The doctor proved to be right: Michael did not make it through, and he never made it to see Helena, his fourth grandchild, to be born a few weeks later.

• References

• 1 Wright IS. The challenge of cerebral vascular diseases. Thromb Diath Haemorrh 1957; 1 (01) 26-36
• 2 Wolf P. TREATMENT of a stroke. Lancet 1959; 1 (7067): 293-294
• 3 Aird RB, Skillicorn SA. The treatment of cerebrovascular accident. Med Clin North Am 1956; 40 (05) 1355-1368
• 4 Nielsen JM. Management of cerebral vascular accidents. Ann Intern Med 1953; 39 (04) 717-722
• 5 Furmanski AR. Histamine therapy in acute ischemia of the brain; a report of fifty new cases. AMA Arch Neurol Psychiatry 1953; 69 (01) 104-117
• 6 Tyler HR. Modern concepts of the pathogenesis, diagnosis and treatment of cerebrovascular accidents. Med Clin North Am 1960; 44: 1215-1236
• 7 Ebinger M, Winter B, Wendt M. , et al; STEMO Consortium. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA 2014; 311 (16) 1622-1631
• 8 Walter S, Kostpopoulos P, Haass A. , et al. Bringing the hospital to the patient: first treatment of stroke patients at the emergency site. PLoS One 2010; 5 (10) e13758
• 9 Psychogios MN, Behme D, Schregel K. , et al. One-stop management of acute stroke patients: minimizing door-to-reperfusion times. Stroke 2017; 48 (11) 3152-3155
• 10 Papanagiotou P, Ntaios G. Endovascular thrombectomy in acute ischemic stroke. Circ Cardiovasc Interv 2018; 11 (01) e005362
• 11 Lip GYH, Freedman B, De Caterina R, Potpara TS. Stroke prevention in atrial fibrillation: Past, present and future. Thromb Haemost 2017; 117 (07) 1230-1239
• 12 Ntaios G, Hart RG. Embolic stroke. Circulation 2017; 136 (25) 2403-2405
• 13 Borre ED, Goode A, Raitz G. , et al. Predicting thromboembolic and bleeding event risk in patients with non-valvular atrial fibrillation: a systematic review. Thromb Haemost 2018; 118 (12) 2171-2187
• 14 Diener HC, Ntaios G, O'Donnell M, Easton JD. Non-vitamin-K oral anticoagulants (NOACs) for the prevention of secondary stroke. Expert Opin Pharmacother 2018; 19 (14) 1597-1602
• 15 Ntaios G, Papavasileiou V, Makaritsis K, Vemmos K, Michel P, Lip GYH. Real-world setting comparison of nonvitamin-K antagonist oral anticoagulants versus vitamin-K antagonists for stroke prevention in atrial fibrillation: a systematic review and meta-analysis. Stroke 2017; 48 (09) 2494-2503
• 16 Proietti M, Mujovic N, Potpara TS. Optimizing stroke and bleeding risk assessment in patients with atrial fibrillation: a balance of evidence, practicality and precision. Thromb Haemost 2018; 118 (12) 2014-2017
• 17 Loewen PS, Ji AT, Kapanen A, McClean A. Patient values and preferences for antithrombotic therapy in atrial fibrillation. A narrative systematic review. Thromb Haemost 2017; 117 (06) 1007-1022
• 18 Ntaios G, Papavasileiou V, Diener HC, Makaritsis K, Michel P. Nonvitamin-K-antagonist oral anticoagulants versus warfarin in patients with atrial fibrillation and previous stroke or transient ischemic attack: an updated systematic review and meta-analysis of randomized controlled trials. Int J Stroke 2017; 12 (06) 589-596
• 19 Rivera-Caravaca JM, Roldán V, Esteve-Pastor MA. , et al. Cessation of oral anticoagulation is an important risk factor for stroke and mortality in atrial fibrillation patients. Thromb Haemost 2017; 117 (07) 1448-1454
• 20 Hohnloser SH, Basic E, Hohmann C, Nabauer M. Effectiveness and safety of non-vitamin K oral anticoagulants in comparison to phenprocoumon: data from 61,000 patients with atrial fibrillation. Thromb Haemost 2018; 118 (03) 526-538
• 21 Lip GYH. The ABC pathway: an integrated approach to improve AF management. Nat Rev Cardiol 2017; 14 (11) 627-628
• 22 Pastori D, Pignatelli P, Menichelli D, Violi F, Lip GYH. Integrated care management of patients with atrial fibrillation and risk of cardiovascular events: the ABC (Atrial fibrillation Better Care) pathway in the ATHERO-AF study cohort. Mayo Clin Proc 2018; S0025-6196(18)30891-7
• 23 Proietti M, Romiti GF, Olshansky B, Lane DA, Lip GYH. Improved outcomes by integrated care of anticoagulated patients with atrial fibrillation using the simple ABC (Atrial Fibrillation Better Care) pathway. Am J Med 2018; 131 (11) 1359-1366