We’re going to move on to the second session entitled: Contemporary Prevention, Management and Treatment of Stroke — Who Will Treat Acute Stroke in 2010 and How Will It Be Treated?

       The data on this first slide (Figure 1) show the magnitude of the problem of stroke. These are

Figure 1

2001 data from the World Health Organization. At that time, the World Health Organization identified that there were 20 million strokes worldwide; 5.5 million of those were fatal. On the east side of the Atlantic, in Europe, there are 650,000 deaths due to stroke every year. On the west side of the Atlantic, there were about 750,000 strokes per year, with an enormous number of deaths related to stroke. Stroke is the third leading cause of death behind diseases of the heart and cancer, and it’s the first cause of serious long-term disability. The final piece of information I want to mention is that stroke costs society about 3% of the total.
       What do we know about the changing incidence of stroke? These data (Figure 2) come from the county in which I live in Minnesota. It shows the stroke rate for a population of 100,000. When you live in a small county with a small population, it is possible to follow every single person. Thus these data, in terms of the stroke incidence rate, are very accurate. It could be that

Figure 3

the stroke

Figure 2

rates are different in Italy or in Germany, but these are data from longitudinal follow up in this patient population, looking at the age-adjusted incidence rate for a population of 100,000.
       You can also see in Figure 2 that there was a progressive decline in stroke from 1955 to 1975. Recall that death rates from coronary artery disease have continued to fall. This is not true for stroke, however. Stroke, at least in the United States, stopped declining in 1975 and, if anything, has increased. It is not continuing to fall for reasons that are not clear, other than the fact that everybody is getting older. So we’re going to have a chance to see a lot of strokes in the future as the patient population increases.
       What are the mechanisms of stroke? Nick Hopkins is going to talk about some of these issues. Figure 3 shows more data that again are from a couple of years ago from CHES looking at the different etiology of stroke. We can see the large artery

Figure 4

atherosclerosis 20%, the lacune infarcts 25%, cardio-embolic 20%, cryptogenic 30%. How do we treat cryptogenic stroke? And then there’s another small group, the 5% of patients whom we don’t have a clue about. So these are going to be issues for us to talk about as we try to design strategies for stroke prevention and treatment.
       The final piece of information following our discussion about the mechanisms and incidence of stroke and the fact that they haven’t changed very much, is the fact that the mechanism of stroke has a substantial implication for subsequent survival. Stroke’s subtype is seen in Figure 4. When we look at these curves for strokes in 2000, we can see that in those patients in whom there was a cardio-embolic stroke, the survival at 5 years is abysmal, at 20%. If you were to ask about the group of patients who have stroke related to atherosclerosis, it’s not all that bad. It’s not great, but it’s not all that bad. Lacune strokes have about an 80% survival rate. Thus stroke outcome will be very dependent upon the mechanism of stroke.
       Now with that background in place, I’ll turn the microphone over to Nick Hopkins.