open access: Nature Reviews: Key Advances in Medicine

STROKE IN 2011
Major advances across the spectrum
of stroke care
Lee H. Schwamm
NEUROLOGY
Several pivotal clinical trials that could have a major impact on the care of patients with stroke were published
in 2011. The studies cover a wide range of stroke-care aspects, including stroke prevention, imaging to select
patients for thrombolysis, therapies for stroke recovery, and stroke registries to improve care quality.
Schwamm, L. H. Nat. Rev. Neurol. 8, 63–64 (2012); published online 10 January 2012; doi:10.1038/nrneurol.2011.225
The current framework for analyzing the
complete spectrum of stroke care is conceptualized
in the ‘stroke systems of care’ model 1
(Figure 1), as delineated in a policy statement
of the American Stroke Association in
2005. The model specifies seven domains of
care—primary prevention; community education;
notification and response of emergency
medical services; acute stroke treatment; subacute
stroke treatment and secon dary prevention;
rehabili tation; and con tinuous quality
improvement activities—and emphasizes the
links between them. In 2011, five domains of
the stroke systems of care model have witnessed
major breakthroughs that have the
potential to dramati cally influence the delivery
of stroke care now and in the future, thereby
further eroding the therapeutic nihilism that
still surrounds much of stroke treatment.
Nonvalvular atrial fibrillation is a major
preventable cause of first ever and recurrent
stroke. Warfarin has been the mainstay of
therapy for almost half a century, but it has
a narrow therapeutic range that is difficult to
maintain in many patients, requires frequent
monitoring, and is highly susceptible to drug
and food interactions. The ARISTOTLE trial 2
compared the oral direct factor Xa inhibitor
apixaban with warfarin for efficacy in stroke
prevention in over 1,800 patients with atrial
fibrillation and an elevated stroke risk score.
In both groups, just under 15% of patients
had a prior myocardial infarction, and 20%
had a prior stroke, transient ischemic attack
or systemic embolism. The results showed
that apixaban is superior to warfarin in
reducing the risk of stroke or systemic embolism
(incidence rates 1.27% versus 1.60% per
year; HR 0.79; P