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The treatment of patients with stroke and cerebrovascular disease has entered a new era. During the 1990s there has been a revolution in technology able to define quickly, safely, and accurately stroke pathophysiological characteristics and the cardiovascular lesions that cause stroke in individual patients. Advanced brain imaging with computed tomography, magnetic resonance imaging, and newer magnetic resonance modalities, including fluid attenuating inversion recovery imaging, diffusion, perfusion, functional magnetic resonance imaging, and magnetic resonance spectroscopy, show clinicians the localization, severity, and potential reversibility of ischemia. Vascular lesions can be defined using spiral computed tomographic angiography, magnetic resonance angiography, and extracranial and transcranial ultrasonography. Cardiac and aortic sources of stroke are now better studied using transesophageal echocardiography. More sophisticated hematologic testing gives new insights into the role of altered coagulability in causing or contributing to thromboembolism. Clinicians can now recognize the key data elements needed to logically treat brain ischemia, including the following: The nature, location, and severity of cardiac and cerebrovascular lesions. The mechanism by which these lesions cause ischemia--hypoperfusion? embolism? functional changes such as vasoconstriction? The cellular and serologic components of the blood that relate to coagulability, viscosity, and blood flow. The state of the brain--normal, reversibly ichemic ("stunned"), or infarcted. With these diagnostic advances have come new treatments, new ideas about treatment, and more and new information about conventional treatments.
Louis R. Caplan (Wed,) studied this question.