Stroke : The Next 30 Years

The only safe prediction about stroke in the next three decades is that it will be very different. Progress largely depends on discovery, and discovery cannot be predicted. However, understanding from where we are coming may help guide where we are going. Each of the previous editors of Stroke has given his view of stroke and the journal during his tenure, providing a concise and unique chronicle of our field by those who helped shape it.1–5 Several trends will likely affect the field and the journal. The Growing Burden of StrokeStroke is the second-leading cause of death in the world6 and rising. In the developed world, the proportion of the population over the age of 65 years is growing. In the developing world, where most strokes occur, the population over 60 will double in the next 2 decades.7 These trends portend sharp increases in stroke incidence. The shift from traditional, rural ways of life to urbanization and Westernization often means less exercise, more calories, and bad habits, such as smoking. If we are serious about prevention, much can be done to lessen this burden.8 The Changing Pathophysiology of StrokeMost attention has been paid to extracranial disease. However, in the developing world and in American minorities, intracranial disease prevails, about which we know little. Moreover, imaging has unveiled the common occurrence of leukoaraiosis and of “silent” infarcts, both of which can be associated with cognitive decline. Increasingly we are becoming aware of not only large strokes that cripple the body, but little strokes that undermine the mind. Cerebral vascular disease and Alzheimer’s disease often coincide and may interact in the brains of elderly individuals. New avenues need to be pursued to see whether stroke precipitates Alzheimer’s disease, and if so, whether this can be prevented, delayed, or mitigated.9When hypertension is treated, intracerebral hemorrhage …