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STROKE: ANOTHER VIEW ROBERT]. JOYNT* andJOHN H. FEIBELf When Shakespeare said, ". . . where is fancy bred, or in the heart or in the head?" he was echoing the ineluctable quest of his and of our own day for the seat of the intellect. However, he might well have raised the same query about cerebrovascular disease and the other systems of the body. There are innumerable and increasing studies on the causes of stroke, but there are few on the converse problem ofwhat stroke causes. The association, for example, ofdysrhythmic and ischemic heart disease, hypertension, certain metabolic disorders, and pulmonary disease with strokes is a common clinical occurrence. In most instances the sequence is such that the stroke is the end result. This is probably true in the overwhelming number of cases and is borne out by clinico-pathologic correlations. However, there are many instances which suggest the sequence may not be the usual one, and the stroke may occupy an earlier place in the concatenation. Part of the reluctance to accept this idea comes from our clinical experience that many systemic illnesses affect the nervous system, but, in general, disease of the nervous system remains confined to the nervous system. Certain clinical observations suggest we alter our thinking, for not only are we interested in the pathophysiology of disease, but there may be therapeutic implications. The evidence suggesting a role reversal was initiated by the observation that electrocardiographic changes were seen after both occlusive and, more frequently, hemorrhagic strokes. Byer and his colleagues [1] reported a 37-year-old woman with a cerebral hemorrhage who showed a prolonged Q-T interval and large T waves in her electrocardiogram. These changes disappeared in 9 days. A few years later, Levine [2] and Burch and his colleagues [3] reported various electrocardiographic abThis work was done while Dr. Joynt was a Senior International Fogarty Scholar and presented by him as the Jacobson Lecture at Newcastle-upon-Tyne, May 23, 1980. Work supported by grants to the Stroke Center from the National Institutes of Health. ?Department of Neurology, University of Rochester School of Medicine, 601 Elmwood Avenue, Rochester, New York 14642. tWaasdorp Laboratory for Stroke Research, Rochester, New York 14642.© 1982 by The University of Chicago. AU rights reserved. 0031-5982/83/2601-0293$01.00 116 I RobertJ.Joynt andJohn H. Fabel · Stroke: Another View normalities in a series of stroke patients. Since that time there have been numerous reports of the association of electrocardiographic changes with stroke [4-12], but also the association with myocardial damage and with dysrhythmias [13-17]. More recently, hypertension refractory to the usual antihypertensive drugs has been noted after subarachnoid hemorrhage [18]. Also, metabolic abnormalities, especially hyponatremia , have been noted after a number of neurologic conditions [19], but especially after strokes [20]. Hyperglycemia after damage to the nervous system has been known since the famous experiment of Claude Bernard [21]. It has been noted after strokes, especially in subarachnoid hemorrhage [22, 23]. Pulmonary edema has also occurred after the onset of the cerebrovascular accident [24, 25]. The actual incidence of these disorders is hard to ascertain as often the presence and degree of heart disease, hypertension, metabolic disorders, or pulmonary disease is not known prior to the hospital admission. An argument against a high occurrence of these disorders resulting from strokes is that they are all risk factors for causing stroke. For example, it cannot be denied that the coincidence of heart disease and strokes is high. However, sometimes these cardiac abnormalities are seen in young patients not in the usual age group for heart diseases [8] or develop after the stroke while being monitored in the hospital [12, 26], or a cardiac arrhythmia must be invoked as a cause of death when no other explanation is found [14]. The hypertension occasionally seen after subarachnoid hemorrhage is unusual in that the usual antihypertensive agents are ineffective [18]. Thus, it is probably not a preexisting essential hypertension. Certain metabolic disorders as hyponatremia may be a cause of stroke [27], but this electrolyte abnormality usually appears in the first few days and is not normally seen on admission [20]. Hyperglycemia is also seen acutely after strokes and disappears [23]. Finally...


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