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This overview focuses on the role of secondary prevention strategies in ensuring that the decline in stroke continues. Better awareness of stroke as a major health care problem and the increased number of investigators in Canada who are studying cerebrovascular diseases will help to enhance the management of stroke. Randomized trials with acetylsalicylic acid (ASA) and/or warfarin in patients who have experienced transient ischemic attacks or have been diagnosed as having atrial fibrillation are excellent examples of stroke prevention that helps to decrease the risk of stroke as well as bring researchers together. A multicentre trial on the effectiveness of extracranial-intracranial bypass surgery proved beyond a doubt that the procedure was not useful in most patients. In symptomatic patients with more than 70% carotid stenosis, endarterectomy has been shown to significantly decrease the risk of subsequent cerebral infarction. Several other ongoing trials in patients with asymptomatic bruits and other problems will also aid in stroke prevention.

It has been accepted that transient monocular blindness (TMB) is highly suggestive of an ipsilateral carotid artery lesion in patients with arterial risk factors. We confirmed this in 55 patients, who had an internal carotid artery severe stenosis, occlusion or ulceration on angiography in more than 50 per cent of the cases. However, 12-lead-ECG, 2 D--echocardiography and Holter monitoring also showed a potential cardiac source of emboli in 22 per cent of the patients. Most of these patients (83 per cent) also had an appropriate arterial lesion, and the exact cause of the episodes of TMB remained undetermined. Our study shows that every fourth of fifth patient with TMB may have a potential cardiac source of emboli, the detection of which could alter the management. Systematic non-invasive cardiac investigations are warranted, especially in TMB patients with known heart disease.