Evolution of Stroke Treatment
Since the beginning of the recorded history of the condition, stroke has been viewed as unable to prevent and untreatable. It was deemed a "stroke of fate" or a "stroke of God's hands." Added to this fatalism was the subtle but important factor of "age-ism" wrongly believing that stroke happens only to the elderly and is therefore not of concern.
Even today, these misperceptions are firmly entrenched, both among the public and among health care providers. Believing that stroke is not preventable, the public has no motivation for complying with prescribed interventions. Believing that stroke is untreatable, the public fails to respond to symptoms. As a result, the average stroke patient waits more than 12 hours before presenting at the emergency room. Believing that stroke is not preventable, health care providers fail to be assertive and diligent about potential preventive measures. Believing that stroke is untreatable, health care providers take an attitude of "watchful waiting" instead of treating stroke as a medical emergency. These outdated attitudes serve as the largest obstacle to the effective prevention and emergency treatment of stroke.
Our notions about stroke and its
treatment are being revolutionized. This truly is the "Decade of the Brain" for
stroke. The new stroke interventionalists (neurologists, neuroradiologists,
emergency medicine physicians and their colleagues) are dedicated to emergent
stroke treatment.
Time to presentation is a monumental obstacle. Recent studies have found that 42
percent of stroke patients wait as long as 24 hours before presenting, with 13
hours as the average. One study reported that the main factors which cause
patients to present earlier are:
· Recognizing stroke symptoms and
· Realizing that the symptoms require emergency treatment
Case in point: The University of Cincinnati developed a model
city-wide response program as a key site during the successful clinical trial of
t-PA (tissue plasminogen activator; see below for detail).
Investigators in local hospitals were faced with the challenge of attempting to test a drug that required patients to present within 90 and 180 minutes from the time of symptom onset. It soon became apparent that to maximize the percentage of stroke patients presenting within this narrow treatment window, community-wide efforts would have to be made involving all hospitals, emergency medical technicians and public information sources. The challenge was to change the way Cincinnati residents viewed stroke and the way the medical and emergency response community responded to and treated stroke.
In an unprecedented cooperative effort, the 11 Cincinnati hospitals collaborated to form an urgent stroke response system incorporating rapid identification and transport by EMS personnel and streamlined, top-priority, in-hospital stat procedures for stroke.
Following these fundamental changes in approach, the improvement in presentation times was impressive: 39 percent of stroke patients presented within 90 minutes, 59 percent presented within three hours and 66 percent presented within six hours (percentages are cumulative). Use of EMS services as a patient's first contact was a major factor in reducing presentation delay.
Similar collaborative approaches have been successful in San Diego (University of California at San Diego), Raleigh-Durham (Duke University), Houston (University of Texas) and other clinical trial locations.
What is driving the current revolution in the way stroke is viewed and treated? Perhaps the two strongest factors are our ever-increasing knowledge of the catastrophic events that occur in the brain during stroke and the research efforts of the last 20 years coming to fruition and pointing the way to the development of breakthrough treatments.