Challenges for Cerebrovascular Disease

ACUTE STROKE CARE: HOW CAN MODERN STROKE CARE BE MADE AVAILABLE TO MORE PATIENTS? Much progress has been made in acute stroke management during the last 20 years. Today we can offer organized stroke unit care in many regions in Europe and some in the United States and Canada; we have an approved acute medical treatment for ischemic stroke, i.v. rtPA. Clot retrieval devices are approved and available and we have evidence-based treatment strategies for critically ill stroke patients. A number of promising new approaches, still await formal evidence, although they are already used quite frequently. However, this progress is not available everywhere. There are large disparities between what is known and what can be offered in many countries and regions throughout the world. The standard of care in some regions is far from routine in others, or may be available only at selected places for very few privileged people. Unfortunately, there is no uniform way in which the application and expansion of what we know in acute stroke management can be promoted throughout the world. Rather, individual routes must be defi ned with respect to availability of resources, standards of training and teaching, and priorities in health economics. The establishment of Stroke Units and Stroke Centers has been the most valuable contribution to the fi eld of acute stroke management. It is not only the single most effective intervention for the vast majority of stroke patients, but it is also a major factor towards increasing the number of patients receiving thrombolytic therapy. Together with pre-hospital system organisation and access to rehabilitation and secondary prevention, these are the most important columns on which the expansion of stroke treatment is built. Once “Stroke” has reached political awareness, implementation of care systems proceeds more smoothly. The political will to improve stroke care will allow new activities in the fi eld of stroke to be launched. Nationor statewide documentation, standards, and quality control instruments can be implemented, and more fi nancial resources will be made available for the development of stroke management and prevention. Stroke care is expensive, and stroke care has to be paid out of the shrinking budgets of general health care. Increasing the resources for one area means cutting resources in others, not an action that will be warmly welcomed by colleagues in other fi elds. Although capitalizing on existing therapies is well justifi ed, fl exibility has to be built into the system to facilitate the successful investigation and application of new diagnostic and therapeutic approaches as they are developed. By doing so, the stroke care system will remain fl exible and will be amenable to incorporate advances that will continue to improve the care of the stroke patient. We propose a stepwise approach to improvement of stroke care.