Strokes are the third-leading cause of death in this country, the No. 1 cause of long-term disability and admissions to long-term care facilities, yet it was not until 1998 that an organization specifically devoted to the advancement of stroke care was established.

The American Stroke Association (ASA) is a division of the American Heart Association (AHA), which for many years served as the umbrella organization over research and education for heart disease and strokes. Dr. Arthur Pancioli, a Cincinnati stroke specialist and ASA spokesman, said the organization was a long time coming: "Unquestionably, there has been an underemphasis on strokes. The cost of strokes is an enormous problem: $50 billion every year, and this is probably an underestimate. Yet, until recently there has not been the emphasis there should have been," Pancioli says. "It's been dramatically undertreated. The American Stroke Association is a breath of fresh air, because we now have a large organization that is doing the right thing."

Pancioli says it was necessary for a breakout organization to address the needs of stroke research and education.
"The American Heart Association was doing a very good job fighting heart disease and strokes through education," he says. "But the leadership of the AHA saw a significant opportunity to advance this cause by making a bold move to form the American Stroke Association itself."

The Advent of Acute Stroke Aggressive Care
Strokes are being treated more aggressively than ever before. TPA, a thrombolytic therapy that dissolves clots and restores blood flow in stroke victims, has been used successfully in recent years as part of aggressive treatments. Dr. Pancioli, who served on a research team studying the use of TPA, says the drug may actually have influenced the recent emphasis and focus on strokes.
"The advent of TPA showed there was something that could be done. We saw a swing in the direction of more aggressive care. Fortunately, a number of other issues have been brought up, which are now more aggressively addressed, including the prevention of stroke-related complications," he says.
Pancioli has lectured throughout North America on TPA and has used the drug in his work for the last six years.
"If you take the population of acute ischemic stroke patients who arrive at an emergency department in time, who are truly proper candidates for this therapy, there is no doubt that the group of patients that gets treated does significantly better than the patients who do not," he says.
TPA is not without its drawbacks, including hemorrhaging, and it's difficult, Pancioli admits, to know upfront who might suffer from such a side effect.
"Certain predictors give you an idea if a patient is more likely to have bleeding problems. For example, a larger stroke is more likely to have bleeding problems than a smaller stroke," he says. "But at the same time, the person with the larger stroke, if left untreated, is unlikely to do well. There is greater risk in some patients, but they also have the most to gain. The problem with TPA is that it is not a cure-all. Its benefit, while absolutely real, is not enormous. There are some patients for whom it does not have a significant effect, and then there are about 6.4 percent of patients who have significant bleeding complications because of the drug."
Aggressive treatment of acute stroke led to the establishment of the ASA's Acute Stroke Treatment Program (ASTP), which Pancioli also helped develop. It is a multistep guide for facilities to determine their readiness for stroke care.
"The ASTP provides the steps required to appropriately and aggressively treat victims of stroke, and asks how the stroke center rates itself on these steps. Where are your strengths and where do you have areas of potential improvement? Then there is the material that helps guide healthcare facilities toward advancing their capabilities to be a stroke center."
A "toolkit" included in the ASTP kits contains: "Recommendations for the Establishment of Stroke Centers: A Consensus Statement from the Brain Attack Coalition"(a reprint from the Journal of the American Medical Association); ASA's Call-to-Action Campaign, patient education materials, hospital and prehospital stroke scales, professional education materials and more. Future components of ASTP include a web-based version of the kit and an ASTP Satellite Symposium offering CME and CEU credits from leaders in acute stroke care.

"EMS has to be the leader"

"There are few disease processes where time makes as great a difference as it does for the acute stroke victim," Dr. Pancioli emphasizes, "and if time matters, EMS has to be involved and has to be the leader."
Aggressive treatment of strokes begins with the prehospital provider, he adds. "With a rapid response by prehospital providers, a quick on-scene diagnosis and rapid communication, followed by rapid transport and good supportive care, you'll have more patients arriving in time, with a facility standing ready to administer aggressive early therapies. Something like TPA requires an absolute clear, defined time of onset, so that you know you are in the three-hour time window. The prehospital provider on-scene is the best person to make that assessment," he says.
Pancioli cites a specific example of a successful interconnection between EMS and hospital. A 42-year-old male stroke victim, who was unable to move one side of his body and could not speak properly, was assessed by an ambulance team who radioed the Hamilton County (OH) base station, who, in turn, notified the trauma facility, who then called in a member of the hospital's stroke team. Pancioli was the stroke team member on call that night.
"This is an example of a stroke physician specifically getting en route because of the prehospital call. I literally beat the ambulance to the hospital because they had an 18-minute transport time, and it only takes me 17 minutes to get to the hospital," he says. "Everything was prepared en route, and we were ready to treat him with TPA. Today he walks and talks. He was able to go back to work in three weeks. If we can impress upon prehospital providers how critical their role is in this process, it will absolutely make a difference for tens of thousands of stroke victims."

The ASA spent $54 million on stroke-related research and programs in the 1998-99 fiscal year. The organization's work serves to educate both the general public and the medical professional communities. Tools established by the ASA that can be incorporated by EMS when they get out into their communities include:
Operation Stroke: Launched in 1997, this community-based program was established to raise awareness of stroke warning signs and the need to quickly obtain emergency treatment. Operation Stroke has been set up in about 51 U.S. cities, with the expectation of more than 125 cities having Operation Stroke programs by 2003.

Consumer Education:
" Programs and services, such as videos, literature and guides for community stroke screenings, that target African Americans, seniors and women, who are the three groups at highest risks for strokes.
" More than 14 different patient brochures with such topics as Are You At Risk of Stroke?, Being A Stroke Family Caregiver and Smoke and Stroke.
" Stomp Out Stroke: a church-based program geared toward African Americans that includes information about planning stroke screenings in local churches.
" Stroke: A Speaker's Outline: a slide-based series for healthcare professionals to use to educate lay audiences.
" Stroke Call-to-Action Campaign: tools for the community, such as billboards and posters, to help bring awareness to the signs of stroke.

Professional Education:
" The annual International Stroke Conference: attended by more than 2,400 neurologists, surgeons, physicians, nurses and other medical professionals, who learn about the latest research and developments in the field.
" The Acute Stroke Treatment Program: developed as a "how-to" guide for stroke center directors and acute stroke teams to help strengthen their programs based on the Brain Attack Coalition's recommendations.
" Curriculum: The ASA is adapting the University of Massachusetts Medical School's stroke-focused first- and second-year medical curriculum to be distributed in print medium and supported by an interactive website for other medical students to incorporate into their education.

Support Services
" The 320-page book A Family Guide to Stroke: deals with the treatment, recovery and prevention of strokes and coping with life after a stroke.
" A National Stroke Support Group Registry: offers a listing of more than 1,900 stroke support groups nationwide.
" Stroke Connection Magazine: a bimonthly publication for families, primarily dealing with "life after stroke" articles concerning rehabilitation, treatments and more.

For more information about the American Stroke Association, call 888/4-STROKE (478-7653), or visit www.strokeassociation.org The Acute Stroke Treatment Program is available for $79 by calling 800/611-6082, or visiting www.channing-bete.com