I know these people are congratulating themselves but they should consider themselves failures. I stake my knowledge against theirs and my agenda against their weasel words. It only took 53 authors with DRs and PhDs behind their names. I won't apologize. Not a single person said they would take on and solve a particular problem.
Stroke Turns 40 Stroke: Working Toward a Prioritized World Agenda
Abstract
Background and Purpose— The aim of the Synergium was to devise and prioritize new ways of accelerating progress in reducing the risks, effects, and
consequences of stroke.
Methods—
Preliminary work was performed by 7 working groups of stroke leaders
followed by a synergium (a forum for working synergistically
together) with approximately 100 additional
participants. The resulting draft document had further input from
contributors
outside the synergium.
Results— Recommendations of the Synergium are:
Basic Science, Drug Development and Technology:
There is a need to develop: (1) New systems of working together to
break down the prevalent “silo” mentality; (2) New models
of vertically integrated basic, clinical, and
epidemiological disciplines; and (3) Efficient methods of identifying
other
relevant areas of science.
Stroke Prevention:
(1) Establish a global chronic disease prevention initiative with
stroke as a major focus. (2) Recognize not only abrupt
clinical stroke, but subtle subclinical stroke,
the commonest type of cerebrovascular disease, leading to impairments of
executive
function. (3) Develop, implement and evaluate a
population approach for stroke prevention. (4) Develop public health
communication
strategies using traditional and novel (eg,
social media/marketing) techniques.
Acute Stroke Management: Continue the establishment of stroke centers, stroke units, regional systems of emergency stroke care and telestroke networks.
Brain Recovery and Rehabilitation:
(1) Translate best neuroscience, including animal and human studies,
into poststroke recovery research and clinical care.
(2) Standardize poststroke rehabilitation based
on best evidence. (3) Develop consensus on, then implementation of,
standardized
clinical and surrogate assessments. (4) Carry
out rigorous clinical research to advance stroke recovery.
Into the 21st Century: Web, Technology and Communications:
(1) Work toward global unrestricted access to stroke-related
information. (2) Build centralized electronic archives and registries.
Foster Cooperation Among Stakeholders (large stroke organizations, nongovernmental organizations, governments, patient organizations and industry) to enhance stroke
care.
Educate and energize professionals, patients, the public and policy makers by using a “Brain Health” concept that enables promotion of preventive measures.
Conclusions—
To accelerate progress in stroke, we must reach beyond the current
status scientifically, conceptually, and pragmatically.
Advances can be made not only by doing, but
ceasing to do. Significant savings in time, money, and effort could
result from
discontinuing practices driven by
unsubstantiated opinion, unproven approaches, and financial gain.
Systematic integration
of knowledge into programs coupled with careful
evaluation can speed the pace of progress.
Key Words:
Birthdays invite reflection and planning. The journal Stroke
has turned 40, providing not only an occasion to celebrate the past,
but also an opportunity to help shape the future. Most
of the leaders in stroke have been involved with
the journal as authors, reviewers, or editors, providing an umbrella for
collaboration. The participants of this synergium
are leaders in the field and although the event was supported by major
stroke
organizations worldwide, it was a gathering of
individuals interested in finding common solutions.
A result has been a Synergium,
a word coined by the first author to describe a forum for working
synergistically together. Seven working groups each suggested
3 main recommendations for progress that were
refined during a 1-day face-to-face meeting. In addition, approximately
100
other participants and contributors from outside
the synergium provided input to the final document.
The Past 40 Years
More progress has been made in stroke over the past 4 decades than in the previous 4 millennia. In 1970, a landmark paper
showed that hypertension was a strong risk factor for all types of stroke.1
Thereafter, other major risk factors for stroke were identified.
Subsequent studies showed that many risk factors can be
reduced and that their control decreases the
incidence of stroke. The late 1970s saw the first proof that aspirin
prevents
stroke.2 This was followed by the introduction of other efficacious antiplatelet agents. The first modern comprehensive stroke unit
was inaugurated in 1975,3 and tissue plasminogen activator’s effectiveness in acute stroke was demonstrated in 1995.4
Carotid endarterectomy was shown to prevent stroke in selected patients
and angioplasty and stenting are currently being
tested for similar purposes. Coiling offers an
alternative to brain aneurysm and arteriovenous malformation surgery.
Brain
imaging has revolutionalized the diagnosis of
stroke and the management of patients with stroke. Steady progress
enhances
our understanding of the mechanisms of brain
injury, repair, plasticity, and recovery. Each of the previous
Editors-in-Chief
of Stroke (Clark Millikan, Fletcher McDowell, Henry Barnett, Oscar Reinmuth, and Mark Dyken) summarized the main developments and issues
in the field during their tenures, covering the years 1970 to 2000.5–9 The developments in subsequent years have been documented in the annual “Advances” feature of Stroke.
Paradoxes of Progress
Progress breeds paradoxes. Stroke is
preventable yet is increasing globally. The same few major risk factors
account for much
of the leading health problems of the world but
remain uncontrolled in the majority of affected individuals. Management
of
risk factors is the most readily applicable and
affordable part of our knowledge, but prevention is neglected, and most
environments
are inhospitable to healthy living.
Although many advances in the
understanding of excitotoxicity, neurotransmitter depletion, oxidative
stress, mitochondrial
failure, inflammation, and apoptosis have
occurred, this has been accomplished in relative isolation from the
knowledge gained
on the same mechanisms that underlie other major
afflictions of the brain such as Alzheimer disease, Parkinson disease,
epilepsy,
multiple sclerosis, and brain trauma.
Although the symptoms of stroke are
well described, the majority at risk do not recognize their
significance. In 1 study,
only 1 in 6 individuals were aware that a
treatment for stroke exists and that at the time of the study, it had to
be given
no more than 3 hours after symptom onset.10
In stroke, we know that time is brain, but too few brains arrive in
time. Although we have learned to treat transient ischemic
attack as an emergency, only approximately 1 in 8
of patients with first-time stroke have a prior transient ischemic
attack.11
We must find other ways of identifying those at high risk for stroke.
Subclinical (“silent”) strokes are the most common
type of stroke, executive function impairment
being its earliest manifestation, but this fact is barely recognized and
cognition
seldom measured.12
Stroke unit care improves outcomes of
patients of all ages, stroke types, and severities but remains the
exception rather
than the rule in stroke care. The understanding
of the neurobiology of brain injury, repair, and plasticity has
advanced,
but no histoprotective or reparative drug has
yet proved efficacious.
Stroke rehabilitation works but is
largely unavailable for the time and intensity required. Effective drugs
are not accessible
or affordable in many developing countries nor
used optimally in developed ones. Unproven, costly, or misdirected
practices
continue to drain resources and prevent the
pursuit of more cost-effective approaches.
Although the challenges are daunting,
the achievements of the past 4 decades are inspiring, having witnessed
the transformation
of stroke from an area notable for diagnostic
precision and therapeutic impotence to a field ripe for further advances
in
prevention, acute treatment, and rehabilitation.
Groups’ Recommendations
Basic Science, Drug Development, and Technology
Step 1: Address Unmet Needs
In all aspects of basic science, drug development, and technology, there is clearly a need to “do things differently” if there
is to be a major advance in the development of new interventions.13,14 Over the last few years, there has been a dearth of advances that have limited genuine leaps in the understanding of the
basic science and pathogenesis of stroke, and hence new targets for therapy.15,16 To counter this, a radical approach is suggested in the following areas.
Recommendations
-
Establish a New Taxonomy of Disease. This could be based on the genetics or another taxonomy that makes scientists and clinical investigators think about the disease process in a completely different way. The natural consequence of this would be the development of personalized medicine.17 A simple example might be the genetic basis of vascular collateralization.
-
Learn From Other Scientific Disciplines and Diseases. It is time to step into other domains so that knowledge in other areas may be readily applied to the problem of stroke. In other words, we need to scan the scientific landscape to embrace new ideas and approaches.
-
Challenge Existing Models of Disease and Embrace Even More Basic Models to Have a More “Blue Sky Approach” to Science. Studies in Drosophila, worms, and zebra fish, among others, might generate novel new ideas about the stroke process.18–20 Yet, at the same time, pursue more clinical models with human cells, tissue, and samples. For example, sampling in patients undergoing carotid endarterectomy or in patients subjected to transient cerebral ischemia during neurosurgical procedures.
Step 2: Implement 3 Approaches That Will Accelerate the Capacity to Address Unmet Needs
There are processes that could be put in place, which may result in needs being met earlier rather than later.
Recommendations
-
Develop new systems of collaboration to break down the silo mentality currently rife in the stroke community. This could involve the gathering together of basic and clinical scientists from a variety of disciplines and putting them to work to solve major stroke problems. Alternatively, it could involve adding 1 or 2 “odd ball” players to existing teams to encourage them to think outside the box. For example, drosophila models have been used for Parkinson disease. Hypoxia-inducible factor-1a responses are conserved from flies to mammals. Can we build on these fundamentals for stroke? In horseshoe crabs (living fossils), coagulation and immune systems are merged. Can we leverage this type of evolutionary biology to dissect and target the links between inflammation and thrombosis in stroke? Evolutionary biology also indicates that neurogenesis and angiogenesis share common genes and pathways. Can we use these principles to develop new methods for stroke repair?
-
Be alert to new models of disease that may vertically integrate basic, clinical, and epidemiological disciplines. For example, could advances in the understanding of infectious diseases or inflammation dramatically change our thinking about stroke pathogenesis?
-
Develop efficient methods of scanning other areas of science to enhance the likelihood of generating new ideas/concepts as well as information likely to be of use in developing new targets, new technologies, and better translational processes.
How, When, and By Whom Should These Goals Be Achieved?
How
In establishing the new systems
described earlier, investigators will need to work in different ways.
For example, sabbaticals
and exchange programs and publication in
completely novel areas could improve the cross-fertilization process.
Mechanisms
should be established that will encourage
investigators by measuring the impact and novelty of their work rather
than the
current trend based on a researcher’s
number of publications and citations. A broad platform of stroke
education should provide
the underpinnings for this change (see
“Education” section) with a focus on national research institutions and,
perhaps, the
establishment of similar global
institutions to cross country/cultural boundaries.
By Whom
Scientific leaders around the
world (organizations, institutes, and others) need to bring together
these new and novel teams.
Industry (eg, pharmaceuticals,
biotechnology) should also be involved with a clear interface with the
academic, regulatory,
and government world. Government funding
agencies should stimulate this new collaborative paradigm by providing
funding for
think tanks, which could be local,
national and, even more importantly, global.
Stroke Prevention: Broadening the Approach and Intensifying the Efforts
Introduction
Major chronic diseases such as
stroke, heart disease, cancer, Alzheimer disease and vascular cognitive
impairment may be linked
by common risk factors and pathophysiological
mechanisms. Few simple steps like eating a balanced diet, exercising,
maintaining
optimal body weight, avoiding smoking, and
limiting alcohol consumption can reduce risk of stroke by up to 80%.21,22
The occurrence of shared risk factors and possible common
pathophysiological mechanisms (eg, inflammation, endothelial
dysfunction)23 provide a backdrop for the establishment of chronic disease prevention or health preservation networks.
We propose 3 steps to influence
future stroke prevention. The approach includes novel means to enhance
stroke prevention and
integrate strategies from within and outside
the medical field with an emphasis on synergistic opportunities and
collaborations.
Step 1: Establish a Global Chronic Disease Prevention Initiative That Includes Stroke as a Major Focus Among a Cluster of Conditions
The Chronic Disease Action Group
has provided a call to action to encourage, support, and monitor
activity on the implementation
of evidence-based efforts to achieve global,
regional, and national programs to prevent and control chronic diseases.24
This group emphasizes the control of 3 key modifiable lifestyle risks:
unhealthy diet, physical inactivity, and tobacco habit.
Multisectorial policies as well as long-term,
sustainable action plans are encouraged to empower individuals,
families, and
communities to affect health-conscious
behavioral change. The creation of the Global Noncommunicable Disease
Network (NCDnet)25
also focuses to reduce risk, morbidity, and mortality related to 4 risk
factors (tobacco use, physical inactivity, unhealthy
diets, and the harmful use of alcohol). It is
a global collaborative effort between the World Health Organization
(WHO), member
states, international partners, and other
stakeholders for the prevention and control of noncommunicable diseases.
Recommendations
-
Develop a leadership group that will work with existing organizations to set and advocate a chronic disease prevention agenda with stroke as a major focus and the establishment of formal strategies to reduce unhealthy lifestyle and other risk factors.
-
Establish collaborations between and representation of major health organizations and/or advocacy groups (eg, WHO, World Federation of Neurology [WFN], World Stroke Organization [WSO], World Heart Federation, National Institutes of Health [NIH], and Fogarty International Center, Centers for Disease Control and Prevention [CDC], American Heart Association [AHA], European Stroke Organization [ESO], Chronic Disease Action Group, health maintenance organizations, etc).
-
Incorporate mechanisms for cost-effective research monitoring into the overall strategy.
-
Government and industry should be represented in these collaborations.
Step 2: Use and Promote the Population Approach for Stroke Prevention
Recommendations
Newer approaches in the United States and some other regions may include:-
Generate a paradigm shift among medical insurance providers, government, and health professionals toward a major emphasis on adequate and effective preventive health care and education programs.
-
Establish collaborations among the global chronic disease prevention group, local stroke health advocacy organizations, and governmental chronic disease prevention offices.
-
Use community health workers to provide a means to assist in providing access to health care, adherence to treatment regimens, and overall adoption of ideal cardiovascular health at the community level.
-
Develop positive incentives for: (a) physicians who successfully achieve lifestyle risk control in their patients (eg, pay-for-performance); and (b) patients/workers who adhere to healthy lifestyle behaviors.
-
Incorporate a broader use of global vascular risk screening tools.
-
Secure funding for additional research to determine the benefits of healthy lifestyle behavior and the most effective ways to modify behavior.
-
Study, for future application, other strategies such as legislation for and education of the community about lowering salt in the diet and polypill strategies26 in conjunction with healthy lifestyle behavior.
Step 3: Develop Public Health Communication Strategies Using Traditional and Novel (Social Media/Marketing) Techniques
The basic components of establishing a public health communication strategy include27:
(a) identification of the health problem and target audience; (b)
determine if the communication should be part of the intervention
and, if so, strategies to best reach the
audience; (c) development and testing of communication concepts,
messages, and materials,
including culturally appropriate messages for
selected populations; (d) implementation of a health communication
program based
on the pretest results; and (e) assessment of
the effectiveness of the messages and modification of the program
accordingly.
Traditional public health communication
channels have included public service announcements, commercials, and
newspapers,
each carrying advantages and disadvantages.
Recommendations
-
An evidence-based communication approach is required and partnership with an organization with substantial experience in public health communication (eg, WHO, WSO, AHA) is desirable.
-
Consider establishing a centralized web site for chronic disease prevention inclusive of stroke prevention and social media/marketing, including but not limited to Twitter, Facebook, MySpace, LinkedIn, YouTube, and blogs. Because of the high penetration use rates of the Internet and cell phones, these communication vehicles should be considered for communicating messages and researched for cost-effectiveness.
-
Overall, the concept of development of a central “power grid” for chronic disease prevention messaging could be accomplished. Local experts should be consulted to help develop and tailor individual, smart communication systems by area.
Acute Stroke Management: Applying and Expanding What We Know
Introduction
The establishment of stroke units
and stroke centers has been the most significant contribution to the
field of acute stroke
management. Stroke units are an effective
intervention for the vast majority of stroke victims. Stroke centers
along with
prehospital system organization, access to
rehabilitation, and secondary prevention improve the quality of stroke
care.
Enormous lobbying to reach
policymakers has been pivotal to all advances in the development of
stroke care systems to date.
Once “stroke” has reached political
awareness, smooth implementation of care systems follows. The activities
may be at the
state or provincial level or even at the
national level of countries such as Russia, Brazil, Spain, or the United
Kingdom.
The political will to improve stroke care
will allow new activities in the field of stroke to be launched. Nation-
or statewide
documentation, standards, and quality control
instruments can be implemented and more financial resources made
available for
the development of stroke management and
prevention initiatives.
The role of physicians in
initiating and guiding such developments is paramount. The achievements
in the prehospital system
in the United States and in the statewide
stroke unit programs in Germany, Brazil, Spain, and Russia were only
possible with
the enormous input of stroke physicians.
Large-scale application of the Scandinavian stroke unit model has
increased access
to thrombolytic therapy and reduced the case
fatality rate leading to remarkable improvement in the quality of stroke
care.28 This should continue to be a major source of strength and direction.
Stroke care is expensive. It has to
be supported in a zero-sum game of allocation in the setting of overall
shrinking budgets
of general health care, an action that will
be not be warmly welcomed by colleagues in other fields. A helpful and
key, evidence-supported
message is that improvements in stroke care
frequently brings net health expenditure savings to governments by
reducing rehabilitation,
nursing home, and lost productivity costs.
Although capitalizing on existing
therapies is well justified, flexibility has to be built into the system
to facilitate the
successful application of new diagnostic and
therapeutic approaches. It should be possible to introduce new tools and
technologies,
revise protocols, and modify the composition
of the stroke care team to fit the requirement of new developments in
the field.
By doing so, the stroke care system will
remain flexible and will be amenable to incorporate advances that will
continue to
improve the care of the patient with stroke.
Steps for Improving Stroke Care Worldwide
Step 1: Establishment of Stroke Centers and Stroke Units to Assist Patients With Acute Stroke as a Priority
Stroke center hospitals with
organized stroke unit care have made the most significant contribution
to current stroke management.
Efforts should be made to establish
hospitals with stroke unit care in locations accessible to all patients
with stroke to
reduce the global burden of stroke. These
specialized centers should be organized according to the local and
regional needs
and classified in different levels of
complexity according to the available resources and treatments.29–31
The lowest tier stroke service can be built with low-cost equipment
primarily focusing on well-trained interdisciplinary
teams. Stroke centers should implement
evidence-based treatment protocols, including thrombolytic therapy.32,33
Recommendations
-
Choose hospitals in each city or region to be established as stroke centers with organized emergency department and stroke unit care in accordance with local health authorities (eg, Scandinavian countries, Spain, Germany, United States, United Kingdom, Russia);
-
Classify stroke centers choosing the model that best fits the region, state, or country and create an official certification process (eg, United States, Germany, Austria, European certification efforts by ESO);
-
Provide training by specialized staff with standardized protocols;
-
Implement thrombolytic therapy for acute ischemic stroke;
-
Implement quality control instruments (database of all patients);
-
Alternatively, to solve the problem of overcrowded emergency rooms, the lack of beds in intensive care unit, and the lack of space to build acute stroke units, more general vascular units can be established that would include acute stroke management as has been done in Brazil. This is a specialized unit in the emergency room with a trained team to assist acute vascular disorders, including stroke, coronary syndromes, pulmonary embolism, and aortic diseases.
Step 2: Development of Regional Systems of Emergency Stroke Care
Activating the prehospital
emergency medical system and transportation to the designated stroke
centers leads to a shorter
delay in arrival at the hospital and
better initial management. The training of ambulance teams and
dispatchers in prehospital
recognition of stroke as an emergency34,35 and the recognition of stroke signs increases the number of patients arriving earlier at hospital (eg, Greater Los Angeles).36
Scientific statements recommend the development of regional systems of
stroke care in which ambulances bring patients with
acute stroke directly to stroke center
hospitals to rapidly provide approved stroke therapies, improving the
outcome of patients.37
Recommendations
-
Training prehospital emergency medical systems teams to recognize stroke and to bring patients with acute stroke directly to designated stroke centers;
-
Develop regional networks of stroke care between prehospital emergency medical systems and stroke centers; and
-
Whenever possible, use the same telephone number region wide to activate the prehospital emergency medical system (eg, the European 112 campaign, 911 in the United States).
Step 3: Improving Stroke Awareness
Lack of recognition of stroke
signs or lack of sense of urgency to seek help by the population is a
major barrier for adequate
stroke treatment. Stroke awareness
campaigns can increase symptom identification, thus resulting in a
decrease in the time
from symptom onset to hospital arrival and
increase in the number of patients who may receive appropriate
interventions.
Recommendations
-
Promote evidence-based media campaigns providing public information about acute stroke signs and the urgency to call prehospital emergency medical systems;
-
Because stroke often renders patients themselves unable to recognize or communicate their symptoms, public education campaigns should inform not only at-risk individuals, but also family, friends, and on-scene witnesses to call the prehospital emergency medical system if they observe an individual having signs of a possible stroke.
A few successful examples from
different parts of the world and different medical systems are described
in Appendix 1 to illustrate
how acute stroke treatment can be made
more widely available.
Brain Recovery and Rehabilitation: Harnessing the Regenerative Powers of the Brain and the Individual
Introduction
After the acute period, a stroke
will often affect a patient’s life for many years. During the early days
to weeks after a
stroke, spontaneous repair events usually
lead to some degree of behavioral recovery. The neurobiology of these
repair events
suggests several therapeutic targets to
promote further recovery. Traditional rehabilitation is one of the
therapeutic tools
to augment the poststroke recovery process. A
wide range of repair-based therapies is also in development.38
Rehabilitation and repair is a
relatively young and diverse field yet extends from the first days of
inpatient care to ensuing
care by rehabilitative specialists to years
of chronic care in a range of settings. Current research topics span
plasticity,
normal learning, pharmacology, genetics,
robotic engineering, occupational therapy, physical therapy, and speech
therapy and
growth in these areas will continue to
improve rehabilitation.39
Four steps for stroke
rehabilitation/recovery therapies are considered subsequently. The goal
of rehabilitation/recovery stroke
medicine is to have more patients achieving
better recovery in the weeks after a stroke and experiencing less
disability during
the years that follow.
Step 1: Translate Best Neuroscience, Including Animal and Human Studies, Into Poststroke Recovery Research and Patient Care
Key Issues
The neurobiology of spontaneous recovery and central nervous system repair40
suggests several potential therapeutic approaches that could improve
patient outcome, but more research is needed. Current
treatment options are limited. Although
traditional rehabilitation medicine helps patients, a better
understanding of its
scientific basis could further increase
its impact. Active research may also lead to design of new therapies
that ultimately
may win approval such as those using
pharmacological, cell-based, electromagnetic, robotic, or
neuroprosthetic approaches.
Recommendations
Increased basic and
translational research is needed. A deeper insight into the neurobiology
of poststroke recovery is required.
The means by which principles of normal
learning and development can be applied to stroke recovery need to be
better understood.41 Tools for measuring the biology of stroke recovery in humans are needed, from behavioral measures with defined psychometric
properties to biomarkers such as for recording physiology of repair-related events.42 Results of such research should be regularly compiled in both clinical and basic science State of the Art for Stroke Recovery Status Reports. This broad area of research may be best addressed by developing a group of Stroke Recovery Research Centers.
Translational studies are needed
to determine the effects that various rehabilitation/repair therapies
have on recovery both
as isolated therapies as well as in
various combinations. A number of combination approaches can be
envisioned, for example,
traditional rehabilitation paired with a
central nervous system stimulant, brain stimulation paired with a
robotic therapy
(with a single computer driving both), an
angiogenic growth factor followed by a synaptogenic growth factor, or
exercise therapy
paired with motor imagery therapy. In this
regard, traditional rehabilitation can be regarded as a key tool, in
the therapeutic
armamentarium for stroke recovery. Like
with any medical therapy, the optimal timing, intensity, duration, and
content of
therapy needs to be continually refined
using scientifically sound approaches. Some of these issues need to be
clarified for
individual therapies before combining into
combination therapies. Specific to stroke recovery are issues such as
defining
the degree of task specificity for
poststroke training. The impact of comorbidities, both prestroke and
poststroke, needs
consideration with a focus on
identification of possible modifiable and nonmodifiable comorbidities.
Step 2: The Practice of Poststroke Rehabilitation Needs to Be Standardized Based on Best Evidence
Key Issues
Substantial data exist on the practice of poststroke rehabilitation.43
As parallel research continues to refine the approaches, there is a
need to apply currently existing knowledge to optimize
patient outcome. Key issues include the
organizational structure, timing, intensity, and task specificity of
poststroke therapy.44 Attention to community reintegration is also needed.
Recommendations
Detailed, standardized
poststroke therapy protocols need to be developed and their practice
associated with proper training.
This should extend to transition to the
community and then to a multiyear chronic phase of rehabilitation.
Monetary and payment
incentives must be redefined to drive
implementation of these protocols. The lessons from published studies
and best practices
must be operationalized.45 This can be partly achieved by improved benchmarking of processes, outcomes, and costs.
Medical school and postgraduate
training should incorporate the protocols and best practices and should
include suitable educational
media and modules to support the
implementation. Many of these solutions can be addressed by development
of Stroke Recovery Research Centers.
Step 3: Develop Consensus on, Then Implementation of, Standardized Clinical and Surrogate Measurements
Key Issues
The best standardized
measures of behavior and outcomes after stroke need to be defined and
then placed into clinical practice,
at the same time continuing to generate
appropriate research. These need to be used across rehabilitation
systems and regions.
These should be measured and
communicated in a consistent manner. Standardized rater training needs
to be developed for these
measures.
Surrogate markers of
treatment effect also are needed, including imaging (anatomic and
functional), physiological, and biological
(such as genetics). These might be used
as predictive tools for outcome and thus be of value for triage; as
entry criteria
in clinical trials of repair-related
therapies; or in evaluating treatment outcomes to guide clinical
decision-making.
Achieving consensus on clinical measures and biomarkers in this context would be useful for clinical practice and also for
developing clinical trials of therapies targeting stroke recovery.
Recommendations
Experts need to be gathered to
discuss these issues and to propose unifying strategies to achieve rapid
progress in the study
of rehabilitation interventions. One
possible mechanism would be an International Harmonization Conference,
which would help
achieve expert consensus on poststroke
behavioral and clinical measures as well as on surrogate markers, as has
been done
in other neurological conditions.
Development of Stroke Recovery Research Centers would be useful to achieve such consensus, for subsequent pilot testing of the recommendations, and for defining means for
broader implementation.
Further research is needed to define the psychometric qualities and performance of proposed surrogate markers.
Step 4: Target Repair-Related Processes in Clinical Research to Advance Stroke Recovery
Key Issues
Available research suggests
many strong candidates for therapies that are likely to improve
poststroke recovery by targeting
repair-related processes. However,
clinical trials in this domain are few and often small in size. A
significant need exists
to design and execute clinical trials
focused on stroke rehabilitation and repair.
Stroke rehabilitation/repair
clinical trials need to be hypothesis-driven, properly designed, and
appropriately powered with
vertical integration of basic,
clinical, and epidemiological disciplines. The clinical trial structure
should extend beyond
mere hypothesis testing to discovery
and exploration, the latter being much needed in this expanding field
with immense potential
to help numerous patients with stroke.
Randomized clinical trials
are the mainstay of examining candidate therapies. Additional research
structures also might be
used to further address these issues.
Examples include innovative trial designs such as a cluster randomized
design as well
as shared databases.
Note that the impact of such trials will be maximized if paralleled by studies of clinical effectiveness and pertinent health
economic topics.
Recommendations
A Neurorecovery Consortium needs to be created consisting of academic (basic and clinical researchers, likely based at the Stroke Recovery Research Centers), industry, government research, clinicians, and payers with the mission being to define priorities and future actions for
stroke recovery trials. Specific Stroke Rehabilitation/Recovery Conferences should be supported to address shared issues related to stroke recovery and rehabilitation.
Centralized strategic plans for
brain recovery science should be developed, akin to the England Stroke
Research Centers. Clinical
trial networks should be developed to
accelerate completion of stroke recovery clinical trials using cardiac
disease or cancer
cooperative groups as examples.
Into the 21st Century: The Web, Technology and Communications, New Tools for Progress
Introduction
Major reductions in the burden of
stroke can be achieved by providing better public education. In many
parts of the world,
access to reliable medical information and
even electricity is limited. The electronic means to disseminate health
information
(eg, healthier lifestyle, risk factors,
stroke symptoms, and emergency response) are available in industrialized
countries,
but less so in developing countries. There is
a wide disparity in global internet penetration46 according to geographic (Figure)
and demographic characteristics with older individuals less likely to
access electronic information. Adoption of universal
technology standards and worldwide
unrestricted access to data will in part define how these disparities
can be addressed.
In the developed world, with the advent of
high-bandwidth wireless delivery systems, there will be few regions
without Internet
access provided that sufficient resources are
invested. In those parts of the world where connectivity is more
limited, different
strategies for knowledge dissemination and
behavior change will need to be adapted to the available communication
means (eg,
mobile phones, print, radio, television, word
of mouth).
Step 1: Worldwide Unrestricted Access to Information
Education for the Public and Professionals
To reduce stroke risk,
electronic media-enabled tools can be used for self-assessment and
motivation for self-management.
These information portals can provide
self-administered programs and/or interactions with professionals.
Support Groups
Lay organizations (eg, church,
community groups) are an underused resource that can provide insights
into the types of support
and problem-solving that are most needed
by stroke survivors, including advice on financial resources, legal
matters, and
social benefits. Resources should be
devoted to supporting these peer-to-peer networks with interfaces to
reliable sources
of health information.
Recommendations
The Public
To be free of bias, health
information should be reviewed or provided by experts in stroke in
collaboration with experts in
public education without conflict of
interest (eg, government and nongovernment stroke-oriented health
organizations) and
delivered in a persuasive and
understandable format consistent with principles of marketing and
behavioral sciences as appropriate
for the region.
Professionals
Special task forces of these
same organizations should prepare evidence-based online education for
general practitioners,
specialists, nurses, therapists, and
other healthcare workers in multiple languages tailored to professional
groups working
in diverse surroundings. These
electronic information clearinghouses should be accessible to health
professionals worldwide
and include interactive educational
methods whenever possible. These materials should be adaptable to
environments where access
to electricity and electronic
communications is limited. This material should also be available as a
degree-based distance
learning program for healthcare workers
worldwide.
Citizens Against Stroke
Communication resources and
social networking tools should be tailored to support local stroke
initiatives consisting of professionals,
decision-makers, politicians,
administrators, representatives of local industry and businesses
together with lay people. All
initiatives should be tailored to raise
public awareness of stroke and to spread information on its prevention
and management.
Step 2: Better Access to Organized Care for All Patients With Stroke
Diagnostics, Acute Care, and Rehabilitation
Evidence exists that advanced telemedicine communication technology for stroke (“telestroke”) is beneficial where immediate
access to stroke expertise is not available.47–50 Telemedicine may help to provide stroke prevention, acute care, and rehabilitation services in remote regions51
and smaller urban hospitals without stroke expertise and to extend
clinical research into a broader global community. In
addition, more innovative rehabilitation
therapies, which can be administered in areas and countries with limited
resources,
must be implemented to reduce inequalities
of access to rehabilitation. Close collaboration of healthcare
administrators,
physicians, allied healthcare providers,
basic scientists, and engineers is needed to develop and implement new
rehabilitation
paradigms.
Connecting Professionals and Patients
Electronic communications
between patients and professionals have an enormous potential to enhance
self-management of risk
factors and promote healthier lifestyles
(eg, obtaining advice on medication use and adherence, prevention,
follow-up laboratory
test results, and medical problems through
a virtual healthcare visit or an e-consultation (www.mayoclinic.org).
Data management
systems need to be developed to maximize
the potential benefits of this emerging area and create manageable tools
and actionable
tasks for healthcare workers.
Recommendations
Leaders and key stakeholders
(including patients) will need to embrace these new models of
telemedicine and virtual patient–provider
interactions that will permit access
especially for patients who are disabled or live in geographically
remote regions. A
first step is to reduce barriers to
telemedicine-enabled practice to encourage broader access to
high-quality stroke care
and rapid treatment for acute stroke
therapies. Development of novel technology-assisted rehabilitation
methods should be
encouraged.
Step 3: Build Centralized Electronic Archives and Registries
Electronic health records are
critical for quick and reliable access to patient information, for
effective communication of
care plans between different providers and
settings, and for reducing medical errors. Furthermore, providing
citizens with
the option of having access to their own
personal health records may enhance their adherence to treatment
recommendations.
Electronic registries can help
evaluate documentation of treatment practices, treatment efficacy and
comparative effectiveness,
and improve clinical management of patients
with stroke. Registries such as Safe Implementation of Thrombolysis in
Stroke
[SITS]; www.acutestroke.org/) and those of
Austria, Finland, Scotland, Sweden, the United Kingdom, and Japan and
national
quality improvement programs in the United
States (www.strokeassociation.org/presenter.jhtml?identifier=3002728)
have improved
stroke care by providing feedback,
benchmarks, and sharing of best practices. Electronic resources should
be developed to
support the capture and analysis of
patient-reported outcomes for clinical care and research.
Recommendations
All nations should pursue to
develop national, interoperable electronic health record systems with
the goal of supporting
continuity of care through delivery of
comprehensive medical information on demand at the point of care for all
their citizens.
Common data elements pertinent to
stroke-relevant risk factors, treatments, and functional outcomes should
be included in
the electronic health record systems.
Ideally, nations should collaborate to develop international standards
for data format
and description to support international
integration.
Registries and Evaluation of Efficacy
All nations should participate
in national or international stroke quality improvement programs or
registries or develop their
own programs if current models are not
suitable for their population or environment to provide the highest
quality stroke
care.
Fostering Cooperation Among Stakeholders to Enhance Stroke Care
Introduction
Interactions among major
stakeholders in the stroke field such as large stroke organizations,
government agencies, nongovernmental
organizations, industry, and patient
organizations can be mutually beneficial. Integrated activities among
these groups can
enhance patient care, the development and
implementation of new therapies, and the dissemination of new and
existing information.
The following sections describe the
activities/contributions of these 5 sectors and also provide 3 concrete
suggestions of
how to enhance mutually beneficial activities
over the next several years.
Large Stroke Organizations and Nongovernmental Organizations
Stroke is a prototype disease
for coordinated actions vertically (with other medical disciplines) as
well as horizontally
by interactions among stakeholder
organizations, government, and industry. Large stroke organizations such
as the WSO serve
as a key component in these networks,
providing important leadership roles in coordinating activities and in
establishing
stroke firmly on the global health agenda.
Improved stroke management is crucially dependent on an effective
organization
in all aspects of care. The large stroke
organizations should establish clear policies and provide
recommendations through
guidelines and other documents. The large
stroke organizations also organize large scientific conferences
providing a platform
for scientific advances and interactions.
Tackling the global burden of stroke constitutes a major health
challenge.
The AHA formation of the
American Stroke Association (ASA) 10 years ago and its evolution to date
is an excellent example
of how an NGO, in this case a voluntary
health organization, can influence scientific discovery and the
translation of science
into guidelines and how it can then
implement programs to support guideline adherence, to improve outcomes,
to provide extensive
provider and patient resources, and to
advocate for system change. AHA/ASA’s expertise as a convener of experts
to develop
consensus statements and guidelines, as a
generator of patient and public education, and its field structure of
staff and
volunteers who implement its programs all
contribute to its success.
Going forward organizations
such as AHA/ASA and WSO will need to collaborate extensively with other
large stroke organizations
and nongovernmental organizations,
government agencies, industry, and academia to further advancements in
patient care and
development of new therapies and
approaches.
Government
The National Institute of
Neurological Disorders and Stroke (NINDS) is committed to the
development of better therapies to
prevent stroke and to improve the outcome
for patients with stroke. The NINDS Stroke Program Review Group52
outlined the priority areas for research and NINDS looks forward to an
exciting new era in stroke research. NINDS has a number
of ongoing clinical trials that are
evaluating novel prevention approaches, acute interventions, and
recovery-enhancing strategies.
In addition to drugs and devices, the
science of behavioral change needs to target the promotion of healthy
behaviors decades
before the age-dependent risk of stroke
starts its exponential ascent. The NINDS translational program works
with and funds
investigators and their industry partners
to bring promising stroke therapies through preclinical development. The
NINDS,
however, faces a plethora of hurdles.
Unfortunately, a number of important and expensive clinical stroke
trials cannot be
completed due to poor enrollment. A
greater emphasis on Phase II studies should be considered to ensure that
experimental
therapies tested in rigorously conducted
animal studies actually engage the intended biological target in
patients.
Patient Organizations
Patient organizations range
from small, informal, local support groups to large corporations with
significant influence. Interactions
between patient organizations and other
organizations flow both ways. The purposes of these interactions are
many and therefore
this topic is quite complex. The triggers
for interactions are generally of 3 types: (1) issues of clinical
service and patient
safety; (2) driving innovation and
science; and (3) influencing business and healthcare economics. Patient
organizations can
be conduits for patients to influence
healthcare organizations, government, industry, and academia. Processes
may be ad hoc
or organized. Actions may be taken
proactively or reactively. Patient organizations can be vehicles for
patients to be influenced
by healthcare organizations, government,
industry, and academia. Again, processes may be ad hoc or organized, and
actions
may be taken proactively or reactively.
Industry
Industry plays a vital role in
the development and implementation of novel therapies directed at
improving the prevention
and treatment of stroke. Most new drug or
device therapies are discovered by relevant companies or in-licensed
from other
sources. The company then performs the
necessary preclinical steps to allow for the performance of clinical
trials. Clinical
trials performed by the company that
demonstrate safety and efficacy of the new therapeutic agent can lead to
regulatory approval,
presuming an adequate data package.
Industry thus provides a key link for stroke patient care, new and
presumably improved
therapeutic agents. Additionally, industry
is an important source for the dissemination of new information about
stroke to
both physicians and the lay public. This
task is performed by sponsorship of conferences, education seminars, and
small group
meetings for both professional and lay
audiences. The content of these educational endeavors should be free of
bias, providing
balanced and educationally sound
information for the intended audience.
Recommendations
Three specific recommendations
to enhance cooperation among large stroke organizations, nongovernmental
organizations, government,
patient organizations, and industry are:
(1) provide an appropriate mechanism for the various stakeholders to
communicate
with each other about their needs and
goals; (2) enhance clinical research by having these entities provide
input about unmet
needs and how to develop and disseminate
new therapies; and (3) enhance patient and physician education by
jointly developing
and implementing educational initiatives.
A method to achieve these
recommendations and those of all aspects of this document is to
establish a consensus working group
of these stakeholders under the aegis of
organizations such as the WSO/WFN to discuss develop and propose an
overall agenda
for stroke worldwide.
Educating and Energizing Professionals, Patients, the Public and Policymakers
Part 1: Educating and Energizing Professionals and Patients
Introduction
Detailed clinical stroke knowledge
is increasingly important in Europe, North America, and other developed
regions and subspecialty
training focused on stroke prevention, acute
care, and rehabilitation has been formalized.32,53 Stroke units have become common in developed countries. In poorer countries, especially in those classified as “low income”
by the World Bank, specialized care hardly exists.54
A first step in improving stroke care globally is to improve the
stroke-related education of care providers in developing
countries. There are mechanisms in place for
distributing knowledge and education related to HIV/AIDS, malaria, and
other
infectious diseases. These same models could
be applied to stroke education.
Several organizations including
the ASA, the ESO, and the WSO have educational and professional training
web sites. For example,
the WSO site is the World Stroke Academy
(www.world-stroke-academy.org/). It is available globally and is free.
It is endorsed
and supported by other educational
initiatives including those from the ASA and the ESO. Other programs
such as those from
the AHA/ASA
(http://my.americanheart.org/professional/) and the ESO
(www.stroke-university.com/) provide professional educational
resources. Globally, there are insufficient
numbers of physicians trained in stroke. Neurovascular Education and
Training
in Stroke Management and Acute Reperfusion
Therapy (NET SMART) is a government-funded, evidence-based, online
educational
system (www.netsmart-stroke.com/) offering
programs to support the learning needs of advanced practice nurses
(nurse practitioners
and clinical nurse specialists).
Stroke-educated nurses, more numerous than physicians, are capable of
playing instrumental
roles within telestroke networks.55 In Europe, a downloadable eCME certificate can be obtained that is recognized by other programs such as the European Masters
in Stroke Medicine (www.donau-uni.ac.at/en/studium/strokemedicine/index.php).
The WSO’s “ABC of Stroke Management” program is directed to healthcare providers in developing countries. It is being used
in China, South Africa, and Vietnam and is an effective tool for postgraduate medical training.56,57 In Vietnam, 6000 medical doctors have finished WSO-sponsored stroke training. Approaches for rapid and accurate diagnosis
and the importance of prevention of complications are emphasized.58 Improving the availability of effective medications throughout the world is critical. The use of telemedicine to extend stroke
expertise to underserved areas may be possible.48
The wider use of early mobilization and task-dependent rehabilitation
to optimize long-term outcomes, including reintegration
of patients with stroke into the family,
workplace, and community, is an important goal. It is important to
develop a concept
of “brain health” that can be promoted for
primordial and secondary prevention.
Patient and bystander responses to stroke symptoms are often delayed.59
Patient-focused voluntary organizations have developed programs to
increase the stroke knowledge of the general public, patients
with stroke, and their families. The AHA/ASA
along with the American Academy of Neurology and the American College of
Emergency
Physicians (Give-Me-5), the ESO, and the
Stroke Alliance for Europe (SAFE) have developed informational brochures
and advertisements
for this purpose. It is important to further
disseminate these materials as teaching aids in schools and communities.
Recommendations
Step 1: Increase education
directed at professionals including healthcare providers on a global
scale by using on-site and
website stroke teaching programs that are
integrated into the medical education curricula. Recommendations should
be based
on a “brain health” concept that enables
promotion of preventive measures. The aim is to make professional
specialized care
available to patients with stroke
throughout the world within the next decade.
Step 2: Further develop
national health education programs offered for stroke survivors and
their families. These programs
should be offered in schools and
communities under the leadership of the scientific organizations such as
the WSO, the AHA/ASA,
the ESO, and other regional organizations.
The aim is to improve stroke prevention and the public’s recognition
and response
to stroke symptoms.
Part 2: Educating and Energizing the Public and Policymakers
Introduction
Worldwide efforts to increase
knowledge and concern about stroke, its prevention, treatment
opportunities, and outcomes have
also focused on politicians and key opinion
leaders. The role of governmental policy on stroke research and care is
increasingly
recognized.
In the United States, advocacy efforts have largely been directed at increasing or at least sustaining funding for research
supported by the NIH.60
Advocacy, in part, led to NIH Progress Review Groups aimed at
identifying targets and strategies for stroke-related research.
In addition, national advocacy efforts have
supported cardiovascular and stroke prevention activities of the CDC.
Specific
targets included support of Food and Drug
Administration oversight of tobacco products. Within states, advocacy
has been aimed
at improving the organization of the delivery
of stroke-related health care.31
Individual states have established stroke task forces or legislative
committees focused on stroke care issues such as assessments
by emergency responders, transport of
patients with stroke to the nearest appropriate hospital, identification
of primary
stroke centers and acute stroke
treatment-capable hospitals, and the use of telemedicine. Legislation to
prevent cigarette
smoking in indoor public spaces has been
enacted in several states.
Educating the public about stroke risk factors, prevention, and response has been challenging. Public knowledge about stroke
in the United States continues to be poor, particularly in minority communities.61,62
Recently, the ASA, American College of Emergency Physicians, and
American Academy of Neurology began a uniform education
campaign, “Give Me 5,” aimed at improving
recognition of stroke symptoms. The ASA Power to End Stroke program
focuses on blacks,
who have approximately twice the risk
compared with white Americans. “You’re the Cure” is the AHA/ASA
grassroots advocacy
network. Through “You’re the Cure,” thousands
of advocates can be mobilized to support specific pieces of legislation
or programs
affecting stroke through targeted e-mails,
phone calls, and letters to relevant policymakers. Although a great deal
has been
accomplished, much remains to be done.
The European Parliament founded the SAFE in 2004, which includes representatives from 17 countries.63
In Europe, policymakers have become engaged in the European Union by
activities from the European Brain Council, the ESO
jointly with the European Stroke Conference,
and the SAFE movement. Topics include the promotion of awareness of
stroke-related
health costs64 and the large discrepancies between eastern and western Europe, including the much higher prevalence of risk factors and
stroke in eastern Europe.
European specialist groups have
lobbied for increased funding from the European Science Foundation and
led to a European Stroke
Workshop in Brussels hosted by the European
Commission. The resulting European Stroke Network links stroke research
from bench
to bedside.65 New initiatives (“Strike Out Stroke” 2009) address the general public as well as members of the European Parliament focusing
on problems related to the use of anticoagulants for patients with stroke.
Recommendations
Step 3: Increase funding for
public education and research supported by regional and national
agencies. Continue support for
advocacy aimed at improving the
organization of the delivery of stroke-related health care based on
evidence-based recommendations
addressing gaps in the care delivery
system.
Step 4: Educate and inform the
general public about stroke risk factors, prevention, and response. Use
best practices such
as “Give Me 5,” aimed at improving
recognition of stroke symptoms, the ASA’s “You’re the Cure” advocacy
program and the “Strike
Out Stroke” campaign in Europe.
Summary
To accelerate progress in stroke, we need to reach beyond it scientifically, conceptually, and pragmatically.
Scientifically the solutions lie
beyond our limited models. All the major neurological brain diseases
share common mechanisms
such as inflammation, apoptosis,
mitochondrial damage, oxidative stress, excitotoxicity, and
neurotransmitter failure.66
By and large these mechanisms are studied in relation to individual
diseases, not from a biological, evolutionary, or integrated
viewpoint. A close study of the development
of the nervous system may hold many clues as to how the brain repairs
itself.
Moreover, development and aging may to some
extent be mirror images of each other. Stroke in the neonatal brain,67 children, and women68,69 has special features that need to be understood and addressed.
Our focus has been on lesions in
the brain. Aging and the complex interaction of genetics, epigenetics,
and environment and
the occurrence of concomitant pathology
render individuals’ brains unique. For example, cerebral infarcts shrink
and the inflammation
subsides with time. The opposite occurs
experimentally in the presence of amyloid.70
Given that several common neurological conditions share the same
mechanisms, a systematic approach may produce therapeutic
targets that would be of benefit to more than
one disease. It matters not only what lesion, but whose brain.
Conceptually we need to think not
only of dramatic strokes of sudden onset, sometimes heralded by sudden
losses of speech,
sight, movement, or feeling, but of
subclinical strokes, the most prevalent type of cerebrovascular disease
identifiable by
subtle cognitive dysfunction, usually a
change in executive function.12 Moreover, in the elderly brain, amyloid deposition and Alzheimer lesions may coexist and at times interact with the vascular
lesions.
Pragmatically we need to realize
that if we are to become more effective in the diagnosis, treatment,
rehabilitation, and
prevention of stroke, we have to reach beyond
our hospitals and clinics into the community, other disciplines, and
the public
and a larger part of the world.
We need to survey, systematize,
and synergize what we do. We need to survey broadly, systematically, and
specifically what
we know of basic brain mechanisms of disease.
We need to become aware of other models such as infectious diseases,
which often
has an integrated, epidemiological, clinical,
and basic science approach.
In terms of acute care and
rehabilitation, an organized approach seems to have been the key to the
many advances. Although
countries like Spain have a national stroke
strategy and effective regional programs such as those of Catalonia71 and Madrid,72
the majority of countries do not. Stroke unit care should be considered
a treatment/intervention in itself similar to any
pharmacological treatment or a surgical
procedure. There may well be other models such as trauma that may
provide useful parallels
and lessons.
Systematization and evaluation has
been a key in many of the advances that have occurred in stroke in the
past 4 decades.
A prototype has been the randomized clinical
trial, in which a hypothesis is tested according to prospectively agreed
protocols,
the collection of the data monitored, and the
results evaluated. Randomized clinical trials are but 1 example of the
more
generic principles.
We need to reach beyond North
America, western Europe, and Japan, where most clinical trials have been
performed. Other parts
of the world are creating infrastructures
that make them capable of participating in clinical trials and other
studies that
can accelerate finding the answers to many
common problems. The Extracranial–Intracranial (EC/IC) Bypass Study73
was an early example of how an international randomized clinical trial
could reach an answer much more quickly than if it
had been done in 1 country alone. More
recently we saw the example of the first proof of tissue plasminogen
activator effectiveness
in stroke being demonstrated in an American
study,4 whereas the extension of the time window was recently shown by a European study.74
We need to become imaginative in
designing multiple types of clinical trials, from active registries to
simple and more complex
randomized clinical trials. The idea would be
that everything that is done in relation to stroke becomes part of some
evaluation.
An important aspect of any evaluation is
standardization with a need to make minimum common definitions of
important items
in a protocol so that databases can be made
compatible and larger volumes of information can become available for
analysis,
model-building, and testing.
At the moment, we have a glut of guidelines but not enough guidance or guides.75 Most guidelines are developed on the basis of the level of evidence, but little attention is devoted to the relative impact
of specific items. Not all are of equal value.76 We need to evaluate and rank the relative value of each activity in terms of return per unit investment of time, resources,
or both.77 The comparative effectiveness research thus generated would improve clinical decision-making and lead to better allocation
of scarce medical resources.
Stroke is no longer a disease of affluence. Approximately 87% of the 5.7 million deaths annually attributable to stroke occur
in low-income and middle-income countries.78 The risk factors like hypertension, diabetes, and obesity are assuming epidemic proportions. Some 285 million people worldwide
will live with diabetes in 2010, 70% of whom will live in developing countries.79 Moreover, by 2050, the population aged ≥60 years is expected almost to triple, increasing to 1.6 billion in the developing
countries.80
The Institute of Medicine’s recent report recommends building evidence-based, locally relevant solutions by improving global
collaboration among stakeholders to promote cardiovascular health in the developing world.81 Aligning chronic disease priorities with other health and development priorities has the potential to synergistically improve
economic and health status.
There is much value in doing the simple things right in terms of prevention. “Death in old age is inevitable, but most deaths
before old age are avoidable.”82
Hypertension is the single most powerful and prevalent risk factor for
ischemic and hemorrhagic stroke and vascular cognitive
impairment and yet too often it remains
unrecognized or untreated. Blood pressure control has the greatest
potential for stroke
prevention.
The concept of “vascular health”
or “brain health” needs to be promoted. Because atherosclerosis starts
early in life, the
preventive efforts should target children,
youth, and mothers. Everyone needs to be involved at all stages of
prevention with
an emphasis on healthy living and creating an
environment that nurtures it.
Finally, we need to synergize with
vertical integration of basic sciences, clinical sciences, and
population approaches. The
digital age provides wonderful opportunities
for integrating and evaluating all aspects of our activities.
Next Steps
The immediate need is to pursue specific recommendations:
-
A systematic review of all that is known of basic brain mechanisms of injury and repair along the life cycle. This can be accomplished at several levels: (a) review of the existing literature; (b) making it a topic of ongoing scientific conferences such as the Princeton Conference or as a priority setting exercise of funding agencies52; and (c) organize a highly interactive synergium with participation of scientists, clinicians, pharmaceutical companies, and health regulators. The synergium should be broad enough that each mechanism can be examined in light of several diseases.
-
To organize a working group that will recommend a minimum set of data points to be collected on all patients with stroke or those with potential stroke. This already has been done for capturing vascular cognitive impairment from the epidemiological, clinical, neuropsychological, imaging, and experimental viewpoint.83 It may be that it simply needs modification or adaptation.
-
Another working group could evaluate the relative advantages and disadvantages of different clinical trials, including novel approaches to use registries to evaluate different diagnoses and treatments.
-
The WSO already has a working group on guidelines that could be enlarged and asked to prioritize them with a simple method of evaluating their impact.
-
A working group on surveying and evaluating stroke education with methods of integrating and credentialing those who engage in stroke work.
-
Develop nodular models of comprehensive stroke care, rehabilitation, and prevention on the principle that some components are essential but that they need to be adapted in the community where they are to be implemented. Professional education including a more comprehensive education on stroke and stroke recovery for medical school curricula as well as residency and fellowship training. The latter may be best done at Centers of Stroke Emphasis or Stroke Recovery Research Centers.
-
Support the efforts of Raad Shakir, Secretary General of the World Federation of Neurology and Chair of the Expert Committee advising on Diseases of the Nervous System for the International Classification of Diseases84 (ICD-11), and Bo Norrving, President of the WSO, to reclassify stroke from a cardiovascular to a disease of the nervous system and vascular dementia from mental diseases to brain diseases.
-
Precompetitive stroke recovery initiative: We should consider precompetitive consortia for stroke recovery that is similar to that currently in operation for Alzheimer disease—the Alzheimer’s Disease Neuroimaging Initiative (ADNI).85 Perhaps collectively (academia, industry, and government), we could create a “SRNI” (stroke recovery neuroimaging initiative), a precompetitive consortia to enroll and carefully study patients for the natural history of stroke recovery: imaging, scales, and biological samples. The groups involved would agree to what end points should be studied. This would help not only in understanding the pathophysiology of stroke, but also in the design of clinical trials to ensure that the proper end points are used and that they are powered appropriately.
-
Educate and energize professionals, patients, the public, and policymakers by using a “brain health” concept that enables promotion of preventive measures.
-
Organize a working group that will oversee these and other initiatives that may arise from the recommendations of the synergium.
Conclusion
We have come a long way, but we have
even further to go. The progressive transformation of our field in the
past 40 years,
the accelerated pace of science, and the growing
need for our contributions will assure that the next 4 decades will
prove
even more fruitful than the last.
Appendix
In this section, a few successful scenarios from different parts of the world and different medical systems are described to illustrate what can be done to make acute stroke treatment more widely available depending on the local conditions.-
I. The statewide program of stroke unit care and implementation of thrombolysis in the German State of Baden–Württemberg, in which the Ministry of Health, together with stroke physicians, has embarked on a statewide program to improve stroke management, is described.
-
II. The strategies for improvement of prehospital management of patients with stroke in the United States is described, a process which was primarily triggered by stroke physicians.
-
III. The government-led nationwide system of medical emergencies, including stroke, which has been started in Brazil is reviewed.
-
IV. The example of South Africa is presented, which shows how stroke medicine can be brought into rural areas with the help of metropolitan stroke centers, which themselves are not similar to centers found in western Europe or North America.
-
V. The current attempts being undertaken in the United Kingdom in organizing stroke center care in the metropolitan areas are also reviewed.
-
VI. The current efforts being undertaken in the Russian Federation to improve stroke care are also described.
Abstract
Background and Purpose— The aim of the Synergium was to devise and prioritize new ways of accelerating progress in reducing the risks, effects, and consequences of stroke.Methods— Preliminary work was performed by 7 working groups of stroke leaders followed by a synergium (a forum for working synergistically together) with approximately 100 additional participants. The resulting draft document had further input from contributors outside the synergium.Results— Recommendations of the Synergium are:Basic Science, Drug Development and Technology: There is a need to develop: (1) New systems of working together to break down the prevalent “silo” mentality; (2) New models of vertically integrated basic, clinical, and epidemiological disciplines; and (3) Efficient methods of identifying other relevant areas of science.Stroke Prevention: (1) Establish a global chronic disease prevention initiative with stroke as a major focus. (2) Recognize not only abrupt clinical stroke, but subtle subclinical stroke, the commonest type of cerebrovascular disease, leading to impairments of executive function. (3) Develop, implement and evaluate a population approach for stroke prevention. (4) Develop public health communication strategies using traditional and novel (eg, social media/marketing) techniques.Acute Stroke Management: Continue the establishment of stroke centers, stroke units, regional systems of emergency stroke care and telestroke networks.Brain Recovery and Rehabilitation: (1) Translate best neuroscience, including animal and human studies, into poststroke recovery research and clinical care. (2) Standardize poststroke rehabilitation based on best evidence. (3) Develop consensus on, then implementation of, standardized clinical and surrogate assessments. (4) Carry out rigorous clinical research to advance stroke recovery.Into the 21st Century: Web, Technology and Communications: (1) Work toward global unrestricted access to stroke-related information. (2) Build centralized electronic archives and registries.Foster Cooperation Among Stakeholders (large stroke organizations, nongovernmental organizations, governments, patient organizations and industry) to enhance stroke care.Educate and energize professionals, patients, the public and policy makers by using a “Brain Health” concept that enables promotion of preventive measures.Conclusions— To accelerate progress in stroke, we must reach beyond the current status scientifically, conceptually, and pragmatically. Advances can be made not only by doing, but ceasing to do. Significant savings in time, money, and effort could result from discontinuing practices driven by unsubstantiated opinion, unproven approaches, and financial gain. Systematic integration of knowledge into programs coupled with careful evaluation can speed the pace of progress.Key Words: - prevention
- rehabilitation
- stroke
- translational
- treatment
Birthdays invite reflection and planning. The journal Stroke
has turned 40, providing not only an occasion to celebrate the past,
but also an opportunity to help shape the future. Most
of the leaders in stroke have been involved with
the journal as authors, reviewers, or editors, providing an umbrella for
collaboration. The participants of this synergium
are leaders in the field and although the event was supported by major
stroke
organizations worldwide, it was a gathering of
individuals interested in finding common solutions.
A result has been a Synergium,
a word coined by the first author to describe a forum for working
synergistically together. Seven working groups each suggested
3 main recommendations for progress that were
refined during a 1-day face-to-face meeting. In addition, approximately
100
other participants and contributors from outside
the synergium provided input to the final document.
The Past 40 Years
More progress has been made in stroke over the past 4 decades than in the previous 4 millennia. In 1970, a landmark paper
showed that hypertension was a strong risk factor for all types of stroke.1
Thereafter, other major risk factors for stroke were identified.
Subsequent studies showed that many risk factors can be
reduced and that their control decreases the
incidence of stroke. The late 1970s saw the first proof that aspirin
prevents
stroke.2 This was followed by the introduction of other efficacious antiplatelet agents. The first modern comprehensive stroke unit
was inaugurated in 1975,3 and tissue plasminogen activator’s effectiveness in acute stroke was demonstrated in 1995.4
Carotid endarterectomy was shown to prevent stroke in selected patients
and angioplasty and stenting are currently being
tested for similar purposes. Coiling offers an
alternative to brain aneurysm and arteriovenous malformation surgery.
Brain
imaging has revolutionalized the diagnosis of
stroke and the management of patients with stroke. Steady progress
enhances
our understanding of the mechanisms of brain
injury, repair, plasticity, and recovery. Each of the previous
Editors-in-Chief
of Stroke (Clark Millikan, Fletcher McDowell, Henry Barnett, Oscar Reinmuth, and Mark Dyken) summarized the main developments and issues
in the field during their tenures, covering the years 1970 to 2000.5–9 The developments in subsequent years have been documented in the annual “Advances” feature of Stroke.
Paradoxes of Progress
Progress breeds paradoxes. Stroke is
preventable yet is increasing globally. The same few major risk factors
account for much
of the leading health problems of the world but
remain uncontrolled in the majority of affected individuals. Management
of
risk factors is the most readily applicable and
affordable part of our knowledge, but prevention is neglected, and most
environments
are inhospitable to healthy living.
Although many advances in the
understanding of excitotoxicity, neurotransmitter depletion, oxidative
stress, mitochondrial
failure, inflammation, and apoptosis have
occurred, this has been accomplished in relative isolation from the
knowledge gained
on the same mechanisms that underlie other major
afflictions of the brain such as Alzheimer disease, Parkinson disease,
epilepsy,
multiple sclerosis, and brain trauma.
Although the symptoms of stroke are
well described, the majority at risk do not recognize their
significance. In 1 study,
only 1 in 6 individuals were aware that a
treatment for stroke exists and that at the time of the study, it had to
be given
no more than 3 hours after symptom onset.10
In stroke, we know that time is brain, but too few brains arrive in
time. Although we have learned to treat transient ischemic
attack as an emergency, only approximately 1 in 8
of patients with first-time stroke have a prior transient ischemic
attack.11
We must find other ways of identifying those at high risk for stroke.
Subclinical (“silent”) strokes are the most common
type of stroke, executive function impairment
being its earliest manifestation, but this fact is barely recognized and
cognition
seldom measured.12
Stroke unit care improves outcomes of
patients of all ages, stroke types, and severities but remains the
exception rather
than the rule in stroke care. The understanding
of the neurobiology of brain injury, repair, and plasticity has
advanced,
but no histoprotective or reparative drug has
yet proved efficacious.
Stroke rehabilitation works but is
largely unavailable for the time and intensity required. Effective drugs
are not accessible
or affordable in many developing countries nor
used optimally in developed ones. Unproven, costly, or misdirected
practices
continue to drain resources and prevent the
pursuit of more cost-effective approaches.
Although the challenges are daunting,
the achievements of the past 4 decades are inspiring, having witnessed
the transformation
of stroke from an area notable for diagnostic
precision and therapeutic impotence to a field ripe for further advances
in
prevention, acute treatment, and rehabilitation.
Groups’ Recommendations
Basic Science, Drug Development, and Technology
Step 1: Address Unmet Needs
In all aspects of basic science, drug development, and technology, there is clearly a need to “do things differently” if there
is to be a major advance in the development of new interventions.13,14 Over the last few years, there has been a dearth of advances that have limited genuine leaps in the understanding of the
basic science and pathogenesis of stroke, and hence new targets for therapy.15,16 To counter this, a radical approach is suggested in the following areas.
Recommendations
-
Establish a New Taxonomy of Disease. This could be based on the genetics or another taxonomy that makes scientists and clinical investigators think about the disease process in a completely different way. The natural consequence of this would be the development of personalized medicine.17 A simple example might be the genetic basis of vascular collateralization.
-
Learn From Other Scientific Disciplines and Diseases. It is time to step into other domains so that knowledge in other areas may be readily applied to the problem of stroke. In other words, we need to scan the scientific landscape to embrace new ideas and approaches.
-
Challenge Existing Models of Disease and Embrace Even More Basic Models to Have a More “Blue Sky Approach” to Science. Studies in Drosophila, worms, and zebra fish, among others, might generate novel new ideas about the stroke process.18–20 Yet, at the same time, pursue more clinical models with human cells, tissue, and samples. For example, sampling in patients undergoing carotid endarterectomy or in patients subjected to transient cerebral ischemia during neurosurgical procedures.
Step 2: Implement 3 Approaches That Will Accelerate the Capacity to Address Unmet Needs
There are processes that could be put in place, which may result in needs being met earlier rather than later.
Recommendations
-
Develop new systems of collaboration to break down the silo mentality currently rife in the stroke community. This could involve the gathering together of basic and clinical scientists from a variety of disciplines and putting them to work to solve major stroke problems. Alternatively, it could involve adding 1 or 2 “odd ball” players to existing teams to encourage them to think outside the box. For example, drosophila models have been used for Parkinson disease. Hypoxia-inducible factor-1a responses are conserved from flies to mammals. Can we build on these fundamentals for stroke? In horseshoe crabs (living fossils), coagulation and immune systems are merged. Can we leverage this type of evolutionary biology to dissect and target the links between inflammation and thrombosis in stroke? Evolutionary biology also indicates that neurogenesis and angiogenesis share common genes and pathways. Can we use these principles to develop new methods for stroke repair?
-
Be alert to new models of disease that may vertically integrate basic, clinical, and epidemiological disciplines. For example, could advances in the understanding of infectious diseases or inflammation dramatically change our thinking about stroke pathogenesis?
-
Develop efficient methods of scanning other areas of science to enhance the likelihood of generating new ideas/concepts as well as information likely to be of use in developing new targets, new technologies, and better translational processes.
How, When, and By Whom Should These Goals Be Achieved?
How
In establishing the new systems
described earlier, investigators will need to work in different ways.
For example, sabbaticals
and exchange programs and publication in
completely novel areas could improve the cross-fertilization process.
Mechanisms
should be established that will encourage
investigators by measuring the impact and novelty of their work rather
than the
current trend based on a researcher’s
number of publications and citations. A broad platform of stroke
education should provide
the underpinnings for this change (see
“Education” section) with a focus on national research institutions and,
perhaps, the
establishment of similar global
institutions to cross country/cultural boundaries.
By Whom
Scientific leaders around the
world (organizations, institutes, and others) need to bring together
these new and novel teams.
Industry (eg, pharmaceuticals,
biotechnology) should also be involved with a clear interface with the
academic, regulatory,
and government world. Government funding
agencies should stimulate this new collaborative paradigm by providing
funding for
think tanks, which could be local,
national and, even more importantly, global.
Stroke Prevention: Broadening the Approach and Intensifying the Efforts
Introduction
Major chronic diseases such as
stroke, heart disease, cancer, Alzheimer disease and vascular cognitive
impairment may be linked
by common risk factors and pathophysiological
mechanisms. Few simple steps like eating a balanced diet, exercising,
maintaining
optimal body weight, avoiding smoking, and
limiting alcohol consumption can reduce risk of stroke by up to 80%.21,22
The occurrence of shared risk factors and possible common
pathophysiological mechanisms (eg, inflammation, endothelial
dysfunction)23 provide a backdrop for the establishment of chronic disease prevention or health preservation networks.
We propose 3 steps to influence
future stroke prevention. The approach includes novel means to enhance
stroke prevention and
integrate strategies from within and outside
the medical field with an emphasis on synergistic opportunities and
collaborations.
Step 1: Establish a Global Chronic Disease Prevention Initiative That Includes Stroke as a Major Focus Among a Cluster of Conditions
The Chronic Disease Action Group
has provided a call to action to encourage, support, and monitor
activity on the implementation
of evidence-based efforts to achieve global,
regional, and national programs to prevent and control chronic diseases.24
This group emphasizes the control of 3 key modifiable lifestyle risks:
unhealthy diet, physical inactivity, and tobacco habit.
Multisectorial policies as well as long-term,
sustainable action plans are encouraged to empower individuals,
families, and
communities to affect health-conscious
behavioral change. The creation of the Global Noncommunicable Disease
Network (NCDnet)25
also focuses to reduce risk, morbidity, and mortality related to 4 risk
factors (tobacco use, physical inactivity, unhealthy
diets, and the harmful use of alcohol). It is
a global collaborative effort between the World Health Organization
(WHO), member
states, international partners, and other
stakeholders for the prevention and control of noncommunicable diseases.
Recommendations
-
Develop a leadership group that will work with existing organizations to set and advocate a chronic disease prevention agenda with stroke as a major focus and the establishment of formal strategies to reduce unhealthy lifestyle and other risk factors.
-
Establish collaborations between and representation of major health organizations and/or advocacy groups (eg, WHO, World Federation of Neurology [WFN], World Stroke Organization [WSO], World Heart Federation, National Institutes of Health [NIH], and Fogarty International Center, Centers for Disease Control and Prevention [CDC], American Heart Association [AHA], European Stroke Organization [ESO], Chronic Disease Action Group, health maintenance organizations, etc).
-
Incorporate mechanisms for cost-effective research monitoring into the overall strategy.
-
Government and industry should be represented in these collaborations.
Step 2: Use and Promote the Population Approach for Stroke Prevention
Recommendations
Newer approaches in the United States and some other regions may include:-
Generate a paradigm shift among medical insurance providers, government, and health professionals toward a major emphasis on adequate and effective preventive health care and education programs.
-
Establish collaborations among the global chronic disease prevention group, local stroke health advocacy organizations, and governmental chronic disease prevention offices.
-
Use community health workers to provide a means to assist in providing access to health care, adherence to treatment regimens, and overall adoption of ideal cardiovascular health at the community level.
-
Develop positive incentives for: (a) physicians who successfully achieve lifestyle risk control in their patients (eg, pay-for-performance); and (b) patients/workers who adhere to healthy lifestyle behaviors.
-
Incorporate a broader use of global vascular risk screening tools.
-
Secure funding for additional research to determine the benefits of healthy lifestyle behavior and the most effective ways to modify behavior.
-
Study, for future application, other strategies such as legislation for and education of the community about lowering salt in the diet and polypill strategies26 in conjunction with healthy lifestyle behavior.
Step 3: Develop Public Health Communication Strategies Using Traditional and Novel (Social Media/Marketing) Techniques
The basic components of establishing a public health communication strategy include27:
(a) identification of the health problem and target audience; (b)
determine if the communication should be part of the intervention
and, if so, strategies to best reach the
audience; (c) development and testing of communication concepts,
messages, and materials,
including culturally appropriate messages for
selected populations; (d) implementation of a health communication
program based
on the pretest results; and (e) assessment of
the effectiveness of the messages and modification of the program
accordingly.
Traditional public health communication
channels have included public service announcements, commercials, and
newspapers,
each carrying advantages and disadvantages.
Recommendations
-
An evidence-based communication approach is required and partnership with an organization with substantial experience in public health communication (eg, WHO, WSO, AHA) is desirable.
-
Consider establishing a centralized web site for chronic disease prevention inclusive of stroke prevention and social media/marketing, including but not limited to Twitter, Facebook, MySpace, LinkedIn, YouTube, and blogs. Because of the high penetration use rates of the Internet and cell phones, these communication vehicles should be considered for communicating messages and researched for cost-effectiveness.
-
Overall, the concept of development of a central “power grid” for chronic disease prevention messaging could be accomplished. Local experts should be consulted to help develop and tailor individual, smart communication systems by area.
Acute Stroke Management: Applying and Expanding What We Know
Introduction
The establishment of stroke units
and stroke centers has been the most significant contribution to the
field of acute stroke
management. Stroke units are an effective
intervention for the vast majority of stroke victims. Stroke centers
along with
prehospital system organization, access to
rehabilitation, and secondary prevention improve the quality of stroke
care.
Enormous lobbying to reach
policymakers has been pivotal to all advances in the development of
stroke care systems to date.
Once “stroke” has reached political
awareness, smooth implementation of care systems follows. The activities
may be at the
state or provincial level or even at the
national level of countries such as Russia, Brazil, Spain, or the United
Kingdom.
The political will to improve stroke care
will allow new activities in the field of stroke to be launched. Nation-
or statewide
documentation, standards, and quality control
instruments can be implemented and more financial resources made
available for
the development of stroke management and
prevention initiatives.
The role of physicians in initiating and guiding such developments is paramount.
The role of physicians in initiating and guiding such developments is paramount.
(BULL, name those doctors then) The achievements
in the prehospital system
in the United States and in the statewide
stroke unit programs in Germany, Brazil, Spain, and Russia were only
possible with
the enormous input of stroke physicians.
Large-scale application of the Scandinavian stroke unit model has
increased access
to thrombolytic therapy and reduced the case
fatality rate leading to remarkable improvement in the quality of stroke
care.28 This should continue to be a major source of strength and direction.
Stroke care is expensive. It has to
be supported in a zero-sum game of allocation in the setting of overall
shrinking budgets
of general health care, an action that will
be not be warmly welcomed by colleagues in other fields. A helpful and
key, evidence-supported
message is that improvements in stroke care
frequently brings net health expenditure savings to governments by
reducing rehabilitation,
nursing home, and lost productivity costs.
Although capitalizing on existing
therapies is well justified, flexibility has to be built into the system
to facilitate the
successful application of new diagnostic and
therapeutic approaches. It should be possible to introduce new tools and
technologies,
revise protocols, and modify the composition
of the stroke care team to fit the requirement of new developments in
the field.
By doing so, the stroke care system will
remain flexible and will be amenable to incorporate advances that will
continue to
improve the care of the patient with stroke.
Steps for Improving Stroke Care Worldwide
Step 1: Establishment of Stroke Centers and Stroke Units to Assist Patients With Acute Stroke as a Priority
Stroke center hospitals with
organized stroke unit care have made the most significant contribution
to current stroke management.
Efforts should be made to establish
hospitals with stroke unit care in locations accessible to all patients
with stroke to
reduce the global burden of stroke. These
specialized centers should be organized according to the local and
regional needs
and classified in different levels of
complexity according to the available resources and treatments.29–31
The lowest tier stroke service can be built with low-cost equipment
primarily focusing on well-trained interdisciplinary
teams. Stroke centers should implement
evidence-based treatment protocols, including thrombolytic therapy.32,33
Recommendations
-
Choose hospitals in each city or region to be established as stroke centers with organized emergency department and stroke unit care in accordance with local health authorities (eg, Scandinavian countries, Spain, Germany, United States, United Kingdom, Russia);
-
Classify stroke centers choosing the model that best fits the region, state, or country and create an official certification process (eg, United States, Germany, Austria, European certification efforts by ESO);
-
Provide training by specialized staff with standardized protocols;
-
Implement thrombolytic therapy for acute ischemic stroke;
-
Implement quality control instruments (database of all patients);
-
Alternatively, to solve the problem of overcrowded emergency rooms, the lack of beds in intensive care unit, and the lack of space to build acute stroke units, more general vascular units can be established that would include acute stroke management as has been done in Brazil. This is a specialized unit in the emergency room with a trained team to assist acute vascular disorders, including stroke, coronary syndromes, pulmonary embolism, and aortic diseases.
Step 2: Development of Regional Systems of Emergency Stroke Care
Activating the prehospital
emergency medical system and transportation to the designated stroke
centers leads to a shorter
delay in arrival at the hospital and
better initial management. The training of ambulance teams and
dispatchers in prehospital
recognition of stroke as an emergency34,35 and the recognition of stroke signs increases the number of patients arriving earlier at hospital (eg, Greater Los Angeles).36
Scientific statements recommend the development of regional systems of
stroke care in which ambulances bring patients with
acute stroke directly to stroke center
hospitals to rapidly provide approved stroke therapies, improving the
outcome of patients.37
Recommendations
-
Training prehospital emergency medical systems teams to recognize stroke and to bring patients with acute stroke directly to designated stroke centers;
-
Develop regional networks of stroke care between prehospital emergency medical systems and stroke centers; and
-
Whenever possible, use the same telephone number region wide to activate the prehospital emergency medical system (eg, the European 112 campaign, 911 in the United States).
Step 3: Improving Stroke Awareness
Lack of recognition of stroke
signs or lack of sense of urgency to seek help by the population is a
major barrier for adequate
stroke treatment. Stroke awareness
campaigns can increase symptom identification, thus resulting in a
decrease in the time
from symptom onset to hospital arrival and
increase in the number of patients who may receive appropriate
interventions.
Recommendations
-
Promote evidence-based media campaigns providing public information about acute stroke signs and the urgency to call prehospital emergency medical systems;
-
Because stroke often renders patients themselves unable to recognize or communicate their symptoms, public education campaigns should inform not only at-risk individuals, but also family, friends, and on-scene witnesses to call the prehospital emergency medical system if they observe an individual having signs of a possible stroke.
A few successful examples from
different parts of the world and different medical systems are described
in Appendix 1 to illustrate
how acute stroke treatment can be made
more widely available.
Brain Recovery and Rehabilitation: Harnessing the Regenerative Powers of the Brain and the Individual
Introduction
After the acute period, a stroke
will often affect a patient’s life for many years. During the early days
to weeks after a
stroke, spontaneous repair events usually
lead to some degree of behavioral recovery. The neurobiology of these
repair events
suggests several therapeutic targets to
promote further recovery. Traditional rehabilitation is one of the
therapeutic tools
to augment the poststroke recovery process. A
wide range of repair-based therapies is also in development.38
Rehabilitation and repair is a
relatively young and diverse field yet extends from the first days of
inpatient care to ensuing
care by rehabilitative specialists to years
of chronic care in a range of settings. Current research topics span
plasticity,
normal learning, pharmacology, genetics,
robotic engineering, occupational therapy, physical therapy, and speech
therapy and
growth in these areas will continue to
improve rehabilitation.39
Four steps for stroke
rehabilitation/recovery therapies are considered subsequently. The goal
of rehabilitation/recovery stroke
medicine is to have more patients achieving
better recovery in the weeks after a stroke and experiencing less
disability during
the years that follow.
Step 1: Translate Best Neuroscience, Including Animal and Human Studies, Into Poststroke Recovery Research and Patient Care
Key Issues
The neurobiology of spontaneous recovery and central nervous system repair40
suggests several potential therapeutic approaches that could improve
patient outcome, but more research is needed. Current
treatment options are limited. Although
traditional rehabilitation medicine helps patients, a better
understanding of its
scientific basis could further increase
its impact. Active research may also lead to design of new therapies
that ultimately
may win approval such as those using
pharmacological, cell-based, electromagnetic, robotic, or
neuroprosthetic approaches.
Recommendations
Increased basic and
translational research is needed. A deeper insight into the neurobiology
of poststroke recovery is required.
The means by which principles of normal
learning and development can be applied to stroke recovery need to be
better understood.41 Tools for measuring the biology of stroke recovery in humans are needed, from behavioral measures with defined psychometric
properties to biomarkers such as for recording physiology of repair-related events.42 Results of such research should be regularly compiled in both clinical and basic science State of the Art for Stroke Recovery Status Reports. This broad area of research may be best addressed by developing a group of Stroke Recovery Research Centers.
Translational studies are needed
to determine the effects that various rehabilitation/repair therapies
have on recovery both
as isolated therapies as well as in
various combinations. A number of combination approaches can be
envisioned, for example,
traditional rehabilitation paired with a
central nervous system stimulant, brain stimulation paired with a
robotic therapy
(with a single computer driving both), an
angiogenic growth factor followed by a synaptogenic growth factor, or
exercise therapy
paired with motor imagery therapy. In this
regard, traditional rehabilitation can be regarded as a key tool, in
the therapeutic
armamentarium for stroke recovery. Like
with any medical therapy, the optimal timing, intensity, duration, and
content of
therapy needs to be continually refined
using scientifically sound approaches. Some of these issues need to be
clarified for
individual therapies before combining into
combination therapies. Specific to stroke recovery are issues such as
defining
the degree of task specificity for
poststroke training. The impact of comorbidities, both prestroke and
poststroke, needs
consideration with a focus on
identification of possible modifiable and nonmodifiable comorbidities.
Step 2: The Practice of Poststroke Rehabilitation Needs to Be Standardized Based on Best Evidence
Key Issues
Substantial data exist on the practice of poststroke rehabilitation.43
As parallel research continues to refine the approaches, there is a
need to apply currently existing knowledge to optimize
patient outcome. Key issues include the
organizational structure, timing, intensity, and task specificity of
poststroke therapy.44 Attention to community reintegration is also needed.
Recommendations
Detailed, standardized
poststroke therapy protocols need to be developed and their practice
associated with proper training.
This should extend to transition to the
community and then to a multiyear chronic phase of rehabilitation.
Monetary and payment
incentives must be redefined to drive
implementation of these protocols. The lessons from published studies
and best practices
must be operationalized.45 This can be partly achieved by improved benchmarking of processes, outcomes, and costs.
Medical school and postgraduate
training should incorporate the protocols and best practices and should
include suitable educational
media and modules to support the
implementation. Many of these solutions can be addressed by development
of Stroke Recovery Research Centers.
Step 3: Develop Consensus on, Then Implementation of, Standardized Clinical and Surrogate Measurements
Key Issues
The best standardized
measures of behavior and outcomes after stroke need to be defined and
then placed into clinical practice,
at the same time continuing to generate
appropriate research. These need to be used across rehabilitation
systems and regions.
These should be measured and
communicated in a consistent manner. Standardized rater training needs
to be developed for these
measures.
Surrogate markers of
treatment effect also are needed, including imaging (anatomic and
functional), physiological, and biological
(such as genetics). These might be used
as predictive tools for outcome and thus be of value for triage; as
entry criteria
in clinical trials of repair-related
therapies; or in evaluating treatment outcomes to guide clinical
decision-making.
Achieving consensus on clinical measures and biomarkers in this context would be useful for clinical practice and also for
developing clinical trials of therapies targeting stroke recovery.
Recommendations
Experts need to be gathered to
discuss these issues and to propose unifying strategies to achieve rapid
progress in the study
of rehabilitation interventions. One
possible mechanism would be an International Harmonization Conference,
which would help
achieve expert consensus on poststroke
behavioral and clinical measures as well as on surrogate markers, as has
been done
in other neurological conditions.
Development of Stroke Recovery Research Centers would be useful to achieve such consensus, for subsequent pilot testing of the recommendations, and for defining means for
broader implementation.
Further research is needed to define the psychometric qualities and performance of proposed surrogate markers.
Step 4: Target Repair-Related Processes in Clinical Research to Advance Stroke Recovery
Key Issues
Available research suggests
many strong candidates for therapies that are likely to improve
poststroke recovery by targeting
repair-related processes. However,
clinical trials in this domain are few and often small in size. A
significant need exists
to design and execute clinical trials
focused on stroke rehabilitation and repair.
Stroke rehabilitation/repair
clinical trials need to be hypothesis-driven, properly designed, and
appropriately powered with
vertical integration of basic,
clinical, and epidemiological disciplines. The clinical trial structure
should extend beyond
mere hypothesis testing to discovery
and exploration, the latter being much needed in this expanding field
with immense potential
to help numerous patients with stroke.
Randomized clinical trials
are the mainstay of examining candidate therapies. Additional research
structures also might be
used to further address these issues.
Examples include innovative trial designs such as a cluster randomized
design as well
as shared databases.
Note that the impact of such trials will be maximized if paralleled by studies of clinical effectiveness and pertinent health
economic topics.
Recommendations
A Neurorecovery Consortium needs to be created consisting of academic (basic and clinical researchers, likely based at the Stroke Recovery Research Centers), industry, government research, clinicians, and payers with the mission being to define priorities and future actions for
stroke recovery trials. Specific Stroke Rehabilitation/Recovery Conferences should be supported to address shared issues related to stroke recovery and rehabilitation.
Centralized strategic plans for
brain recovery science should be developed, akin to the England Stroke
Research Centers. Clinical
trial networks should be developed to
accelerate completion of stroke recovery clinical trials using cardiac
disease or cancer
cooperative groups as examples.
Into the 21st Century: The Web, Technology and Communications, New Tools for Progress
Introduction
Major reductions in the burden of
stroke can be achieved by providing better public education. In many
parts of the world,
access to reliable medical information and
even electricity is limited. The electronic means to disseminate health
information
(eg, healthier lifestyle, risk factors,
stroke symptoms, and emergency response) are available in industrialized
countries,
but less so in developing countries. There is
a wide disparity in global internet penetration46 according to geographic (Figure)
and demographic characteristics with older individuals less likely to
access electronic information. Adoption of universal
technology standards and worldwide
unrestricted access to data will in part define how these disparities
can be addressed.
In the developed world, with the advent of
high-bandwidth wireless delivery systems, there will be few regions
without Internet
access provided that sufficient resources are
invested. In those parts of the world where connectivity is more
limited, different
strategies for knowledge dissemination and
behavior change will need to be adapted to the available communication
means (eg,
mobile phones, print, radio, television, word
of mouth).
Step 1: Worldwide Unrestricted Access to Information
Education for the Public and Professionals
To reduce stroke risk,
electronic media-enabled tools can be used for self-assessment and
motivation for self-management.
These information portals can provide
self-administered programs and/or interactions with professionals.
Support Groups
Lay organizations (eg, church,
community groups) are an underused resource that can provide insights
into the types of support
and problem-solving that are most needed
by stroke survivors, including advice on financial resources, legal
matters, and
social benefits. Resources should be
devoted to supporting these peer-to-peer networks with interfaces to
reliable sources
of health information.
Recommendations
The Public
To be free of bias, health
information should be reviewed or provided by experts in stroke in
collaboration with experts in
public education without conflict of
interest (eg, government and nongovernment stroke-oriented health
organizations) and
delivered in a persuasive and
understandable format consistent with principles of marketing and
behavioral sciences as appropriate
for the region.
Professionals
Special task forces of these
same organizations should prepare evidence-based online education for
general practitioners,
specialists, nurses, therapists, and
other healthcare workers in multiple languages tailored to professional
groups working
in diverse surroundings. These
electronic information clearinghouses should be accessible to health
professionals worldwide
and include interactive educational
methods whenever possible. These materials should be adaptable to
environments where access
to electricity and electronic
communications is limited. This material should also be available as a
degree-based distance
learning program for healthcare workers
worldwide.
Citizens Against Stroke
Communication resources and
social networking tools should be tailored to support local stroke
initiatives consisting of professionals,
decision-makers, politicians,
administrators, representatives of local industry and businesses
together with lay people. All
initiatives should be tailored to raise
public awareness of stroke and to spread information on its prevention
and management.
Step 2: Better Access to Organized Care for All Patients With Stroke
Diagnostics, Acute Care, and Rehabilitation
Evidence exists that advanced telemedicine communication technology for stroke (“telestroke”) is beneficial where immediate
access to stroke expertise is not available.47–50 Telemedicine may help to provide stroke prevention, acute care, and rehabilitation services in remote regions51
and smaller urban hospitals without stroke expertise and to extend
clinical research into a broader global community. In
addition, more innovative rehabilitation
therapies, which can be administered in areas and countries with limited
resources,
must be implemented to reduce inequalities
of access to rehabilitation. Close collaboration of healthcare
administrators,
physicians, allied healthcare providers,
basic scientists, and engineers is needed to develop and implement new
rehabilitation
paradigms.
Connecting Professionals and Patients
Electronic communications
between patients and professionals have an enormous potential to enhance
self-management of risk
factors and promote healthier lifestyles
(eg, obtaining advice on medication use and adherence, prevention,
follow-up laboratory
test results, and medical problems through
a virtual healthcare visit or an e-consultation (www.mayoclinic.org).
Data management
systems need to be developed to maximize
the potential benefits of this emerging area and create manageable tools
and actionable
tasks for healthcare workers.
Recommendations
Leaders and key stakeholders
(including patients) will need to embrace these new models of
telemedicine and virtual patient–provider
interactions that will permit access
especially for patients who are disabled or live in geographically
remote regions. A
first step is to reduce barriers to
telemedicine-enabled practice to encourage broader access to
high-quality stroke care
and rapid treatment for acute stroke
therapies. Development of novel technology-assisted rehabilitation
methods should be
encouraged.
Step 3: Build Centralized Electronic Archives and Registries
Electronic health records are
critical for quick and reliable access to patient information, for
effective communication of
care plans between different providers and
settings, and for reducing medical errors. Furthermore, providing
citizens with
the option of having access to their own
personal health records may enhance their adherence to treatment
recommendations.
Electronic registries can help
evaluate documentation of treatment practices, treatment efficacy and
comparative effectiveness,
and improve clinical management of patients
with stroke. Registries such as Safe Implementation of Thrombolysis in
Stroke
[SITS]; www.acutestroke.org/) and those of
Austria, Finland, Scotland, Sweden, the United Kingdom, and Japan and
national
quality improvement programs in the United
States (www.strokeassociation.org/presenter.jhtml?identifier=3002728)
have improved
stroke care by providing feedback,
benchmarks, and sharing of best practices. Electronic resources should
be developed to
support the capture and analysis of
patient-reported outcomes for clinical care and research.
Recommendations
All nations should pursue to
develop national, interoperable electronic health record systems with
the goal of supporting
continuity of care through delivery of
comprehensive medical information on demand at the point of care for all
their citizens.
Common data elements pertinent to
stroke-relevant risk factors, treatments, and functional outcomes should
be included in
the electronic health record systems.
Ideally, nations should collaborate to develop international standards
for data format
and description to support international
integration.
Registries and Evaluation of Efficacy
All nations should participate
in national or international stroke quality improvement programs or
registries or develop their
own programs if current models are not
suitable for their population or environment to provide the highest
quality stroke
care.
Fostering Cooperation Among Stakeholders to Enhance Stroke Care
Introduction
Interactions among major
stakeholders in the stroke field such as large stroke organizations,
government agencies, nongovernmental
organizations, industry, and patient
organizations can be mutually beneficial. Integrated activities among
these groups can
enhance patient care, the development and
implementation of new therapies, and the dissemination of new and
existing information.
The following sections describe the
activities/contributions of these 5 sectors and also provide 3 concrete
suggestions of
how to enhance mutually beneficial activities
over the next several years.
Large Stroke Organizations and Nongovernmental Organizations
Stroke is a prototype disease
for coordinated actions vertically (with other medical disciplines) as
well as horizontally
by interactions among stakeholder
organizations, government, and industry. Large stroke organizations such
as the WSO serve
as a key component in these networks,
providing important leadership roles in coordinating activities and in
establishing
stroke firmly on the global health agenda.
Improved stroke management is crucially dependent on an effective
organization
in all aspects of care. The large stroke
organizations should establish clear policies and provide
recommendations through
guidelines and other documents. The large
stroke organizations also organize large scientific conferences
providing a platform
for scientific advances and interactions.
Tackling the global burden of stroke constitutes a major health
challenge.
The AHA formation of the
American Stroke Association (ASA) 10 years ago and its evolution to date
is an excellent example
of how an NGO, in this case a voluntary
health organization, can influence scientific discovery and the
translation of science
into guidelines and how it can then
implement programs to support guideline adherence, to improve outcomes,
to provide extensive
provider and patient resources, and to
advocate for system change. AHA/ASA’s expertise as a convener of experts
to develop
consensus statements and guidelines, as a
generator of patient and public education, and its field structure of
staff and
volunteers who implement its programs all
contribute to its success.
Going forward organizations
such as AHA/ASA and WSO will need to collaborate extensively with other
large stroke organizations
and nongovernmental organizations,
government agencies, industry, and academia to further advancements in
patient care and
development of new therapies and
approaches.
Government
The National Institute of
Neurological Disorders and Stroke (NINDS) is committed to the
development of better therapies to
prevent stroke and to improve the outcome
for patients with stroke. The NINDS Stroke Program Review Group52
outlined the priority areas for research and NINDS looks forward to an
exciting new era in stroke research. NINDS has a number
of ongoing clinical trials that are
evaluating novel prevention approaches, acute interventions, and
recovery-enhancing strategies.
In addition to drugs and devices, the
science of behavioral change needs to target the promotion of healthy
behaviors decades
before the age-dependent risk of stroke
starts its exponential ascent. The NINDS translational program works
with and funds
investigators and their industry partners
to bring promising stroke therapies through preclinical development. The
NINDS,
however, faces a plethora of hurdles.
Unfortunately, a number of important and expensive clinical stroke
trials cannot be
completed due to poor enrollment. A
greater emphasis on Phase II studies should be considered to ensure that
experimental
therapies tested in rigorously conducted
animal studies actually engage the intended biological target in
patients.
Patient Organizations
Patient organizations range
from small, informal, local support groups to large corporations with
significant influence. Interactions
between patient organizations and other
organizations flow both ways. The purposes of these interactions are
many and therefore
this topic is quite complex. The triggers
for interactions are generally of 3 types: (1) issues of clinical
service and patient
safety; (2) driving innovation and
science; and (3) influencing business and healthcare economics. Patient
organizations can
be conduits for patients to influence
healthcare organizations, government, industry, and academia. Processes
may be ad hoc
or organized. Actions may be taken
proactively or reactively. Patient organizations can be vehicles for
patients to be influenced
by healthcare organizations, government,
industry, and academia. Again, processes may be ad hoc or organized, and
actions
may be taken proactively or reactively.
Industry
Industry plays a vital role in
the development and implementation of novel therapies directed at
improving the prevention
and treatment of stroke. Most new drug or
device therapies are discovered by relevant companies or in-licensed
from other
sources. The company then performs the
necessary preclinical steps to allow for the performance of clinical
trials. Clinical
trials performed by the company that
demonstrate safety and efficacy of the new therapeutic agent can lead to
regulatory approval,
presuming an adequate data package.
Industry thus provides a key link for stroke patient care, new and
presumably improved
therapeutic agents. Additionally, industry
is an important source for the dissemination of new information about
stroke to
both physicians and the lay public. This
task is performed by sponsorship of conferences, education seminars, and
small group
meetings for both professional and lay
audiences. The content of these educational endeavors should be free of
bias, providing
balanced and educationally sound
information for the intended audience.
Recommendations
Three specific recommendations
to enhance cooperation among large stroke organizations, nongovernmental
organizations, government,
patient organizations, and industry are:
(1) provide an appropriate mechanism for the various stakeholders to
communicate
with each other about their needs and
goals; (2) enhance clinical research by having these entities provide
input about unmet
needs and how to develop and disseminate
new therapies; and (3) enhance patient and physician education by
jointly developing
and implementing educational initiatives.
A method to achieve these
recommendations and those of all aspects of this document is to
establish a consensus working group
of these stakeholders under the aegis of
organizations such as the WSO/WFN to discuss develop and propose an
overall agenda
for stroke worldwide.
Educating and Energizing Professionals, Patients, the Public and Policymakers
Part 1: Educating and Energizing Professionals and Patients
Introduction
Detailed clinical stroke knowledge
is increasingly important in Europe, North America, and other developed
regions and subspecialty
training focused on stroke prevention, acute
care, and rehabilitation has been formalized.32,53 Stroke units have become common in developed countries. In poorer countries, especially in those classified as “low income”
by the World Bank, specialized care hardly exists.54
A first step in improving stroke care globally is to improve the
stroke-related education of care providers in developing
countries. There are mechanisms in place for
distributing knowledge and education related to HIV/AIDS, malaria, and
other
infectious diseases. These same models could
be applied to stroke education.
Several organizations including
the ASA, the ESO, and the WSO have educational and professional training
web sites. For example,
the WSO site is the World Stroke Academy
(www.world-stroke-academy.org/). It is available globally and is free.
It is endorsed
and supported by other educational
initiatives including those from the ASA and the ESO. Other programs
such as those from
the AHA/ASA
(http://my.americanheart.org/professional/) and the ESO
(www.stroke-university.com/) provide professional educational
resources. Globally, there are insufficient
numbers of physicians trained in stroke. Neurovascular Education and
Training
in Stroke Management and Acute Reperfusion
Therapy (NET SMART) is a government-funded, evidence-based, online
educational
system (www.netsmart-stroke.com/) offering
programs to support the learning needs of advanced practice nurses
(nurse practitioners
and clinical nurse specialists).
Stroke-educated nurses, more numerous than physicians, are capable of
playing instrumental
roles within telestroke networks.55 In Europe, a downloadable eCME certificate can be obtained that is recognized by other programs such as the European Masters
in Stroke Medicine (www.donau-uni.ac.at/en/studium/strokemedicine/index.php).
The WSO’s “ABC of Stroke Management” program is directed to healthcare providers in developing countries. It is being used
in China, South Africa, and Vietnam and is an effective tool for postgraduate medical training.56,57 In Vietnam, 6000 medical doctors have finished WSO-sponsored stroke training. Approaches for rapid and accurate diagnosis
and the importance of prevention of complications are emphasized.58 Improving the availability of effective medications throughout the world is critical. The use of telemedicine to extend stroke
expertise to underserved areas may be possible.48
The wider use of early mobilization and task-dependent rehabilitation
to optimize long-term outcomes, including reintegration
of patients with stroke into the family,
workplace, and community, is an important goal. It is important to
develop a concept
of “brain health” that can be promoted for
primordial and secondary prevention.
Patient and bystander responses to stroke symptoms are often delayed.59
Patient-focused voluntary organizations have developed programs to
increase the stroke knowledge of the general public, patients
with stroke, and their families. The AHA/ASA
along with the American Academy of Neurology and the American College of
Emergency
Physicians (Give-Me-5), the ESO, and the
Stroke Alliance for Europe (SAFE) have developed informational brochures
and advertisements
for this purpose. It is important to further
disseminate these materials as teaching aids in schools and communities.
Recommendations
Step 1: Increase education
directed at professionals including healthcare providers on a global
scale by using on-site and
website stroke teaching programs that are
integrated into the medical education curricula. Recommendations should
be based
on a “brain health” concept that enables
promotion of preventive measures. The aim is to make professional
specialized care
available to patients with stroke
throughout the world within the next decade.
Step 2: Further develop
national health education programs offered for stroke survivors and
their families. These programs
should be offered in schools and
communities under the leadership of the scientific organizations such as
the WSO, the AHA/ASA,
the ESO, and other regional organizations.
The aim is to improve stroke prevention and the public’s recognition
and response
to stroke symptoms.
Part 2: Educating and Energizing the Public and Policymakers
Introduction
Worldwide efforts to increase
knowledge and concern about stroke, its prevention, treatment
opportunities, and outcomes have
also focused on politicians and key opinion
leaders. The role of governmental policy on stroke research and care is
increasingly
recognized.
In the United States, advocacy efforts have largely been directed at increasing or at least sustaining funding for research
supported by the NIH.60
Advocacy, in part, led to NIH Progress Review Groups aimed at
identifying targets and strategies for stroke-related research.
In addition, national advocacy efforts have
supported cardiovascular and stroke prevention activities of the CDC.
Specific
targets included support of Food and Drug
Administration oversight of tobacco products. Within states, advocacy
has been aimed
at improving the organization of the delivery
of stroke-related health care.31
Individual states have established stroke task forces or legislative
committees focused on stroke care issues such as assessments
by emergency responders, transport of
patients with stroke to the nearest appropriate hospital, identification
of primary
stroke centers and acute stroke
treatment-capable hospitals, and the use of telemedicine. Legislation to
prevent cigarette
smoking in indoor public spaces has been
enacted in several states.
Educating the public about stroke risk factors, prevention, and response has been challenging. Public knowledge about stroke
in the United States continues to be poor, particularly in minority communities.61,62
Recently, the ASA, American College of Emergency Physicians, and
American Academy of Neurology began a uniform education
campaign, “Give Me 5,” aimed at improving
recognition of stroke symptoms. The ASA Power to End Stroke program
focuses on blacks,
who have approximately twice the risk
compared with white Americans. “You’re the Cure” is the AHA/ASA
grassroots advocacy
network. Through “You’re the Cure,” thousands
of advocates can be mobilized to support specific pieces of legislation
or programs
affecting stroke through targeted e-mails,
phone calls, and letters to relevant policymakers. Although a great deal
has been
accomplished, much remains to be done.
The European Parliament founded the SAFE in 2004, which includes representatives from 17 countries.63
In Europe, policymakers have become engaged in the European Union by
activities from the European Brain Council, the ESO
jointly with the European Stroke Conference,
and the SAFE movement. Topics include the promotion of awareness of
stroke-related
health costs64 and the large discrepancies between eastern and western Europe, including the much higher prevalence of risk factors and
stroke in eastern Europe.
European specialist groups have
lobbied for increased funding from the European Science Foundation and
led to a European Stroke
Workshop in Brussels hosted by the European
Commission. The resulting European Stroke Network links stroke research
from bench
to bedside.65 New initiatives (“Strike Out Stroke” 2009) address the general public as well as members of the European Parliament focusing
on problems related to the use of anticoagulants for patients with stroke.
Recommendations
Step 3: Increase funding for
public education and research supported by regional and national
agencies. Continue support for
advocacy aimed at improving the
organization of the delivery of stroke-related health care based on
evidence-based recommendations
addressing gaps in the care delivery
system.
Step 4: Educate and inform the
general public about stroke risk factors, prevention, and response. Use
best practices such
as “Give Me 5,” aimed at improving
recognition of stroke symptoms, the ASA’s “You’re the Cure” advocacy
program and the “Strike
Out Stroke” campaign in Europe.
Summary
To accelerate progress in stroke, we need to reach beyond it scientifically, conceptually, and pragmatically.
Scientifically the solutions lie
beyond our limited models. All the major neurological brain diseases
share common mechanisms
such as inflammation, apoptosis,
mitochondrial damage, oxidative stress, excitotoxicity, and
neurotransmitter failure.66
By and large these mechanisms are studied in relation to individual
diseases, not from a biological, evolutionary, or integrated
viewpoint. A close study of the development
of the nervous system may hold many clues as to how the brain repairs
itself.
Moreover, development and aging may to some
extent be mirror images of each other. Stroke in the neonatal brain,67 children, and women68,69 has special features that need to be understood and addressed.
Our focus has been on lesions in
the brain. Aging and the complex interaction of genetics, epigenetics,
and environment and
the occurrence of concomitant pathology
render individuals’ brains unique. For example, cerebral infarcts shrink
and the inflammation
subsides with time. The opposite occurs
experimentally in the presence of amyloid.70
Given that several common neurological conditions share the same
mechanisms, a systematic approach may produce therapeutic
targets that would be of benefit to more than
one disease. It matters not only what lesion, but whose brain.
Conceptually we need to think not
only of dramatic strokes of sudden onset, sometimes heralded by sudden
losses of speech,
sight, movement, or feeling, but of
subclinical strokes, the most prevalent type of cerebrovascular disease
identifiable by
subtle cognitive dysfunction, usually a
change in executive function.12 Moreover, in the elderly brain, amyloid deposition and Alzheimer lesions may coexist and at times interact with the vascular
lesions.
Pragmatically we need to realize
that if we are to become more effective in the diagnosis, treatment,
rehabilitation, and
prevention of stroke, we have to reach beyond
our hospitals and clinics into the community, other disciplines, and
the public
and a larger part of the world.
We need to survey, systematize,
and synergize what we do. We need to survey broadly, systematically, and
specifically what
we know of basic brain mechanisms of disease.
We need to become aware of other models such as infectious diseases,
which often
has an integrated, epidemiological, clinical,
and basic science approach.
In terms of acute care and
rehabilitation, an organized approach seems to have been the key to the
many advances. Although
countries like Spain have a national stroke
strategy and effective regional programs such as those of Catalonia71 and Madrid,72
the majority of countries do not. Stroke unit care should be considered
a treatment/intervention in itself similar to any
pharmacological treatment or a surgical
procedure. There may well be other models such as trauma that may
provide useful parallels
and lessons.
Systematization and evaluation has
been a key in many of the advances that have occurred in stroke in the
past 4 decades.
A prototype has been the randomized clinical
trial, in which a hypothesis is tested according to prospectively agreed
protocols,
the collection of the data monitored, and the
results evaluated. Randomized clinical trials are but 1 example of the
more
generic principles.
We need to reach beyond North
America, western Europe, and Japan, where most clinical trials have been
performed. Other parts
of the world are creating infrastructures
that make them capable of participating in clinical trials and other
studies that
can accelerate finding the answers to many
common problems. The Extracranial–Intracranial (EC/IC) Bypass Study73
was an early example of how an international randomized clinical trial
could reach an answer much more quickly than if it
had been done in 1 country alone. More
recently we saw the example of the first proof of tissue plasminogen
activator effectiveness
in stroke being demonstrated in an American
study,4 whereas the extension of the time window was recently shown by a European study.74
We need to become imaginative in
designing multiple types of clinical trials, from active registries to
simple and more complex
randomized clinical trials. The idea would be
that everything that is done in relation to stroke becomes part of some
evaluation.
An important aspect of any evaluation is
standardization with a need to make minimum common definitions of
important items
in a protocol so that databases can be made
compatible and larger volumes of information can become available for
analysis,
model-building, and testing.
At the moment, we have a glut of guidelines but not enough guidance or guides.75 Most guidelines are developed on the basis of the level of evidence, but little attention is devoted to the relative impact
of specific items. Not all are of equal value.76 We need to evaluate and rank the relative value of each activity in terms of return per unit investment of time, resources,
or both.77 The comparative effectiveness research thus generated would improve clinical decision-making and lead to better allocation
of scarce medical resources.
Stroke is no longer a disease of affluence. Approximately 87% of the 5.7 million deaths annually attributable to stroke occur
in low-income and middle-income countries.78 The risk factors like hypertension, diabetes, and obesity are assuming epidemic proportions. Some 285 million people worldwide
will live with diabetes in 2010, 70% of whom will live in developing countries.79 Moreover, by 2050, the population aged ≥60 years is expected almost to triple, increasing to 1.6 billion in the developing
countries.80
The Institute of Medicine’s recent report recommends building evidence-based, locally relevant solutions by improving global
collaboration among stakeholders to promote cardiovascular health in the developing world.81 Aligning chronic disease priorities with other health and development priorities has the potential to synergistically improve
economic and health status.
There is much value in doing the simple things right in terms of prevention. “Death in old age is inevitable, but most deaths
before old age are avoidable.”82
Hypertension is the single most powerful and prevalent risk factor for
ischemic and hemorrhagic stroke and vascular cognitive
impairment and yet too often it remains
unrecognized or untreated. Blood pressure control has the greatest
potential for stroke
prevention.
The concept of “vascular health”
or “brain health” needs to be promoted. Because atherosclerosis starts
early in life, the
preventive efforts should target children,
youth, and mothers. Everyone needs to be involved at all stages of
prevention with
an emphasis on healthy living and creating an
environment that nurtures it.
Finally, we need to synergize with
vertical integration of basic sciences, clinical sciences, and
population approaches. The
digital age provides wonderful opportunities
for integrating and evaluating all aspects of our activities.
Next Steps
The immediate need is to pursue specific recommendations:
-
A systematic review of all that is known of basic brain mechanisms of injury and repair along the life cycle. This can be accomplished at several levels: (a) review of the existing literature; (b) making it a topic of ongoing scientific conferences such as the Princeton Conference or as a priority setting exercise of funding agencies52; and (c) organize a highly interactive synergium with participation of scientists, clinicians, pharmaceutical companies, and health regulators. The synergium should be broad enough that each mechanism can be examined in light of several diseases.
-
To organize a working group that will recommend a minimum set of data points to be collected on all patients with stroke or those with potential stroke. This already has been done for capturing vascular cognitive impairment from the epidemiological, clinical, neuropsychological, imaging, and experimental viewpoint.83 It may be that it simply needs modification or adaptation.
-
Another working group could evaluate the relative advantages and disadvantages of different clinical trials, including novel approaches to use registries to evaluate different diagnoses and treatments.
-
The WSO already has a working group on guidelines that could be enlarged and asked to prioritize them with a simple method of evaluating their impact.
-
A working group on surveying and evaluating stroke education with methods of integrating and credentialing those who engage in stroke work.
-
Develop nodular models of comprehensive stroke care, rehabilitation, and prevention on the principle that some components are essential but that they need to be adapted in the community where they are to be implemented. Professional education including a more comprehensive education on stroke and stroke recovery for medical school curricula as well as residency and fellowship training. The latter may be best done at Centers of Stroke Emphasis or Stroke Recovery Research Centers.
-
Support the efforts of Raad Shakir, Secretary General of the World Federation of Neurology and Chair of the Expert Committee advising on Diseases of the Nervous System for the International Classification of Diseases84 (ICD-11), and Bo Norrving, President of the WSO, to reclassify stroke from a cardiovascular to a disease of the nervous system and vascular dementia from mental diseases to brain diseases.
-
Precompetitive stroke recovery initiative: We should consider precompetitive consortia for stroke recovery that is similar to that currently in operation for Alzheimer disease—the Alzheimer’s Disease Neuroimaging Initiative (ADNI).85 Perhaps collectively (academia, industry, and government), we could create a “SRNI” (stroke recovery neuroimaging initiative), a precompetitive consortia to enroll and carefully study patients for the natural history of stroke recovery: imaging, scales, and biological samples. The groups involved would agree to what end points should be studied. This would help not only in understanding the pathophysiology of stroke, but also in the design of clinical trials to ensure that the proper end points are used and that they are powered appropriately.
-
Educate and energize professionals, patients, the public, and policymakers by using a “brain health” concept that enables promotion of preventive measures.
-
Organize a working group that will oversee these and other initiatives that may arise from the recommendations of the synergium.
Conclusion
We have come a long way, but we have
even further to go. The progressive transformation of our field in the
past 40 years,
the accelerated pace of science, and the growing
need for our contributions will assure that the next 4 decades will
prove
even more fruitful than the last.
Appendix
In this section, a few successful scenarios from different parts of the world and different medical systems are described to illustrate what can be done to make acute stroke treatment more widely available depending on the local conditions.-
I. The statewide program of stroke unit care and implementation of thrombolysis in the German State of Baden–Württemberg, in which the Ministry of Health, together with stroke physicians, has embarked on a statewide program to improve stroke management, is described.
-
II. The strategies for improvement of prehospital management of patients with stroke in the United States is described, a process which was primarily triggered by stroke physicians.
-
III. The government-led nationwide system of medical emergencies, including stroke, which has been started in Brazil is reviewed.
-
IV. The example of South Africa is presented, which shows how stroke medicine can be brought into rural areas with the help of metropolitan stroke centers, which themselves are not similar to centers found in western Europe or North America.
-
V. The current attempts being undertaken in the United Kingdom in organizing stroke center care in the metropolitan areas are also reviewed.
-
VI. The current efforts being undertaken in the Russian Federation to improve stroke care are also described.
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