"Brain attack": the rationale for treating stroke as a medical emergency.

Stroke is the third leading cause of death in the United States, behind only heart disease and cancer. With an estimated three million survivors of stroke in the United States, the cost to society, both directly in health care and indirectly in lost income, is staggering. Despite recent advances in basic and clinical neurosciences, which have the potential to improve the treatment of acute stroke, the general approach to the acute stroke patient remains one of therapeutic nihilism. Most basic science studies show that to be effective, acute intervention to reperfuse ischemic tissue must take place within the first several hours, as is the case with ischemic myocardium. In addition, most neuroprotective agents must also be administered within a short time frame to be effective at salvaging at-risk tissue. Recent studies have suggested that the outcome after intracerebral and subarachnoid hemorrhage is improved with early intervention. However, most stroke patients fail to present to medical attention within this short "window of opportunity." The public's knowledge about stroke is woefully inadequate. However, clinicians who deal with stroke can use the dramatic changes in the treatment of acute myocardial infarction over the last 2 decades as a guide for shaping changes in the management of acute stroke. Comprehensive educational efforts aimed at clinicians and the public at large have dramatically reduced the time from symptom onset to presentation and treatment for acute myocardial infarction, enabling treatment methods such as thrombolysis to be effective. The Decade of the Brain offers a unique opportunity to all concerned with the treatment of the patient with acute stroke to engage in a concerted effort to bring patients with a "brain attack" to specialized neurological attention within the same timeframe that the "heart attack" patient is handled. Such an effort is justified because, although at the present time there are few therapeutic interventions of "proven" value in the treatment of acute stroke, there is more than sufficient suggestive evidence that a number of approaches may be beneficial within the first few hours after the onset of the stroke.