The American Association of Neurological Surgeons (AANS) is playing a pivotal role in the development and implementation of a professional education and information program aimed at improving the response to, and management of, patients with acute stroke.
The “Brain Attack” campaign promotes the concept that stroke is an emergency requiring the same medical response accorded to heart attack. It is being implemented by a coalition of the six leading stroke-related health care organizations (including the AANS) and constitutes the largest coordinated effort of its kind and is the first-ever multi-specialty, multi-society collaboration in stroke. Volunteer faculty to teach the initial phase of the educational program are now being recruited from the memberships of the Coalition organizations.
Read “Brain Attack. A Body of Knowledge. A Coalition of Support,” to learn how you can become part of this important national effort.
Brain Attack: A Body of Knowledge. A Coalition of Support
Stroke is the third leading cause of death in the United States, ranked behind only heart disease and cancer. With an estimated 500,000 new cases each year and three million survivors of stroke — most of whom are disabled, the cost to society, both in direct health care costs and indirectly in terms of lost income (estimated to be approximately $30 billion), is staggering.
Unfortunately, despite recent advances in stroke treatment and research, the general approach to caring for the acute stroke patient has been one of benign neglect. The traditional response to stroke by both health care providers and the public has been commonly described as “nihilistic,” meaning nothing can be done. Though recent studies have shown that outcome following intracerebral and subarachnoid hemorrhage is improved with early intervention, most stroke patients fail to receive treatment during this therapeutic “window of opportunity.”
Thus far, the most significant educational efforts regarding stroke have been directed towards prevention through control of risk factors such as smoking, hypertension and obesity. Little has been done to educate the public or even the general medical community on the importance of early recognition of stroke and its warning signs and the importance of swift treatment of the stroke victim.
In the summer of 1994, a group of medical organizations — led by the American Association of Neurological Surgeons — joined forces in an effort to improve this situation. The result was a project called “Brain Attack: A Body of Knowledge, A Coalition of Support.”
The Coalition represents the largest coordinated effort of its kind and encompasses six leading stroke-related health care organizations in the U.S. It represents more than 36,000 physicians and is the first-ever multi-specialty, multi-society collaboration in stroke.
The Coalition chose to use the term “Brain Attack” in order to help convey the message that stroke is a medical emergency that needs to be viewed and treated with the same urgency as a heart attack.
Program Rationale
In a scientific paper entitled “Brain Attack: The Rationale for Treating Stroke as a Medical Emergency,” neurosurgeons Roberto Heros, MD and Paul Camarata, MD, along with neuroradiologist Richard E. Latchaw, MD, described the deficiencies which exist currently in the early treatment of stroke.
Published in the January 1994 issue of Neurosurgery, the paper described a two-fold problem: 1) lack of public understanding of stroke and its symptoms and, 2) medical support systems which are not adequately attuned to quick and effective response once the condition is identified. The authors noted that the 30-day death rate from stroke has been estimated at 40% to 84% following cerebral hemorrhage, and 15% to 33% following cerebral infarction. This paper became the scientific platform for the “Brain Attack” Coalition effort.
Although there have been advances in treatment for stroke patients, providing that immediate treatment is obtained, too often there are delays in patients receiving emergency care. For example, patients may not realize they are experiencing a stroke. In a 1989 survey of 500 San Francisco residents, 65% of those surveyed were unable to correctly identify any of the early warning signs of stroke when given a list of symptoms.
The authors identified another group that may need more education about stroke: Those who provide medical care before the patient arrives at the hospital. For example, only about 1% of the 1,000 hours of training given to paramedics in Cincinnati, Ohio is devoted to the recognition and management of acute stroke.
Another major source of delay is in lesion diagnosis. Current neuroradiologic diagnosis of acute ischemic stroke mostly involves the use of computed tomography (CT) scanning. CT scanning does not show significant changes in parenchymal density following ischemic stroke until about 24 hours after an acute episode. Magnetic Resonance Imaging (MRI), however, has many advantages over CT in stroke diagnosis, although it is currently much less readily available that CT scanning and is much more expensive.
Delays in getting to the hospital were also identified as a problem. Potential roadblocks to admission included how the patient goes to the hospital — via emergency services transportation or by private car (private car takes longer), and whether he or she lives alone. (Those living alone arrived significantly longer after onset of symptoms than those living with relatives or friends.)
In the emergency department, delays in admission resulted from triage, the registration process, overcrowding, starting intravenous treatment, and consultation. Overall, stroke patients have often been considered as moderate-to-low priority in ERs.
According to the Neurosurgery paper authors, “Neurosurgeons, neurologists and neuroradiologists working with basic scientists who are acutely interested not only in the mechanisms of neural cell injury and death, but also in the development of protective agents, have a golden opportunity to use the ‘Decade of the Brain’ to make a major impact in reducing the costs of stroke, not only in economic terms but, more importantly, in terms of suffering and disability. Although preventative and rehabilitative efforts have been emphasized in the past, the acute treatment of stroke has been relatively neglected . . . Taking the lead from the current treatment of heart attacks, we should concentrate on efforts at cerebral resuscitation and protection during the first hours after a ‘brain attack'”
The paper authors recommended a three-pronged approach to addressing the problem. First, they suggested creating a comprehensive educational campaign aimed at primary care physicians and other “first responders.” Second, they advocated developing a regionalized system of early transfer to specialized stroke care units. Third, they stressed the importance of designing appropriate scientific studies to test the validity of the various diagnostic techniques and medical treatments that have been found to be beneficial when administered in during the first few hours after the onset of ischemia.
From these recommendations, the Brain Attack Coalition was born.
Brain Attack Coalition
The Brain Attack Coalition was initiated by the AANS (under the leadership of Roberto Heros, MD, and Julian T. Hoff, MD). The mission of the Coalition is to improve clinical outcomes for stroke patients by reducing the time from the patient’s first encounter with the health care system to optimal treatment.
The Coalition is a dynamic group, and continuing growth in its membership is anticipated due to the importance of its message. The founding group of organizations includes:
- The American Association of Neurological Surgeons
- American Academy of Neurology
- American College of Emergency Physicians
- American Society of Neuroradiology
- National Institute of Neurological Disorders and Stroke
- National Stroke Association
Program Strategies
The initial phase of the Brain Attack program focuses on an educational initiative that targets audiences of those health care professionals who potentially come into early contact with a stroke victim, including neurosurgeons, neurologists, family physicians, internists, emergency physicians, emergency medical technicians/paramedics, nurse practitioners, emergency department staff (admitting clerks, neuroimaging specialists, etc.) and 911 dispatchers. The goal is to promote improved response to, and management of patients with acute stroke.
The key messages of the educational program are:
- It is important that health care providers, as well as the public, understand that stroke is preventable.
- When stroke symptoms appear, it is an emergency.
- Getting the patient with stroke into the hands of competent medical care quickly can make a difference. Brain cell injury during stroke is progressive and a therapeutic “window of opportunity” exists during which treatment may reverse the effects of stroke or at least prevent further damage.
- Effective therapies are currently available for improving the outcome of acute stroke.
- New stroke treatments are being developed.
To help accomplish this mission, the Coalition has developed a detailed syllabus and slide materials. The teaching package offers current, authoritative information presented in full-color, high-impact slides with accompanying descriptive text. The curriculum covers clinical management and acute intervention for stroke. Topics include, history, etiology, epidemiology, costs, prevention, diagnosis, interventional treatment and clinical trials.
Additional activities being considered for later development include CME courses and medical symposia, remote site teleconferencing, video and audio tapes, and interactive electronic presentations.
Faculty Recruitment
The Coalition is enlisting as many neurosurgeons, neurologists, neuroradiologists, emergency physicians, and specialized neuro-nurses as possible throughout the U.S. to promote the Brain Attack mission of ultra-rapid triage, transport, evaluation, and treatment of suspected stroke patients. The curricula will be taught in such venues as grand rounds, clinics, teaching hospitals, and medical conferences/symposia.
Volunteer faculty — who must be members of one of the Coalition organizations — will receive, free of charge, the Brain Attack Coalition Slide Presentation and Syllabus when they enroll. As faculty, they must commit to conducting a minimum of three educational presentations to a medical professional/peer group (i.e., grand rounds, staff meetings, professional associations) within a one-year period. They also must agree to complete and return a faculty report form each time they make a presentation. This valuable feedback will help the Coalition evaluate the scope and impact of the campaign.
In the future, faculty also will receive a special newsletter that will keep them informed about general Coalition activities and events promoting stroke prevention, highlight case histories of innovative educational efforts, provide presentation tips, etc. And, to keep them current about stroke-related topics, periodic updates regarding the latest research findings and treatment protocols will be provided.
To date, more than 525 faculty have been recruited nationwide. AANS members who are interested in becoming Brain Attack faculty may enroll by completing and returning the sign-up form which has been included in this issue of the Bulletin. It can be mailed or faxed to the AANS National office.
The Brain Attack project is supported by a generous educational grant from The Upjohn Company.