Conclusions

An effective treatment strategy for stroke has been severely hampered by three factors: the acute onset of the condition, the difficulty in quickly and unambiguously separating people with ischaemic stroke from those with haemorrhagic stroke, and the limited time frame during which acute medicines can be of value.

Acute onset is a characteristic of the condition and is always likely to be so. Hence the emphasis must be on raising awareness, so that medical help is sought at once if stroke is suspected. The separation of ischaemic from haemorrhagic stroke is now much more practicable using CT scanning, but not all hospitals have access to these instruments and those that have may not be capable of handling large numbers of people who may have had a stroke. Both the Royal College of Physicians of Edinburgh and the independent Clinical Standards Advisory Group reported during 1998 that they regarded cerebral CT scanning as the cornerstone of effective stroke care. The more extensive use of scanning needs to be encouraged and would follow if stroke care units with their specialist teams were more widely available.

This would greatly increase the numbers of people diagnosed within the critical period after a stroke, and would permit those with ischaemic stroke to be given treatment in the form of antiplatelet or thrombolytic therapy. Evidence suggests that early diagnosis and treatment would give far more people a degree of functional independence after recovery.

Though many of the anti-platelet agents have been available for some time, there have been major strides in recent years in the understanding of when and how to use them and the likely benefits. As a result, aspirin, modified release dipyridamole and clopidogrel seem to have a well-defined role, especially in secondary stroke prevention, and, in the case of aspirin, as an early form of therapy. The jury remains out on the wider utility of thrombolytic agents such as rt-PA, but it is clear that certain groups of people who have had a stroke derive real benefit if they can be diagnosed with confidence. In addition, pravastatin has been licensed for stroke prevention, and other members of this class are under investigation. By contrast, the neuroprotective agents have been disappointing so far, but there are many alternative leads in the clinic and in the laboratory and the way forward should become clearer within the next four to five years.

There now seems to be the political will to reduce the threat of stroke. There has been a clear recognition of the advantages of integrated stroke services. There has been a clear identification of the key risk factors, and finally the role of medicines has been greatly enhanced, with new ones in the pipeline. Hence, although it remains a serious condition, the outlook for individuals and their families faced with the consequences of stroke now seems better than at any time in the past – though there remains much more to be done.