Twenty-five years ago, stroke care in the United States was fragmented, and hospitals, for the most part, weren’t adhering to evidence-based guidelines. The majority of stroke patients arrived more than an hour after symptom onset, and less than 20% received lifesaving thrombolytics during the recommended timeframe.
The public was largely unaware of stroke symptoms or how to respond to a suspected stroke. As a result, many individuals delayed seeking medical attention, which contributed to poorer patient outcomes.
Steven Messe, MD, professor of neurology, Hospital of the University of Pennsylvania, Philadelphia, described the research revealing these deficits as “eye-opening.”
“We all knew we had to do better,” he said.
Enter the Brain Attack Coalition (BAC), a group of professional, voluntary, and governmental organizations that published a plan in 2000 to establish a framework for primary stroke centers (PSCs) across the country. It was a novel approach to build systems of care that would swiftly deliver proven treatments to patients with acute stroke while also confronting the inequities that hinder access.
While advances have been made, stroke continues to be a leading cause of adult-onset disability, claiming approximately 140,000 lives each year in the United States. It also carries a hefty price tag — an estimated $34 billion annually in healthcare costs, medications, and lost productivity.
To mark the 25th anniversary of BAC’s initiative, Medscape Medical News spoke with leading experts in the field to understand what progress has been made to strengthen stroke center networks nationwide — and what gaps remain.
A Bleak Outlook
The outlook for patients with stroke was bleak in 2000 when Mark Alberts, MD, then in the Division of Neurology at Duke University Medical Center in Durham, North Carolina, and BAC colleagues drafted their plan. More than 60% of hospitals lacked stroke protocols, and 82% had no procedure to rapidly identify acute stroke. Only 2%-3% of patients were treated with tissue-type plasminogen activator, which had been approved a few years earlier by the US Food and Drug Administration as the first treatment for acute stroke.
“To provide optimal, evidence-based care of stroke patients, hospitals needed to commit to providing the infrastructure and resources to facilitate rapid diagnosis and treatment,” said Messe. “That was lacking at many centers before the BAC recommendations came out.”
The BAC initially looked to trauma centers as a model for PSCs because both trauma and stroke strike without warning, are highly time-sensitive, and demand specialized resources, staffing, infrastructure, and protocols to ensure optimal outcomes.
However, key differences soon emerged. Most notably, trauma is usually immediately apparent — caused by events like car accidents or falls — while stroke can be far more subtle, noted Mark Alberts, MD, now chief of Neurology at Hartford Hospital in Hartford, Connecticut, and co–physician-in-chief of the Ayer Neuroscience Institute.
Ultimately, the BAC developed recommendations specific to PSCs. The criteria included an acute stroke team with at least one physician and another healthcare provider available around the clock, a dedicated stroke unit, written care protocols, an integrated emergency response system, and access to neurosurgical services within 2 hours, even if this requires patient transfer.
The BAC also emphasized the need for support services such as 24/7 access to CT scans and rapid laboratory testing. Administrative backing and ongoing continuing medical education were also identified as key components.
The recommendations were long overdue and a welcome direction for stroke care, wrote H.J.M. Barnett, MD, John P. Robarts Research Institute and The University of Western Ontario, London, Ontario, Canada, and Alastair M. Buchan, BM, BCh, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, in an editorial that accompanied the BAC consensus statement.
“Mobilization of a multidisciplinary team to care for patients with acute stroke may seem to some to be a daunting undertaking. Convincing evidence exists, however, that stroke centers already in existence reduce the devastation wrought on patients with stroke,” Barnett and Buchan wrote. “The Brain Attack Coalition deserves the full cooperation of healthcare professionals at all levels. This cooperation will be made easier if healthcare systems recognize the progress that has occurred and make the treatment of acute stroke a major initiative at the beginning of this new century.”
Building a ‘Chain of Survival’
Twenty-five years later, PSCs now represent one tier within the broader hierarchy of stroke care. At the most basic level are acute stroke–ready hospitals, which are equipped to manage patients during the initial phase of a stroke — including administering thrombolytics — but transfer more complex cases to a PSC.
Facilities with endovascular capabilities, staffed by specialized teams of vascular neurologists, radiologists, and neurosurgeons, are designated as Thrombectomy-Capable Stroke Centers.
The top tier of stroke care is Comprehensive Stroke Centers (CSCs), which have the most resources, including advanced neuroimaging, the capacity to care for multiple acute strokes simultaneously, and vascular neurosurgeons and resources to care for patients with subarachnoid hemorrhages, among the rarest and most fatal of strokes.
There are about 5000 acute care hospitals with emergency departments (EDs) across the United States. In a 2022 paper, the American College of Emergency Physicians determined that 44% of EDs in the United States are stroke centers, including 297 comprehensive centers, 14 thrombectomy centers, 1459 primary centers, and 678 acute stroke–ready hospitals.
It’s difficult to estimate the ideal ratio of stroke centers to population. The issue is more about having the right number and type of stroke centers in the right locations, which depends on population density and the health of the local population, said Messe.
Not every hospital needs to be a comprehensive or even a PSC, Alberts noted. “But they need to be plugged into a system so that if somebody comes in with a stroke, the hospital knows what to do and where that person needs to go,” he said. “You can’t send every person who’s weak, numb, or dizzy to a comprehensive stroke center; there just aren’t enough beds.”
In areas without a nearby stroke center, telestroke services allow emergency department staff to rapidly access specialist expertise through interactive video conferencing. These services are particularly valuable for very rural hospitals — such as those in remote areas — enabling clinicians to initiate care, perform an initial assessment, and, if needed, arrange transfer to a more equipped facility, Alberts said.
In addition to the various levels of stroke centers, pillars of the stroke care system include patient education, emergency medical services (EMS), hospital staffing, and in-hospital infrastructure. Significant progress has been made over the years, boosting the capacity of stroke centers to offer emergency care.
In a 2019 JAMA Network Open Research Letter, experts found that 96% of the population had access within 60 minutes to an ED with any acute stroke capabilities.
“It’s like a chain of survival where all those links in the chain need to be up and running to give the patient the best chance of getting great treatment within a timely manner and having a great outcome,” said Alberts.
‘Tremendous Strides’
“We have made tremendous strides” in creating local and regional stroke systems of care nationwide, said Messe. “I’m thrilled with how far we’ve come.”
The development of a comprehensive stroke care network was linked to a reduction in stroke-related mortality. One large US study analyzed 3.7 million stroke deaths among adults aged 55 years or older between 1999 and 2020.
The results showed that all states experienced a decline in stroke-related deaths, with the largest decrease observed in California (−61.9%) and the smallest in Mississippi (−35.0%). However, following this decline, stroke-related deaths surged during the COVID-19 pandemic.
The significant expansion in access to acute stroke care is due in part to the widespread adoption of stroke center accreditation. This process ensures that stroke programs meet established clinical performance and compliance standards. Its goals are to reduce unwarranted variations in care, promote adherence to evidence-based best practices, and ultimately improve efficiency and patient outcomes — potentially at a lower cost.
There are several pathways to stroke center certification. The Joint Commission certifies and accredits more than 2000 healthcare organizations and programs across the United States, while some state governments also certify or designate hospitals as stroke centers.
Research conducted in Scandinavia and Finland over a decade ago — along with more recent studies in the United States — has shown that the stroke center model improves patient outcomes, according to Alberts. One such study found that patients treated at a CSC were more likely to receive timely care and to be discharged either home or to a rehabilitation facility.
Distribution Remains ‘Uneven’
Although the field has made significant strides over the past 25 years, further progress is needed to achieve the ultimate goal of timely, efficient stroke care for all patients. Continued efforts are required to improve public education, enhance training for healthcare professionals and EMS providers, and develop new technologies, said Messe.
He and other experts also point to rural areas as a key focus for improvement. In many of these regions, Americans still face limited access to acute stroke services, a challenge driven by geographic barriers and resource constraints.
The distribution of stroke centers is still “very uneven,” noted Alberts, with most located along the coasts and far fewer in the central parts of the country. A 2019 study showed that only 19% of rural emergency departments were located in hospitals with any level of stroke center designation.
One region in need of more attention is the so-called “stroke belt” — a stretch of the United States that extends from Washington, DC, south to Florida and west to Texas. The stroke rate is relatively high here and even higher in the “belt buckle” — the Carolinas and Georgia.
In addition to limited access to healthcare, contributing factors include diets high in fried and processed foods, elevated rates of hypertension, diabetes, obesity, high cholesterol, and smoking, said Ameer Hassan, DO, professor of neurology, The University of Texas Rio Grande Valley, Harlingen, Texas. Lower socioeconomic status and environmental exposures are also potential contributors to the higher stroke rate.
Challenging stroke care disparities in rural areas with relatively few resources was the subject of a 2024 scientific statement from the American Heart Association (AHA). The statement considers issues such as the expansion of certification of acute stroke–ready hospitals and PSCs in rural areas, the role of telehealth and improved transfer processes, and mentorship from larger, comprehensive centers to the rural hospitals to which they’re connected.
Public health education remains a key priority. Among underserved groups and other high-risk populations, limited awareness of stroke risk factors, poor recognition of stroke symptoms, and underuse of 911 continue to pose significant challenges, said authors of a 2022 BAC report.
Barriers to Thrombectomy
Another critical area in need of attention is timely access to mechanical thrombectomy (MT), which depends on specialized facilities, skilled interventionalists, and trained support staff.
“The vast majority of hospitals have capacity to do a CT scan of the brain and a CT angiogram of the blood vessels, and that’s great, but a CT perfusion scan is available at fewer hospitals, although that capacity has increased dramatically over the past 4 or 5 years,” said Messe.
While some studies suggest CT perfusion may not be essential for selecting thrombectomy candidates, many stroke centers still rely on it to rapidly identify ischemic brain tissue that could be salvaged with timely reperfusion. Ideally, the procedure should be performed within 6 hours of acute stroke symptom onset. And research suggests 1 in 6 patients in the United States lack timely access to MT — a gap that is particularly pronounced in rural areas.
Messe emphasized the need to improve the system’s efficiency in transferring patients who require thrombectomy for large vessel occlusion strokes or surgery for hemorrhagic strokes to the appropriate center promptly, citing a 2023 study showing a median door-in-door-out time of 174 minutes — well above the recommended target of 120 minutes or less.
The retrospective analysis included over 108,000 patients with acute stroke treated at hospitals in the Get With The Guidelines-Stroke registry, an AHA program that promotes adherence to evidence-based care. Messe noted that the registry now captures about 75% of all strokes in the United States.
A 2024 systematic review identified 12 key barriers to accessing MT for acute ischemic stroke, including significant rural and racial disparities and persistent gaps in treatment and outcomes between urban and rural areas.
Improving access will likely require better EMS education and planning, potentially through routing algorithms that help triage patients more effectively. “We’re developing tools to support EMS in rural areas, including protocols to bypass primary centers and go directly to a comprehensive stroke center when appropriate,” Hassan said.
Attracting appropriate medical personnel remains an issue. At his own center, it took several years to achieve comprehensive stroke center status, with significant challenges in recruiting neurovascular specialists, intensive care unit staff, coordinators, and research personnel — difficulties that have only intensified since the COVID-19 pandemic, said Hassan.
Alberts emphasized that this area of stroke care requires not only specialists in neurology, neuroradiology, and endovascular procedures but also expertise in neurocritical care. Effective treatment involves more than performing a thrombectomy — it requires comprehensive care before, during, and after the procedure, with rehabilitation posing a major challenge due to limited resources, he said.
To help address these disparities, Alberts and other stroke experts are exploring the expansion of telehealth into areas like tele-rehabilitation and tele-psychology, as well as increasing the use of mobile stroke units. Some experts have proposed creating additional registries, but Alberts contends that instead, efforts should focus on optimizing the stroke center system.
“I’m all in favor of registries; they give you the ability to analyze data, but they’re not the same as stroke centers,” he said. “Stroke centers treat people; registries just collect data.”