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2002 Stroke Testimony

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Statement of

Audrey S. Penn, M.D.
Acting Director

National Institute of Neurological Disorders and Stroke
National Institutes of Health

before the
House Committee on Energy and Commerce
Subcommittee on Health

House Date: June 06, 2002

Mr. Chairman and Members of the Committee, I am Dr. Audrey Penn, Acting Director of the National Institute of Neurological Disorders and Stroke (NINDS). I am pleased to be here before you today to discuss our efforts in addressing stroke - the third leading cause of death in the United States after heart disease and cancer, and a leading cause of long-term disability. The National Institute of Neurological Disorders and Stroke at the National Institutes of Health (NIH) is the leading federal organization committed to research on improving stroke prevention, treatment, and recovery, through increased understanding of how to protect and restore the brain. Historically, NINDS has committed more funding to stroke research than to any other single disease or disorder within our mission. In Fiscal Year (FY) 2001, NINDS funding for stroke research was more than $117 million, and the NIH total was nearly $239 million. More importantly, our stroke programs impact all areas of scientific opportunity and public health priority - from stroke awareness to rehabilitation - and are advancing the state of cutting-edge knowledge about the ways to prevent, diagnose, treat, and educate the public and health professionals about stroke.

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Background

As many of you know, a stroke is a "brain attack" caused by an interruption of blood flow to the brain. There are two different types of stroke - ischemic and hemorrhagic. Ischemic strokes occur when blood flowing to a region of the brain is reduced or blocked, either by a blood clot or by the narrowing of a vessel supplying blood to the brain. Approximately 80 percent of all strokes are ischemic. The remaining 20 percent of strokes are caused by the rupture of a blood vessel, and leakage of blood into the brain tissue. These hemorrhagic strokes can occur from the rupture of an aneurysm, which is a blood-filled sac ballooning from a vessel wall, or leakage from a vessel wall itself weakened by an underlying condition like high blood pressure.

At every conceivable level, stroke is a tremendous public health burden to our country. More than 600,000 people experience a stroke each year. Of the more than 4 million stroke survivors alive today, many experience permanent impairments of their ability to move, think, understand and use language, or speak - losses that compromise their independence and quality of life. Furthermore, stroke risk increases with age, and as the American population is growing older, the number of persons at risk for experiencing a stroke is increasing. Over the past several decades, NINDS has supported some of the most significant achievements in stroke research, which have contributed to reductions in the death rate from stroke. We continue to be committed to reducing this burden.

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Historical Progress in Stroke Prevention and Treatment

NINDS has a long and distinguished history of supporting productive clinical studies in the field of stroke prevention and acute treatment. Indeed, successes in prevention date back more than twenty years, and there has been remarkable progress in stroke prevention - which reflects sustained efforts of private organizations, NIH, and other government agencies. Stroke prevention is also highly cost-effective because it averts the direct costs of hospitalization and rehabilitation. As NINDS celebrated its 50th anniversary, the U.S. Centers for Disease Control and Prevention estimated that the age-standardized stroke death rate declined by 70 percent for the U.S. population from 1950 to 1996 [MMWR Weekly 48:649-56 1999], and the American Heart Association tallied a 15 percent decline just from 1988 to 1998. I would like to briefly summarize a few of the major NINDS-supported efforts, which have included dozens of clinical trials, that have contributed significantly to our knowledge of stroke.

Several early studies investigated medical management approaches to the prevention of recurrent strokes in people with atrial fibrillation (AF). This irregular heart rate and rhythm is a common disorder in older Americans, and a significant stroke risk factor. It has been estimated that two million Americans, primarily over the age of 60, have AF and are six times more likely to have a stroke as a result. The drugs aspirin and warfarin had been used to prevent recurrent stroke in these individuals, however their use was based on little hard scientific evidence. To address this issue, NINDS supported a series of three trials in Stroke Prevention in Atrial Fibrillation - referred to as the SPAF trials. The SPAF I, II and III trials evaluated the use of aspirin and warfarin for stroke prevention in more than 3,800 human subjects. The SPAF I study reported in 1990 that both aspirin and warfarin were so beneficial in preventing stroke in patients with atrial fibrillation that the risk of stroke was cut by 50 to 80 percent. The results suggested that 20,000 to 30,000 strokes could be prevented each year with proper treatment. The SPAF II study results in 1994 identified the 60 percent of people with atrial fibrillation for whom a daily adult aspirin provides adequate protection against stroke with minimal complications. This group consists of those younger than 75 and those older than 75 with no additional stroke risk factors such as high blood pressure or heart disease. SPAF III, which included 1,044 patients at 20 medical centers in the U.S. and Canada, studied the remaining 40 percent of atrial fibrillation patients with additional risk factors for stroke and for whom warfarin had been shown to be effective. The study was stopped ahead of schedule in 1996 because early results clearly demonstrated the benefit of standard warfarin therapy over the combination therapy of aspirin and fixed-dose warfarin, in these high-risk patients. Other reports have estimated that the use of warfarin to prevent strokes in persons with AF costs as much as $1,000 annually, but a year of post-stroke treatment can cost $25,000. Based on these estimates, optimal use of standard warfarin therapy in the appropriate patients could prevent as many as 40,000 strokes a year in the U.S., and save nearly $600 million a year in health care costs.

Other studies supported by the Institute, such as the Warfarin Antiplatelet Recurrent Stroke Study, the Vitamin Intervention for Stroke Prevention study, the African-American Antiplatelet Stroke Prevention Study, and the Women's Estrogen for Stroke Trial, build on these earlier findings, and continue to add to our knowledge about medical interventions that can affect the incidence of stroke in different at-risk groups.

The NINDS has also supported several major studies of surgical approaches to the secondary prevention of stroke. This work has particular significance for people with carotid artery stenosis, a narrowing of the major blood vessels that supply the brain. One definitive study in the late 1970s examined a procedure called extracranial/intracranial (EC/IC) bypass. EC/IC bypass had been used for several years as a means to restore blood flow to the brain. The NINDS-funded study of the procedure's effectiveness found that the data did not support its continued use in medical practice to prevent stroke. These findings were of significant benefit to patients, who could avoid the risks and costs of this surgery, and to researchers, who used this information to redirect their attention to other promising approaches. As a result, investigators explored an alternative surgical strategy, called carotid endarterectomy, which involves the removal of fatty deposits, or plaque, in the carotid arteries. In two NINDS-funded trials - the North American Symptomatic Carotid Endarterectomy Trial (NASCET), and the Asymptomatic Carotid Atherosclerosis Study (ACAS) - this approach was examined more extensively.

The results of the 12-year NASCET trial were reported in two stages. The investigators' early data led to a radical change in the recommended treatment for severe (70-99 percent) carotid stenosis, or blockage, when it was determined that, together with appropriate medical care, carotid endarterectomy for patients with severe blockage prevented more strokes than did medical treatment alone. NINDS responded to this finding by halting the part of the study involving patients with severe blockage, and issuing a nationwide alert to physicians asking them to consider the study results in making recommendations to their patients. The rest of the study focused on determining the efficacy of this surgery for symptomatic patients with moderate carotid stenosis (30-69 percent blockage). Those results showed that patients with the higher grades of moderate stenosis (50-69 percent) clearly benefit from surgery. There was no significant benefit for patients with less than 50 percent stenosis. As a result of the NASCET trial, patients with moderate stenosis are better able to decide whether to risk surgery in order to prevent possible future strokes.

In the ACAS trial, carotid endarterectomy was found highly beneficial for persons who are symptom-free, but have a carotid stenosis of 60 to 99 percent. In this group, the surgery reduces the estimated 5-year risk of stroke by more than one-half, from about 1 in 10 to less than 1 in 20.

To the long list of studies contributing to improvements in secondary stroke prevention, we can add a more recent NINDS-funded trial, which resulted in the first FDA-approved acute treatment for ischemic stroke, in 1996. This therapy - tissue plasminogen activator or t-PA - dissolves blood clots and restores blood flow, if given intravenously within the first three hours after an ischemic stroke. Patients must be screened carefully before receiving t-PA, since it is not appropriate for use in treating hemorrhagic stroke, and should not be given beyond the three-hour window. However, in carefully selected patients, use of t-PA can achieve a complete recovery. Unfortunately many, indeed most, stroke patients do not receive t-PA because they do not arrive at the hospital in time to be evaluated and treated within the crucial three-hour window of effectiveness. Or, in many cases, hospitals are not prepared to rapidly identify and treat these patients. It is this dual challenge that NINDS is actively pursuing through the development of model systems and through education and outreach efforts that are discussed later in my testimony.

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Recent Advances

Within the framework of these historical successes, NINDS continues to build its basic science and clinical stroke programs, and to reap the rewards of past investments. A sampling of these recent advances includes:

The use of medical therapy to prevent recurrent stroke in people without cardiac risk factors
As described above, past clinical studies provided important information about preventing recurrent stroke in people with cardiac arrhythmias. However, it has been difficult for physicians to choose between aspirin and warfarin for patients who do not present with cardiac risk factors. To help address these questions, another large clinical trial - the Warfarin versus Aspirin Recurrent Stroke Study (WARSS) was initiated with NINDS support. More than 2000 individuals with a history of stroke unrelated to cardiac problems participated in this study, with equal groups receiving aspirin and warfarin. After two years of treatment, there was no significant difference in the prevention of recurrent stroke or death, or in the rate of brain hemorrhage, in the aspirin and warfarin groups. This finding will likely have a major impact on the standard of care for this group of stroke survivors, since aspirin is considerably less expensive, safer, and easier to administer than warfarin.

The use of the "warning signs" of stroke to aid in prevention
Recently, NINDS-funded researchers evaluated the risk of stroke after a transient ischemic attack (TIA), or "mini-stroke." The symptoms of TIAs pass quickly, within a day or even hours, and are often ignored. After following 1700 people with a TIA, the study found that these episodes warn of a dramatically increased likelihood of experiencing a stroke within the subsequent 90-day period. Other risk factors, such as advanced age, other health conditions, and severity of the TIA, also helped to predict stroke risk, and may be useful in determining whether patients should be hospitalized immediately and/or receive preventive interventions following a TIA.

The development of clinical tools that can be used to predict stroke recovery
In order to offer clinicians the best possible methods for evaluating patients after a stroke, intramural investigators at NINDS have explored the types of clinical measurements and diagnostic tools that might be used to predict how well a person will recover from a stroke. They found that the combined use of a unique type of magnetic resonance imaging, the score on the NIH Stroke Scale - a diagnostic tool developed at NINDS for evaluating stroke patients, and the time from the onset of symptoms to the brain scan, can effectively predict the extent of stroke recovery. Future studies will focus on the potential of computerized tomography (CT) scanning to predict recovery as this is a technology more commonly available in most hospitals. We expect that all of these tools will help physicians manage patients more efficiently and reduce distress and anxiety among patients and their families.

Brain plasticity
Over the last several years research has revealed the remarkable extent of brain plasticity - that is, the capacity of the brain to change in response to experience or injury. Scientists are now using brain imaging techniques that reveal the activity of brain cells, as well as structure, to understand why some patients recover lost abilities following stroke and others do not. In other efforts, researchers are trying to apply what has been learned about brain plasticity to encourage stroke recovery through a method called "constraint-induced therapy." This therapy involves constraining an unaffected extremity while actively exercising the affected one, thereby inducing use-dependent brain reorganization.

The use of stem cells to treat stroke in animal models
Stem cells are immature cells that can multiply and form more specialized cell types. Recent animal studies have provided evidence that transplanted stem cells can help restore brain function after stroke. Other animal research suggests that the adult brain may itself have a latent capacity to regenerate new cells following stroke, which might be encouraged in efforts to repair the brain. The continuing efforts to develop these approaches to restoration of function in survivors of stroke build on active NINDS support to understand the basic biology of animal embryonic stem cells and adult human stem cells. Within the President's policy guidelines, the Institute is encouraging research to evaluate the capabilities of human embryonic stem cells.

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Current Stroke Initiatives

The generous appropriations provided by Congress have made it possible for us to expand our programs in stroke, and we are grateful for the opportunity. Since the doubling of the NIH budget began in FY 1999, the Institute has initiated many new clinical and basic science projects. Currently, the Institute is supporting 14 Phase III clinical trials in stroke, eight of which have been initiated since the start of the doubling effort. Even more importantly, the doubling effort has enabled NINDS to fund 17 Phase I and II clinical trials in stroke. These numbers are impressive and indicate that many novel prevention strategies, therapeutic interventions, and rehabilitation techniques for stroke are closer to the clinic as a result of the significant investments in NIH over the past several years. Areas of clinical research that are under exploration include the use of hypothermia to improve outcome following aneurysm surgery, the use of magnesium to treat stroke, and improvements in stroke imaging techniques. Several studies, including research in the NINDS intramural program at the NIH Clinical Center, are examining various strategies for rehabilitation after stroke including the use of constraint therapy, exercise, anesthesia, and electrical stimulation to improve functional recovery.

NINDS also continues to be committed to exploring stroke at the basic science level, and has provided funding for many new projects since the doubling effort began. These include studies of procedures and drugs that may protect the brain against further injury, a possible vaccine for stroke, the role of inflammation, the expression of genes and proteins in response to stroke, and pre-clinical testing of therapies - just to name a few. Cellular "communications" between blood vessels, neurons, and glia, and the role of the blood-brain barrier, are also subjects of intense interest. In addition to studies specifically targeted to stroke, NINDS also provides support for many areas of basic neuroscience research that have broad applicability to stroke and other brain injuries. These include mechanisms of cell survival and death, neural growth factors, stem cell therapy, neuronal plasticity, and glial cell biology.

In addition to the investigator-initiated projects that make up the core of our grant programs, NINDS is constantly looking for understudied areas in stroke research that the Institute could address through the use of targeted initiatives. Several years ago, NINDS identified a need for acute stroke centers, and in May 2001, we issued a grant solicitation for Specialized Programs of Translational Research in Acute Stroke (SPOTRIAS). The goal of the SPOTRIAS program is to reduce disability and mortality in stroke patients, by promoting rapid diagnosis and effective interventions. It will support a collaboration of clinical researchers from different specialties whose collective efforts will lead to new approaches to early diagnosis and treatment of acute stroke patients. In its report language for the Institute's FY2001 appropriation, the Senate also encouraged the creation of acute stroke research or treatment research centers to provide rapid, early, continuous 24-hour treatment to stroke victims, and noted that a dedicated area in a medical facility with resources, personnel and equipment dedicated to treat stroke, would also provide an opportunity for early evaluation of stroke treatments. The SPOTRIAS program is responsive to the recommendation highlighted by the Senate. Institutions supported under this program must be able to deliver rapid treatment for acute stroke and to conduct the highest quality translational research on the diagnosis and treatment of acute ischemic and hemorrhagic stroke. They will also help to recruit and train the next generation of stroke researchers. The SPOTRIAS initiative will facilitate the translation of basic research findings into clinical research, and ultimately, the incorporation of clinical research findings into clinical practice. The first two centers have recently been approved for funding under this program, and as more centers are added, it is expected that they will form a national network that will lead to significant changes in the care of stroke patients.

On a more local level, NINDS is also developing the "Acute Brain Attack Research Program" in the Baltimore-Washington Area. This effort has already established a 24-hour stroke research program in diagnosis and treatment at Suburban Hospital in Bethesda, Maryland, and our plan is to replicate this program in other medical facilities in the Baltimore-Washington metropolitan area, next targeting those serving predominantly inner city minority populations.

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Stroke Research Planning

While a significant knowledge base about stroke has been amassed through research supported by the NINDS, continually emerging discoveries and new technologies create constantly increasing research needs and scientific opportunities. Coupled with the increases in the NINDS budget as a result of the recent NIH doubling effort, it is necessary to identify clear scientific priorities, so that the Institute can determine the best uses for its resources. Such priorities will also serve as benchmarks for the broader scientific community against which progress can be measured. NINDS convened a Stroke Progress Review Group (Stroke PRG) to identify priorities in stroke research. The Stroke PRG had its origins in Fiscal Year 2001 report language from the House and Senate Appropriations Committees to the NINDS urging us to develop a national research plan for stroke. Following on the success of the Brain Tumor Progress Review Group, a joint collaboration between NINDS and the National Cancer Institute to identify priorities for research on brain tumors, NINDS decided to use a Progress Review Group to develop a plan for stroke research. Members of the Stroke PRG include approximately 140 prominent scientists, clinicians, consumer advocates - including leaders from the American Stroke Association and the National Stroke Association, industry representatives, and participants from other NIH Institutes. Together, these individuals represent the full spectrum of expertise required to identify and prioritize scientific needs and opportunities that are critical to advancing the field of stroke research.

At the Stroke PRG Roundtable meeting in July 2001, and in many subsequent discussions, the Stroke PRG report was developed - a comprehensive document that identifies the national needs and opportunities in the field of stroke research. The final draft of this report was submitted for deliberation and acceptance by the National Advisory Neurological Disorders and Stroke Council in February, and the final report was published in April 2002. The PRG report will be widely disseminated to the stroke community, and is available online at www.ninds.nih.gov (Search: Stroke PRG); copies were provided to the Committee earlier this week.

Several areas of scientific need are identified in the Stroke PRG report, but five consensus priorities emerged from the PRG:

  • Identification of the genes and proteins that contribute to stroke;
  • An improved understanding of the relationship of blood, blood vessels, and brain tissue;
  • A better appreciation of how blood flow is regulated and how it can be improved after stroke;
  • The development of combination therapies based on molecular and cellular pathways of injury; and
  • A better understanding of the neural mechanisms that regulate recovery after stroke.

Participants also identified a number of scientific resource needs including:

  • Access to new technologies that allow for large numbers of genes or proteins to be analyzed simultaneously;
  • Improved animal models of stroke that better simulate the human disease;
  • Improved methods of imaging the brain;
  • Improvements in clinical trial design and methods;
  • Development of a network of stroke centers;
  • A national database that would capture information on the burden of stroke; and
  • Better education and training for clinicians in the care of stroke patients.

The full PRG report expands on all of these issues, and provides in-depth analysis of the status of 15 different fields of stroke research. As we move forward from the planning process into the implementation phase, the Stroke PRG members will work with NINDS staff to "map" the Institute's current stroke research efforts to the recommendations of the report. Using this approach, we will be able to identify existing research gaps and resource needs, and to incorporate these into a formal implementation plan.

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Health Disparities in Stroke

NINDS recognizes that stroke is one of several neurological disorders that has a disproportionate effect on minority and underserved populations. For example, African Americans are twice as likely to die of stroke or complications from stroke as people in any other racial or ethnic group in the country, and Hispanics have a stroke rate two times higher than that of Caucasians. For this reason, we have identified stroke as a critical health disparities issue in several Institute planning efforts: health disparities in stroke was considered as an over-arching issue by the Stroke PRG panel; stroke is one of the top research priorities in the NINDS Five-Year Strategic Plan on Minority Health Disparities; and the Institute is also in the process of establishing a planning panel that will specifically address health disparities in stroke.

The NINDS is also working to establish prevention/intervention research networks throughout the extramural community, particularly in regions of the "Stroke Belt," an area in the Southeastern U.S. with stroke mortality rates approximately 25 percent above the rest of the nation. The goal is to foster stronger linkages between investigators at minority and majority institutions and community-based organizations in order to improve minority recruitment and retention in clinical studies - as one way of addressing health disparities. As part of this program, NINDS, working with the National Heart, Lung and Blood Institute (NHLBI) and the National Center for Research Resources, is developing the "Stroke and Cardiovascular Prevention-Intervention Research Program." The pilot phase of this program is at the Morehouse School of Medicine in Atlanta, Georgia.

In addition to these programs, NINDS supports a number of ongoing clinical projects that specifically address stroke in minority populations, including a new study that will examine the phenomenon of the "Stroke Belt." In this study, the role of geographic and racial differences as contributors to differential mortality rates will be examined and risk factors estimated. We are also engaged in targeting special public education efforts to minority populations, as I will describe later in my testimony.

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Stroke in Women

In addition, we recognize that stroke is a major health problem for women. To address this critical research area, NINDS is supporting studies that will help us to better understand gender differences in stroke. Specific projects include a clinical study to determine if hormone replacement therapy affects stroke severity, and a study examining blood flow in the brain and the role of female hormones in protecting brain tissue during ischemia. In all clinical trials, we ensure that appropriate numbers of women are enrolled, and many of these trials involve specific analyses to examine the effects of the intervention tested in the female participants. For example, we are currently supporting a clinical study that is comparing the efficacy of two procedures - carotid endarterectomy and carotid stenting - that unblock a clogged carotid artery in the neck, a significant risk factor for stroke. Previous research has shown that women may not benefit from carotid endarterectomy as much as men do, so one facet of the trial will examine gender differences in these procedures.

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Education and Outreach Programs

NINDS recognizes that supporting research into new prevention strategies and treatment options is only part of the battle in reducing the health burden of stroke. Helping people to recognize that they are having a stroke, so that they can seek help immediately, is a critical first step. To address this problem, the NINDS directs an extensive health promotion effort to raise awareness of the signs and symptoms of stroke, the need for urgent action if experiencing a stroke, and the possibility of a positive outcome with timely hospital treatment.

In May 2001, the NINDS launched the "Know Stroke. Know the Signs. Act in Time" campaign, a multi-faceted public education campaign to educate people about how to recognize stroke symptoms, and then to call 911 to get to a hospital quickly for treatment. The campaign's target audiences are those most at-risk for stroke - primarily people over the age of 50 - and their family members, caregivers and health care providers. Because stroke attacks the brain, a stroke patient often cannot act alone to call 911 and seek medical treatment, so bystanders are integral to acting quickly and getting stroke patients to the hospital. For this activity, the NINDS developed a wide variety of public education materials including airport dioramas jointly sponsored with the National Stroke Association, billboard displays, an award-winning eight minute film, consumer education brochures, exhibits, and new radio and television public service announcements (PSAs). All indications are that the "Know Stroke" campaign has been extremely well-received and effective. The television PSA garnered more than 87 million viewer impressions and hundreds of thousands of dollars worth of free broadcast time; the radio PSAs received more than 46,000 broadcasts on 272 stations; the airport dioramas received more than 800 million annual impressions; and thousands of nursing homes, hospitals, senior centers and other organizations have received consumer education materials.

All of our public education strategies are designed to increase awareness of stroke. However, since the problem of stroke is even more acute in the African American and Hispanic communities, some are targeted to specific at-risk minority communities. These campaigns started with outreach to the media in May 2002 for Stroke Awareness Month and, in the coming months and years, will include public service advertising and grassroots community education components. NINDS also co-sponsored a "Stroke Sunday" program in October 2000, with the American Stroke Association and the Black Commissioned Officers' Advisory Group of the U.S. Public Health Service. This program was led by the former U.S. Surgeon General, Dr. David Satcher, and I participated on behalf of the NINDS. Held at a Rockville, Maryland church, the event was designed to bring attention to the major impact of stroke in the African American community and to help inform participants about reducing their stroke risk.

NINDS also participates in "Operation Stroke," a coalition of health care professionals, allied health providers, civic leaders and representatives of community organizations for stroke education. This effort is being coordinated by the American Stroke Association, and is aimed at the public as well as medical professionals. An intramural investigator at NINDS, who is a stroke clinician, is chairing this coalition in the greater D.C. and Maryland suburban areas.

Finally, NINDS has held several meetings and workshops to help educate health care professionals about advancements in stroke research, like t-PA. For example, our Institute held a major national scientific meeting after the publication of the t-PA study that involved more than 400 medical professionals. We plan to convene another conference later this year to revisit stroke treatment, and to explore how more people can be encouraged to recognize stroke as an emergency medical situation. The Institute hopes to use this symposium to educate healthcare professionals about the benefits of early treatment for all stroke patients. In addition, NINDS scientists speak at medical meetings all over the country in order to educate physicians about effective stroke care, and our grantees produce educational videos and offer continuing medical education courses on proper administration of t-PA. To complement these efforts, NINDS also distributes free copies of the NIH Stroke Scale.

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Partnerships

As part of our ongoing prevention efforts, we have formed collaborative relationships with other NIH Institutes and federal agencies, and numerous voluntary organizations. NINDS coordinates the Brain Attack Coalition - a group of professional, voluntary, and government groups dedicated to reducing the occurrence, disabilities, and death associated with stroke - to increase awareness of stroke symptoms. To encourage improvements in stroke care, the Brain Attack Coalition published an article in June 2000 designed to help physicians and hospitals set up stroke centers.

In February 2001, the NINDS signed a memorandum of understanding (MOU) with NHLBI, the Centers for Disease Control and Prevention (CDC), the HHS Office of Disease Prevention and Health Promotion, and the American Heart Association to foster cooperation in reaching the heart disease and stroke goals for the nation articulated in the Healthy People 2010 initiative. These goals include: the prevention of risk factors for cardiovascular disease (CVD) and stroke; the detection and treatment of risk factors; the early identification and treatment of CVD and stroke, especially in their acute phases; and the prevention of recurrent CVD and stroke, and their complications.

In order to achieve these goals, we will work with the participating partners on focused initiatives such as population- and community-based public education and health promotion programs; activities to bring about improvements in the nation's cardiovascular health care delivery systems; media-based public awareness campaigns about the warning signs and symptoms of heart attack and stroke; promoting professional education and training, and other activities. CDC has already used our public education materials in cooperation with their networks, and we are enthusiastic about this partnership, and anticipate that it will continue for the next several years.

NINDS is also participating in the development of a comprehensive National Action Plan for Cardiovascular Health - A Comprehensive Public Health Strategy to Combat Heart Disease and Stroke. This planning process was initiated last year by the CDC. It will chart a course for the CDC with the states, territories and other partners - including public health agencies, health care providers, and the public - for achieving national goals for heart disease and stroke prevention over the next two decades. The pillars of this public health strategy incorporate the three core functions of public health: assessment, policy development, and assurance.

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Conclusion

NINDS has made, and continues to make, significant contributions to the achievements in stroke prevention, treatment, and rehabilitation, and we are extremely proud of our accomplishments. However, the incremental nature of progress in stroke prevention has confirmed that there is no easy route to success. There are still difficult challenges to be addressed, and we have invested more than a year in gathering recommendations from the best clinicians and researchers in the field, as well as our committed partners in the advocacy community, in order to help us make the best use of our resources.

Our planning efforts tell us we must continue to pursue, in parallel, several areas of basic, translational, and clinical research that may have an impact on stroke. We must find better ways to prevent strokes before they occur. We must improve upon and encourage acceptance of pioneering diagnostic tools and acute treatments for when stroke happens. We must capitalize on the prospect, for the first time, of actually repairing the brain damaged by stroke and recovering function. The broad portfolio of NINDS research on stroke offers a glimpse of what the future might bring - the possibility of vaccines, genetic tests to tailor preventive measures for each individual, studies that may link infections or inflammation within blood vessels to stroke, biological markers that could aid in the identification of stroke risk, and new information about how chronic stress and hormones may affect susceptibility to stroke damage. Encouraged by the recent progress in neuroscience, guided by extensive and inclusive planning, and enabled by the support from Congress, I assure you that NINDS is committed to pursuing all of these opportunities to alleviate the devastating effects of stroke on our society.

Thank you again for the opportunity to speak with you today. I would be happy to answer any questions you may have.

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Last updated February 09, 2005