As stroke therapies develop, the context in which stroke care is provided is becoming more important. Creating and maintaining a good organization of stroke care within a region or even a hospital requires much commitment and effort. The European Stroke Initiative provides a good set of evidence-based recommendations. An American Stroke Association task force recently published a set of recommendations on systems of stroke care.

Timely care

Time is emerging as an important factor in improving outcome. IV TPA must be given within 3 hours, with better results the earlier it is administered. Most investigational stroke therapies for both ischemic and hemorrhagic strokes are focusing on early therapies. A number of important points arise:

• Promotion of public awareness. Patients, family and the general public must be educated regarding stroke symptom recognition, available stroke therapies, and the importance of emergency medical care.

• Education of prehospital providers. Dispatch personnel, ambulance drivers, emergency medical technicians, paramedics, and their medical supervisors must agree to prioritize acute stroke and train to increase stroke recognition.

• Coordination of speedy triage and evaluation. Acute stroke patients must be evaluated in a timely fashion, and preferentially transported to a stroke center if one is available. In Houston, prehospital providers notify the receiving facility or stroke team directly and shorten the time to evaluation. Emergency department physicians should evaluate immediately after patient arrival. Stroke team members should be notified at the earliest yet most practical time possible.

• Stroke team. The establishment of a specialized stroke team helps in concentrating expertise and improving the availability of acute stroke care.