1. Basic Premise In well organized systems, IV tPA is an effective therapy for appropriately selected acute ischemic stroke patients In well organized systems, IV tPA is an effective therapy for appropriately selected acute ischemic stroke patients

2. In years since 1995 for patients you have:- Refined “appropriate” selectionRefined “appropriate” selection Tested and refined evaluation and delivery protocolsTested and refined evaluation and delivery protocols Established worse outcome for protocol violationEstablished worse outcome for protocol violation

3. In years since 1995 for systems you have:- Developed dedicated stroke centers or strategic networksDeveloped dedicated stroke centers or strategic networks Tested models of stroke center structureTested models of stroke center structure Studied regional environment and adapted centers and networks to suitStudied regional environment and adapted centers and networks to suit Recognized the need to generalize the systemsRecognized the need to generalize the systems

4. Outcomes of your efforts:- Less than five percent of acute stroke receive tPA on average nationwide Best centers treat around ten percent stroke admissions

5. Problems you face are:- You use TIME as marker of therapeutic windowYou use TIME as marker of therapeutic window Awareness in a disease that destroys awarenessAwareness in a disease that destroys awareness Pre-admission delaysPre-admission delays Geographic limitationsGeographic limitations Disagreements on basic premise of effectivenessDisagreements on basic premise of effectiveness No reimbursementNo reimbursement Health care SYSTEMNESS variableHealth care SYSTEMNESS variable Aging enthusiasts! Disinterested young!Aging enthusiasts! Disinterested young!

6. What you need is:- UNIVERSAL HEALTH CARE

7. What you need is:- Community/EMS based intense simple sustained message for EXPECTED immediate actionCommunity/EMS based intense simple sustained message for EXPECTED immediate action Employ PROFESSIONALS,educationalists, social and systems scientists, health policy and managementEmploy PROFESSIONALS,educationalists, social and systems scientists, health policy and management Comprehensive accredited stroke centers and networks, including rural systems?Comprehensive accredited stroke centers and networks, including rural systems? Professional educationProfessional education

8. What you need is:- National guidelines for stroke care with oversight and societal priority for emergent stroke care systemNational guidelines for stroke care with oversight and societal priority for emergent stroke care system Incentive of societal and professional cost effectiveness systemIncentive of societal and professional cost effectiveness system Accessible advanced communicative, diagnostic, and material support to the systemAccessible advanced communicative, diagnostic, and material support to the system

9. What you need is a CHAMPION:- SECRETARY FOR STROKE IN THE BUSH CABINET !! PEPE FOR PRESIDENT !!