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Development of botulinum toxin therapy.

MR techniques, however, promise to increase the capacity to define early changes. Diffusion-weighted imaging measuring translational movements of water detects and localizes ischemic fields within 30 minutes of onset. Perfusion imaging with ultrafast tracking of the passage of a bolus of contrast provides an immediate quantitative assessment of cerebral tissue blood flow and volume. Magnetic resonance spectroscopy allows the tracking of metabolites within neurons that distinguishes normal cells, infarcted cells, and ailing but still viable penumbral cells. At selected centers developing new echo planar hardware, concurrent standard MR imaging, MR angiography, diffusion MR, and perfusion MR imaging can be done in patients with acute stroke in only 12 minutes. The result is a comprehensive pathophysiologic picture of brain anatomy, vessel stenoses, tissue ischemia, and tissue perfusion available in the acute stage to guide therapeutic decision making. Mobilization of the clinical care system for patients with acute stroke is necessary for emerging therapies to be applied. The few studies in animals and humans that have examined the duration of focal ischemia required to produce irreversible neuronal damage suggest that the therapeutic window for brain resuscitation is brief, between one and six hours after onset. In the past, however, the identification, triage, and treatment of patients with ischemic stroke have rarely been rapid, and most patients had therapy initiated after this window had closed. Clinical centers participating in trials of cytoprotective and thrombolytic therapies have shown that intensive education of the public and referring physicians, the development of dedicated stroke teams and units, and the institution of code stroke protocols may dramatically reduce delays to patient presentation, emergency evaluation, and the initiation of treatment. The optimal delivery of current therapies and continued progress in developing promising new therapies depend on galvanizing the medical system to approach stroke like trauma, as a treatable, rapidly evolving neuroemergency.