Bold aim in stroke: spare the brain.

Doctors of stroke patients were once so hampered by the lack of a remedy that they served mainly as "guides on a tragic journey," as one physician put it. Now, a newly available drug promises to change that-and health authorities have proposed a national strategy to speed patients into treatment in an effort to limit brain damage.

"The goal is to change the paradigm for the treatment of stroke in this country," Zach W. Hall, director of the National Institute of Neurological Disorders and Stroke (NINDS) in Bethesda, Md., told members of 50 medical groups meeting in Arlington, Va., last week to draft the plan.

The drug is tissue plasminogen activator, tPA, which dissolves blood clots. Developed by Genentech of South San Francisco, Calif., the intravenous drug has been used for 9 years to treat people having heart attacks. In June, the Food and Drug Administration approved a low-dose version for people suffering from strokes caused by clots that obstruct blood flow to the brain.

Trade-named Activase, tPA is effective only against these so-called ischemic strokes; it cannot help someone with a stroke caused by a hemorrhage. Since 80 percent of the 500,000 strokes that occur each year in the United States are ischemic, however, tPA could save thousands of people from paralysis and dependence on others.

A blood clot that causes ischemic stroke forms elsewhere in the body before breaking loose and traveling to the proximal cerebral artery. There, it cuts off blood flowing to the nerve centers that control speech and movement, causing weakness or numbness of the face or limbs, impaired vision, slurred speech, and unsteadiness.

Doctors must begin treating stroke victims within 3 hours in order to restore blood flow. The new strategy begins with a publicity campaign to ensure that anyone who experiences or witnesses a stroke knows what symptoms to look for. Other key elements include quick transportation to the hospital, rapid diagnosis using a CT scan of the brain, treatment with tPA, and rehabilitation.

"Brain cells are dying each minute after a stroke occurs-time equals brain," said John R. Marler, the NINDS medical officer who voiced jubilation that doctors would no longer have to serve merely as guides for patients descending into debility. Marler supervised a multicenter trial showing that 12 percent of patients given tPA quickly reverted to normal. Six percent of the patients who got tPA suffered hemorrhaging, however, and had to forgo the treatment.

Just 4,000 stroke patients have been treated with the drug since it was approved, said Paul Laland, a Genentech spokesman. Doctors would like to extend treatment to 40,000 people by the end of next year.

The drug costs $2,200 per treatment, but this figure is a fraction of the $30,000 annual cost of sustaining one stroke patient in a nursing home.

Most hospitals have stocks of tPA on hand to treat heart attack patients, who get a higher dose. The new strategy, to be released in a month through the groups that attended the meeting, would also recommend that all hospitals have a CT scanner available and a stroke "code team" of trained doctors, nurses, and technicians on call around the clock.

The new procedures don't guarantee that treatment will reach most patients. Just 10 to 15 percent of hospitals now have stroke protocols. Although tPA has been available for nearly a decade, fewer than 35 percent of heart attack patients receive it.

James C. Grotta of the University of Texas Medical School in Houston objected that the new stroke guidelines fail to designate qualified hospitals as stroke centers. Consequently, paramedics won't know where to take patients, he said, and patients who expect tPA may not get it and "will be upset."

William G. Barsan of the University of Michigan Medical Center in Ann Arbor said the guidelines "rely on primary physicians to send the patient to the right place."