Background--More than 700 000 strokes occurred in the United States during 2002, of which approximately 500 000 are first-ever strokes and 200 000 recurrent strokes. If we would decrease the enormous burden of stroke throughout the world, we first need to know the barriers that we have to overcome. These are quite similar to the barriers that we have tried to surmount during the last 25 years.

Stroke Prevention--We have developed many successful primary and secondary therapies to prevent stroke over the past 25 years and have begun to understand some of the genetic risk factors underlying stroke. Yet, the incidence rate of stroke in Rochester, Minn, remained unchanged from 1975 to the mid-1990s, and mortality rates for Ohio have changed little for men, women, blacks, and whites over the past decade. The primary reason that we have made little progress in decreasing the burden of stroke is that we have made little progress in modifying the primary risk factors for stroke in the population. Other barriers of improved stroke prevention in the future include costs of therapy and aging of blood vessels and brain, which is the most important risk factor for stroke.

Acute Stroke--Breakthroughs in acute stroke treatment are likely to follow the steps of cardiology with the primary focus for ischemic stroke on the restoration of oxygenated blood flow to ischemic brain as quickly as possible. To improve acute stroke therapy in the year 2025, we need to have more focused messages sent to the lay public about stroke warning signs, better and safer methods to open arteries quickly, truly effective neuroprotection in the setting of reperfusion, regional organization for acute stroke therapy, and large randomized trials to find clinically important but smaller benefits. A scientifically proven treatment for treatment of acute intracerebral hemorrhage is another major goal.

Recovery After Stroke--Brain recovery after stroke is the area of scientific discovery with the largest potential for advances far into the next century. Obstacles that block effective therapies in the recovery from stroke include the extent of initial injury from stroke, the brain plasticity of a given patient, and, most importantly, understanding the "neural code"--how the brain is organized and how cells communicate with one another.