Recently, a question has been raised about the use of the term brain attack to refer to a cerebrovascular clinical episode. To put this term in context, I offer the following historical summary of the terms used in modern times and the factors that led to their adoption.In the 1950s, cerebral vascular disease (CVD) was the common term used to describe disorders of the cerebral circulation. The clinical entity was usually referred to as a stroke. Although not as popular as stroke, the term cerebral vascular accident (CVA) also was sometimes used to describe the clinical event; however, some felt uneasy about the implications of describing the event as an accident.The clinical responsibility for diagnosis and treatment (what little were available) was the responsibility primarily of family physicians and internists; neurologists and neurosurgeons typically were involved as consultants in unusual or difficult cases. Only a small number of clinical neurology units gave targeted attention to stroke (eg, the clinical neurology units at Massachusetts General Hospital, Mayo Clinic, University of Minnesota College of Medicine, Bowman Gray School of Medicine, Baylor University College of Medicine, and Duke University College of Medicine). At the National Institutes of Health (NIH), research into cerebral vascular disease was considered a responsibility of the National Heart Institute (NHI); however, the NHI devoted no targeted research to this area. CVD was included in the NHI programs on atherosclerosis and hypertension and used as an example of the clinical consequences of those pathologies. NHI-supported clinical studies were rare.Dr Pearce Bailey, director of the newly authorized NIH National Institute of Neurological Diseases and Blindness (NINDB), felt that clinical disorders due to dysfunction of the cerebral circulation were disorders of the brain and should be included as an identified endeavor of the NINDB. In testimony to the US Congress in the mid-1950s, Dr Bailey discussed the need for targeted neurologic attention to stroke research, using the terms cerebrovascular disease and stroke in his presentation and discussion. But although it laid claim to responsibility for research in this area, the NINDB initiated no targeted endeavors on stroke research. Brain-oriented investigator-initiated stroke research grant proposals were funded by the NINDB (with vascular-oriented grants funded by the NHI), but the support for cerebrovascular research was a passive activity in both organizations; if a research grant application was received and approved, it was funded.Dr Bailey's successor at the NINDB, Dr Richard Masland, recognized the need for a staff focal point to promote the active development of neurologically oriented stroke research in the NINDB's extramural grant and contract programs. In 1960, Dr Masland recruited a small staff, directed by Dr Murray Goldstein, to further the stroke research program. One of the new stroke program's targeted activities was to address the confusing language being used when discussing and reporting on stroke research; another targeted activity was the awarding of NINDB program project grants to 10 institutions for the development of stroke clinical research centers.In response to the need for improved communication, in the mid-1960s, an ad hoc NINDB Committee on Cerebrovascular Disease was organized, with Dr Clark Millikan as chair. The responsibility of this committee was to “place in classified form the known types of cerebrovascular disease in such a manner that all or a portion of the classification will be of value to clinicians, pathologists, physiatrists as well as other disciplines; give practical meaning to the classification by defining the terms so they can be used interchangeably by clinicians and investigators in various parts of the country; and set down in organized fashion the salient diagnostic criteria for a number of clinical entities.”1National Institutes of Health. A Blueprint for National Action Against Stroke: Report of the Commission on Stroke of the National Institute of Neurological Diseases and Stroke, National Institutes of Health. March 30, 1973.Google ScholarThe Committee used the term cerebrovascular diseases to denote all disorders in which there is an area of brain transiently or permanently affected by ischemia or bleeding, or in which one or more brain blood vessels are primarily involved in a pathological process, or a combination of the two. The Committee used the term stroke to describe specific clinical events (eg, progressing stroke, completed stroke).The Committee's report, titled “A Classification and Outline of Cerebrovascular Diseases,” was widely distributed nationally and internationally by the NINDB.1National Institutes of Health. A Blueprint for National Action Against Stroke: Report of the Commission on Stroke of the National Institute of Neurological Diseases and Stroke, National Institutes of Health. March 30, 1973.Google Scholar It was well received and became the lingua franca of the international stroke community. In 1975, in response to the considerably expanded body of knowledge on cerebrovascular disease, this classification system was revised by a second ad hoc NINDB Committee on Cerebrovascular Disease, again chaired by Dr Clark Millikan. That Committee's report, titled “A Classification and Outline of Cerebrovascular Diseases II,”2National Institute of Neurological Diseases and Blindness, Committee on Cerebrovascular Disease. A Classification and Outline of Cerebrovascular Diseases II.Stroke. 1975; 6: 565-616Google Scholar also was widely distributed by the NINDB and continues to serve as a common language for physicians and scientists. But with the extensive development of brain imaging technologies since 1975, the time is probably right to revisit cerebrovascular terminology.Through individual and sometimes joint efforts of the NINDB (later the National Institute of Neurological Disorders and Stroke), the Stroke Council of the American Heart Association (AHA), and the National Stroke Association, national public information programs to alert the public to the warning signs of stroke were initiated in the 1980s and 1990s. Some working on these programs felt that a catchy term was needed to capture the public's attention, particularly regarding the warning signs of stroke. Cerebrovascular disease was not a term the public used easily; cerebrovascular accident also was not in common use. The more common term “stroke” was considered insufficiently dramatic. In response, the AHA Stroke Council believed that an emotionally labeled term comparable to heart attack needed to be developed and suggested the term brain attack. Thus, a public alert term was born for public information purposes and was adopted by a number of organizations as a label for educating the public to the warning signs of a pending cerebrovascular clinical event. Brain attack was not intended to substitute for cerebrovascular disease, just as the term heart attack was not intended to substitute for cardiovascular disease. A Brain Attack Coalition was organized to foster joint activities of the several organizations interested in public education about the clinical event.Having said all of the foregoing, it is my impression that at this time, stroke is the most common term used by the public and physicians when discussing with the public either the warning signs of a cerebrovascular clinical episode (eg, The person is in danger of having a stroke), an acute clinical episode (eg, The person is having a stroke), or a completed episode (eg, The person has had a stroke). Other terms—CVA, brain attack—are used in some settings and may or may not be useful, depending on the background, objective, and pros and cons of the available alternatives.To the best of my recollection, that is the background of the cerebrovascular terminology in use at this time. Recently, a question has been raised about the use of the term brain attack to refer to a cerebrovascular clinical episode. To put this term in context, I offer the following historical summary of the terms used in modern times and the factors that led to their adoption. In the 1950s, cerebral vascular disease (CVD) was the common term used to describe disorders of the cerebral circulation. The clinical entity was usually referred to as a stroke. Although not as popular as stroke, the term cerebral vascular accident (CVA) also was sometimes used to describe the clinical event; however, some felt uneasy about the implications of describing the event as an accident. The clinical responsibility for diagnosis and treatment (what little were available) was the responsibility primarily of family physicians and internists; neurologists and neurosurgeons typically were involved as consultants in unusual or difficult cases. Only a small number of clinical neurology units gave targeted attention to stroke (eg, the clinical neurology units at Massachusetts General Hospital, Mayo Clinic, University of Minnesota College of Medicine, Bowman Gray School of Medicine, Baylor University College of Medicine, and Duke University College of Medicine). At the National Institutes of Health (NIH), research into cerebral vascular disease was considered a responsibility of the National Heart Institute (NHI); however, the NHI devoted no targeted research to this area. CVD was included in the NHI programs on atherosclerosis and hypertension and used as an example of the clinical consequences of those pathologies. NHI-supported clinical studies were rare. Dr Pearce Bailey, director of the newly authorized NIH National Institute of Neurological Diseases and Blindness (NINDB), felt that clinical disorders due to dysfunction of the cerebral circulation were disorders of the brain and should be included as an identified endeavor of the NINDB. In testimony to the US Congress in the mid-1950s, Dr Bailey discussed the need for targeted neurologic attention to stroke research, using the terms cerebrovascular disease and stroke in his presentation and discussion. But although it laid claim to responsibility for research in this area, the NINDB initiated no targeted endeavors on stroke research. Brain-oriented investigator-initiated stroke research grant proposals were funded by the NINDB (with vascular-oriented grants funded by the NHI), but the support for cerebrovascular research was a passive activity in both organizations; if a research grant application was received and approved, it was funded. Dr Bailey's successor at the NINDB, Dr Richard Masland, recognized the need for a staff focal point to promote the active development of neurologically oriented stroke research in the NINDB's extramural grant and contract programs. In 1960, Dr Masland recruited a small staff, directed by Dr Murray Goldstein, to further the stroke research program. One of the new stroke program's targeted activities was to address the confusing language being used when discussing and reporting on stroke research; another targeted activity was the awarding of NINDB program project grants to 10 institutions for the development of stroke clinical research centers. In response to the need for improved communication, in the mid-1960s, an ad hoc NINDB Committee on Cerebrovascular Disease was organized, with Dr Clark Millikan as chair. The responsibility of this committee was to “place in classified form the known types of cerebrovascular disease in such a manner that all or a portion of the classification will be of value to clinicians, pathologists, physiatrists as well as other disciplines; give practical meaning to the classification by defining the terms so they can be used interchangeably by clinicians and investigators in various parts of the country; and set down in organized fashion the salient diagnostic criteria for a number of clinical entities.”1National Institutes of Health. A Blueprint for National Action Against Stroke: Report of the Commission on Stroke of the National Institute of Neurological Diseases and Stroke, National Institutes of Health. March 30, 1973.Google Scholar The Committee used the term cerebrovascular diseases to denote all disorders in which there is an area of brain transiently or permanently affected by ischemia or bleeding, or in which one or more brain blood vessels are primarily involved in a pathological process, or a combination of the two. The Committee used the term stroke to describe specific clinical events (eg, progressing stroke, completed stroke). The Committee's report, titled “A Classification and Outline of Cerebrovascular Diseases,” was widely distributed nationally and internationally by the NINDB.1National Institutes of Health. A Blueprint for National Action Against Stroke: Report of the Commission on Stroke of the National Institute of Neurological Diseases and Stroke, National Institutes of Health. March 30, 1973.Google Scholar It was well received and became the lingua franca of the international stroke community. In 1975, in response to the considerably expanded body of knowledge on cerebrovascular disease, this classification system was revised by a second ad hoc NINDB Committee on Cerebrovascular Disease, again chaired by Dr Clark Millikan. That Committee's report, titled “A Classification and Outline of Cerebrovascular Diseases II,”2National Institute of Neurological Diseases and Blindness, Committee on Cerebrovascular Disease. A Classification and Outline of Cerebrovascular Diseases II.Stroke. 1975; 6: 565-616Google Scholar also was widely distributed by the NINDB and continues to serve as a common language for physicians and scientists. But with the extensive development of brain imaging technologies since 1975, the time is probably right to revisit cerebrovascular terminology. Through individual and sometimes joint efforts of the NINDB (later the National Institute of Neurological Disorders and Stroke), the Stroke Council of the American Heart Association (AHA), and the National Stroke Association, national public information programs to alert the public to the warning signs of stroke were initiated in the 1980s and 1990s. Some working on these programs felt that a catchy term was needed to capture the public's attention, particularly regarding the warning signs of stroke. Cerebrovascular disease was not a term the public used easily; cerebrovascular accident also was not in common use. The more common term “stroke” was considered insufficiently dramatic. In response, the AHA Stroke Council believed that an emotionally labeled term comparable to heart attack needed to be developed and suggested the term brain attack. Thus, a public alert term was born for public information purposes and was adopted by a number of organizations as a label for educating the public to the warning signs of a pending cerebrovascular clinical event. Brain attack was not intended to substitute for cerebrovascular disease, just as the term heart attack was not intended to substitute for cardiovascular disease. A Brain Attack Coalition was organized to foster joint activities of the several organizations interested in public education about the clinical event. Having said all of the foregoing, it is my impression that at this time, stroke is the most common term used by the public and physicians when discussing with the public either the warning signs of a cerebrovascular clinical episode (eg, The person is in danger of having a stroke), an acute clinical episode (eg, The person is having a stroke), or a completed episode (eg, The person has had a stroke). Other terms—CVA, brain attack—are used in some settings and may or may not be useful, depending on the background, objective, and pros and cons of the available alternatives. To the best of my recollection, that is the background of the cerebrovascular terminology in use at this time.
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