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(Stroke. 2005;36:1616.)
© 2005 American Heart Association, Inc.

Special Report

Editorial Comment—Organized Stroke Care

The Core of Effective Stroke Care Provision

Bo Norrving, MD, PhD

Department of Neurology, University Hospital, Lund, Sweden.

	Introduction

Top Introduction Basic Stroke Care: Still... Comprehensive Stroke Care Most Patients Are Not... Comprehensive Stroke Centers:... References

 
The past decade has witnessed a dramatic change in treatment of acute stroke, leaving the era of an indifferent approach firmly behind. However, equally important to the development of particular emergency treatments is the recognition that the organization of stroke services per se plays a key role in the provision of effective therapies and in improving the overall outcome after stroke.

In this issue of the journal, the consensus statement from the Brain Attack Coalition (BAC), a group with representatives from major professional and advocacy organizations involved in stroke care, with extensive recommendations for comprehensive stroke centers is published.¹ The report is a companion to the recommendations for the establishment of primary stroke centers published by the same group in 2000.²

	Basic Stroke Care: Still Not Fully Established

Top Introduction Basic Stroke Care: Still... Comprehensive Stroke Care Most Patients Are Not... Comprehensive Stroke Centers:... References

 
The previous report of the BAC² detailed 11 key elements of a primary stroke center to improve patient care and outcomes. Recommendations included acute stroke teams, stroke units, written care protocols, and an integrated emergency response system. A major impetus for the recommendation was clearly to establish the infrastructure and logistics to permit broad implementation of intravenous tissue plasminogen activator therapy within the 3-hour window according to the criteria of the NINDS trial. A survey showed that in 2001, emergency services for acute stroke therapy were in place at the majority of hospitals,³ and the situation has further improved later on.

However, and somewhat surprisingly from a non-US perspective, establishment of stroke units was given less emphasis in the BAC recommendations. Stroke units were not considered to be required for primary stroke centers that did not intend to provide care beyond the hyperacute period (ie, longer than the emergency department evaluation and emergency therapy), and stroke units did not need to be distinct hospital wards or units. In contrast, acute stroke teams, which lack scientific support for efficacy, were included among the key elements. The hospital survey³ showed that stroke units (and continuing staff education—an integral component of a stroke unit) were established at only 38% of the hospitals. A recent report provided a much more positive result (stroke units at 85% of hospitals), but only data from 34 academic centers participating in a quality improvement project were included in this study.⁴

Similar problems in translating knowledge into practice are presents in almost all other regions and countries worldwide. In the registry of the Canadian Stroke Network 31% received care on a stroke unit.⁵ The proportion was also low (23%) in an Australian stroke audit.⁶ In Europe, the 1995 Helsingborg declaration, prepared by World Health Organization Europe and the European Stroke Council in collaboration with 4 other professional societies, strongly emphasized the need to establish stroke units with acute admissions and set the target that organized stroke care should be available for all patients in the year 2005.⁷ However, this development is still in progress and the target has not been met. In most European countries, stroke unit care is available for half of all patients or less and is unevenly distributed.⁸ Only in Scandinavia has the proportion gradually increased to 75%. In most European countries, the elements of comprehensive stroke unit care outlined by the Stroke Unit Trialists’ collaboration^9,10 have been adopted and include assessment and monitoring, physiological management, early mobilization, skilled nursing care, and short-term multidisciplinary team rehabilitation services. At most centers, intravenous tissue plasminogen activator is given in such a unit. Thus, acute thrombolytic therapy is an integral part of the activities of a stroke unit, closely linked to prehospital and emergency services.

Clearly, the emphasis on various aspects of organized stroke care differs between regions, countries, and continents, which may reflect traditions as well as variations in health care systems. Intravenous tissue plasminogen activator therapy and stroke unit care are both top priorities in modern stroke management. However, we should not forget that because stroke unit care is applicable to all patients with stroke, the overall impact of this therapy is several-fold larger than that of intravenous tissue plasminogen activator therapy, for which patient selection criteria apply.¹¹

	Comprehensive Stroke Care

Top Introduction Basic Stroke Care: Still... Comprehensive Stroke Care Most Patients Are Not... Comprehensive Stroke Centers:... References

 
A proportion of stroke patients need more specialized therapy than what could be provided by a primary stroke center or nonintensive care stroke unit. The BAC defines a comprehensive stroke center (CSC) as a facility for stroke patients who require high-intensity medical and surgical care, specialized tests, and interventional therapies. The report reviews the scientific background and delineates the personnel expertise, advanced neuroimaging capabilities, surgical and endovascular techniques, and infrastructure at a CSC.¹

There is clear consensus that intensive care facilities are needed for a proportion of patients with stroke, eg, those patients who require intubation, ventilatory support, and intracranial pressure (ICP) monitoring. There is also strong scientific support (level 1 evidence) for surgical and endovascular therapy of intracranial aneurysms. However, the precise application of several other advanced therapies reviewed still remains to be established because of paucity of data from randomized controlled trials. Endovascular interventions for acute arterial occlusions intracranially (intra-arterial thrombolysis, clot removal, angioplasty), decompressive craniectomy for malignant middle cerebral artery infarction, extracranial carotid angioplasty and stenting, and microsurgical procedures for large-vessel occlusive disease belong to this group of treatments for which level I evidence permitting a grade A recommendation are still not available. Such procedures are today performed at many centers on an individual patient basis, but further studies are needed before their widespread use can be endorsed. The BAC recommendations adequately emphasize that, if performed, they should be performed by physicians who have the necessary skill and expertise. CSC also have an important role in contributing to systematic collection of data on such procedures and to provide the framework for performing randomized controlled trials and contribute to high-quality research. Quality control and stroke registers are also rightly emphasized as important elements at a CSC.

Comprehensive stroke centers also have an important role to act as an expertise resource and to provide education for other stroke facilities in the region. Establishment of partnerships between medical centers is necessary to provide best possible care and may include, eg, telemedicine service. Public education is another important activity. Even very recently published data show that more than two-thirds or more of all patients with stroke cannot even be considered for intravenous thrombolytic therapy within a 3-hour window because of patient delays in seeking emergency care.¹² Changing the patients’ behavior in the event of acute suspected stroke remains a major challenge.

	Most Patients Are Not Cured by Acute Stroke Therapies

Top Introduction Basic Stroke Care: Still... Comprehensive Stroke Care Most Patients Are Not... Comprehensive Stroke Centers:... References

 
For almost all patients with stroke, even those with a mild one,¹³ the event represents a major change in life. Although much attention has been given to management issues in the acute phase, the initial hospital period is extremely short viewed in a lifetime perspective. Even with intravenous tissue plasminogen activator and more advanced therapies, the proportion of all patients who are actually cured is very small. The majority will need further rehabilitation for long periods. Rehabilitation should start already in the acute phase, and even at an intensive care unit, as the patient’s condition permit. Appropriately, rehabilitation has been given a separate section in the BAC recommendations, although this part is less detailed than the other sections.

	Comprehensive Stroke Centers: Part of the Broad Package of Stroke Services Needed

Top Introduction Basic Stroke Care: Still... Comprehensive Stroke Care Most Patients Are Not... Comprehensive Stroke Centers:... References

 
Despite scientific proof for more than a decade on the effectiveness of organized stroke care, stroke systems are not fully implemented in practice. Opportunities for treatment are missed with serious consequences. All efforts to improve organization of stroke care should therefore be welcomed. Whereas activities at a CSC will certainly be modified as advanced diagnostic and therapeutic options are redefined or new therapies will emerge, it is an advantage that the infrastructure is in place so that organization of care is not lagging behind scientific advances.

The present recommendations should be viewed as an important part of the broad range of facilities that needs be implemented for stroke management in different stages.¹⁴ Establishing well-organized systems for stroke care is a major challenge for all regions and continents, and it deserves the full cooperation of professionals and health care providers

	References

Top Introduction Basic Stroke Care: Still... Comprehensive Stroke Care Most Patients Are Not... Comprehensive Stroke Centers:... References

 

1. Recommendations for Comprehensive Stroke Centers: A Consensus Statement from the Brain Attack Coalition. Stroke. 2005; 36: 1597–1616.[Abstract/Free Full Text]
2. Alberts MA, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayberg MR, Starke RD, Todd HW, Viste KM, Girgus M, Shephard T, Emr M, Schwayder P, Walker MD, for the Brain Attack Coalition. Recommendations for the establishment of primary stroke centers. J Am Med Assoc. 2000; 283: 3102–3109.[Abstract/Free Full Text]
3. Kidwell CS, Shephard T, Tonn S, Lawyer B, Murdock M, Koroshetz W, Alberts M, Hademenos GJ, Saver JL. Establishment of primary stroke centers. A survey of physician attitudes and hospital resources. Neurology. 2003; 60: 1452–1456.[Abstract/Free Full Text]
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9. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev. 2002; Issue 2:CD000197.
10. Langhorne P, Pollock A. What are the components of effective stroke unit care? Age Aging. 2002; 31: 365–371.[Abstract/Free Full Text]
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12. California Acute StrokePilot Registry (CASPR) Investigators. Prioritizing interventions to improve rates of thrombolysis for ischemic stroke. Neurology. 2005; 64: 654–659.[Abstract/Free Full Text]
13. Carlsson GE, Möller A, Blomstrand C. Consequences of mild stroke in persons <75 years—1 1-year follow-up. Cerebrovasc Dis. 2003; 16: 383–388.[CrossRef][Medline] [Order article via Infotrieve]
14. Schwamm LH, Pancioli A, Acker JE III, Goldstein LB, Zorowitz RD, Shephard TJ, Moyer P, Gorman M, Johnston SC, Duncan PW, Gorelick P, Frank J, Stranne SK, Smith R, Federspiel W, Horton KB, Magnis E, Adams RJ; American Stroke Association’s Task Force on the Development of Stroke Systems. Recommendations for the Establishment of Stroke Systems of Care. Recommendations from the Am Stroke Association’s Task Force on the Development of Stroke Systems. Stroke. 2005; 36: 690–703.[Free Full Text]

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