Stroke Unit Design: High Tech Versus Low Tech
There are compelling parallels between the management of patients with acute stroke and acute myocardial infarction. Common themes include the importance of organized expert care, the value of acute reperfusion strategies in selected patients, and the application of similar early secondary prevention therapies. In both conditions, physiological parameters such as blood pressure, oxygenation, and glycemic status are thought to be important. However, coronary care units (CCUs) were high-technology monitoring units from the outset in the late1960s, while stroke care units (SCUs) have in most cases consisted of low-technology care, where stroke patients are treated by a multidisciplinary team in a geographically specific location. Interestingly, CCUs became “high tech” early with no real evidence that this improved clinical outcomes. Both of our protagonists have emphasized the benefits of SCUs and the uncertainties about the precise components of care, which are relevant to improved outcomes. However, Steiner emphasizes the benefits of monitoring in the rapid diagnosis of physiological changes that might require intervention and would be missed by less frequent clinical monitoring. Conversely, Indredavik points out the relative lack of evidence in favor of intensive monitoring in SCUs and recommends more trials to evaluate this management approach. In this debate, it is also important to realize that there are regional differences in the design of SCUs around the world. For example, high-technology monitoring is common in Germany but rare in Scandinavia and the United Kingdom.1 In our own stroke care units, we monitor selected patients for the first 48 to 72 hours.
Some evidence has been recently presented to suggest that monitoring may identify changes in physiological and neurological status requiring intervention and possibly lead to improved outcomes.2 Since our protagonists submitted their opinions, a further publication has indicated that admission of acute stroke patients to a monitored SCU may positively influence their outcome at discharge.3 While this information may suggest that a higher-tech approach is appropriate to stroke patient management, there is a need to replicate these findings in larger studies, particularly using a randomized controlled design. Furthermore, cost-effectiveness needs to be evaluated generally and within specific stroke subtypes and severities.
What in the interim? In patients with acute myocardial infarction, it would not be considered appropriate or indeed ethical to admit a patient to a nonmonitored bed in most parts of the world. Should acute stroke patients remain the “poor relation” of their cardiac cousins, purely because of historical precedents and while we await a high level of evidence from randomized trials? We are of the view that, where possible, a higher-tech approach should be taken in the hyperacute phase in many patients. However, we recognize that in many parts of the world the establishment of at least some form of SCU is the more urgent priority. Indeed, improving the relatively low access levels of patients with stroke to SCUs remains one of the major global challenges facing stroke clinicians.4
Davis SM. Acute stroke management around the world. In: Bogousslavsky J, ed. Acute Stroke Treatment, 2nd ed. London, UK: Dunitz Publishers; 2003.
Sulter G, Elting JW, Langedijk M, Maurits NM, De Keyser J. Admitting acute ischemic stroke patients to a stroke care monitoring unit versus a conventional stroke unit: a randomized pilot study. Stroke. 2003; 34: 101–104.
Cavallini A, Micieli G, Marcheselli S, Quaglini S. Role of monitoring in management of acute ischemic stroke patients. Stroke. 2003; 34: 2599–2603.