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Stroke Care in Europe - The Role of Stroke Units

European Neurological Review, 2007;(2):24-26 DOI: http://doi.org/10.17925/ENR.2007.00.02.24

The stroke burden upon society is increasingly high. We expect around 1,800 new stroke cases and 600 stroke recurrences per one million people per year. Due to the changing age structure of most populations, these numbers are set to increase in the future.

An organised stroke unit is an infrastructure that provides certain key processes for acute stroke patients. Stroke unit care constitutes a highly effective treatment. It decreases mortality, disability and the need for institutional care.2 This is true of all age groups and any stroke type or severity. Elderly patients and those with severe strokes benefit most.3 The number needed to treat at organised stroke units has been calculated to be as low as 15 to avoid one death or disability.3 This number may in fact be even lower, as thrombolysis with tissue plasminogen activator (tPA)4 and multimodal automated monitoring5,6 were not available in the trials of the Stroke Unit Trialists’ Collaboration. A major component of the beneficial effect of stroke unit care is the increasing number of patients treated with thrombolytic therapy. The concomitant improvement of expertise leads to better outcomes and fewer complications.7–10 Several recent publications have confirmed that organised stroke care leads to shorter hospital stay, fewer complications and a better functional outcome.6,11–14 This is why the recent Helsingborg Declaration clearly stated that “all patients in Europe with stroke will have access to a continuum of care from organised stroke units in the acute phase to appropriate rehabilitation and secondary prevention by 2015.”15 Other recent papers argue for the same ideal.16–18

Five factors are particularly important for stroke units to have a beneficial effect: the dedicated stroke unit, i.e. care is confined exclusively to acute stroke patients; the multidisciplinary team approach, including physicians, nurses, physiotherapists, occupational therapists, speech and swallowing therapists, social workers and neuropsychologists, all specialised in stroke treatment; the comprehensive stroke unit concept delivering both hyperacute treatment and early mobilisation and rehabilitation by the same multidisciplinary team; automated multimodal monitoring of vital functions within the first 72 hours; and thrombolysis within the time limits of up to three hours and beyond in selected patients.

European Stroke Initiative (EUSI) investigators19 recently performed an interrogation of 83 European stroke specialists from 18 countries to establish what, in their opinion, are the essential components and necessary facilities on the various levels of hospital care where acute stroke patients are routinely treated. One hundred and seven potential components collected from the relevant literature were proposed for evaluation.

References:
  1. Hankey GJ, Warlow CP, Lancet,1999;354:1457–63.
  2. Stroke Unit Trialists’ Collaboration Cochrane Database Syst Rev, 2002;1:CD000197.
  3. Langhorne P, Dennis M, Stroke Units BMJ Books,1998.
  4. Hacke W, Donnan G, Fieschi C, et al., Lancet, 2004;363:768–74.
  5. Sulter G, Elting JW, Langedijk M, et al.,Stroke, 2003;34:101–4.
  6. Candelise L, Gattinoni M, Bersano A, et al., Lancet, 2007;369:299–305.
  7. Tanne D, Kasner SE, Demchuk AM, et al., Circulation, 2002;105:1679–85.
  8. Albers GW, Bates VE, Clark WM, et al., JAMA, 2000;283:1189–91.
  9. Lopez-Yunez AM, Bruno A, Williams LS, et al., Stroke, 2001;32:12–16.
  10. Heuschmann PU, Berger K, Misselwitz B, et al., Stroke, 2003;34:1106–13.
  11. Mitchell JB, Ballard DJ, Whisnant JP, et al., Stroke, 1996;27:1937–43.
  12. Petty GW, Brown RD Jr, Whisnant JP, et al., Neurology, 1998;50:1669–78.
  13. Webb DJ, Fayad PB, Wilbur C, et al., Stroke, 1995;26:1353–7.
  14. Kaste M, Palomaki H, Sarna S, Stroke, 1995;26:249–53.
  15. Kjellstrom T, Norrving B, Shatchkute A, Cerebrovasc Dis, 2007;23:231–41.
  16. Hacke W, Kaste M, Bogousslavsky J, et al., Cerebrovasc Dis, 2003;16:311–37.
  17. Berlit P, Busse O, Diener H, et al., Nervenarzt, 1998;69:180–85.
  18. Ringelstein EB, Berlit P, Busse O, et al., Akt Neurol, 2000;27:101–3.
  19. Leys D, Ringelstein EB, Kaste M, Hacke W, Cerebrovasc Dis, 2007;23:344–52.
  20. Alberts MJ, Latchaw RE, Selman WR, et al., Stroke, 2005;36:1597–1616.
  21. Engelter S, Lyrer P, Schweiz Med Forum, 2004;4:200–203.
  22. Ringelstein EB, Busse O, Grond M, Time is brain. Nervenarzt, 2005;76:1024–7.
  23. Roine S, Linna M, Marttila R, et al., Suomen Lääkärilehti, 2006;5:451–7.
  24. Leys D, Ringelstein EB, Kaste M, et al., Stroke, 2007.