53  General Stroke Management and Stroke Units
Turgut Tatlisumak, Risto O. Roine
KEY POINTS
• All stroke patients should be admitted to hospitals
that offer 24/7 specialized stroke care with access to
stroke unit care.
• Multiprofessional stroke unit care reduces
significantly death, dependency, and long-term
institutional care independent of patients’ age and
gender or subtype and severity of stroke.
• Each stroke patient should undergo a full
investigation including clinical, laboratory, and
imaging examinations that ascertain diagnosis,
subtype, etiology, mechanisms, as well as risk factors
of stroke.
• Prevention, early diagnosis, and aggressive treatment
of medical complications are essential, as well as
early prevention of recurrence and timely
rehabilitation.
• Incorporating research, teaching, and stroke registry
activity to patient care as well as implementation of
quality measures are the key for success.
INTRODUCTION
Only few acute treatments have been shown to improve the
outcome of stroke. Whereas most acute treatments could only
be given to limited numbers of patients, stroke unit care has
the advantage of being applicable to almost all stroke patients.
This chapter characterizes stroke unit care, including all aspects
of general stroke management that can optimally be delivered
in stroke units. There is strong evidence that treatment of
patients with stroke in dedicated stroke units significantly
results in lower rates of death, dependency, and the need for
institutional care than treatment in general medical wards.
The acute stroke unit is a key element in the critical care
pathway and the chain of recovery of a patient with stroke
after emergency care in the emergency department. Early rec-
ognition of stroke in the field, rapid transfer to a fully equipped
stroke center, stat neurological evaluation including brain
imaging and laboratory testing, as well as delivery of acute
treatments such as intravenous thrombolysis for eligible
patients, access to interventional procedures and intensive care
unit are discussed in other chapters. This chapter will cover
the stroke care after the patient has received acute treatments
and transferred to a stroke unit although we are aware that
some centers has the practice of admitting stroke patients
directly to stroke units and giving acute treatments in the same
facility.
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STROKE UNIT CARE
Following numerous trials on efficacy of stroke unit care in
various stroke patient populations in several countries, The
Stroke Unit Trialists’ Collaboration verified these results and
demonstrated that organized care in stroke units reduced the
rates of death or institutional care and death or dependency.1
The most recent review of this working group, including 28
randomized controlled trials involving almost 6000 partici-
pants, compared stroke unit care with alternative services.2
Stroke unit care reduced significantly the risk of death (odds
ratio [OR], 0.76; confidence interval [CI], 0.66–0.88), death
or dependency (OR, 0.80; CI, 0.67–0.97), and death or insti-
tutional care (OR, 0.76; CI, 0.67–0.86) without prolonging
length of stay in a hospital or institution in up to 1-year
follow-up.2 These benefits were independent of patient age,
sex, initial stroke severity or stroke type (ischemic or hemor-
rhagic), and appeared to be better in stroke units based in a
discrete ward.2 Patients with more severe strokes and those
with hemorrhagic stroke seemed to benefit even more.2 Fur-
thermore, these results sustained at 5-year follow-up time
points when available. The authors, thus, concluded that
stroke patients who received organized inpatient care in a
stroke unit were more likely to be alive, independent, and
living at home 1 year after the stroke.2
The target population of stroke unit covers ischemic stroke
(IS), intracerebral hemorrhage (ICH), intraventricular hemor-
rhage (IVH), transient ischemic attack (TIA), cerebral venous
thrombosis (CVT), and subarachnoidal hemorrhage (SAH)
patients. Patients with cerebral vasculitides or reversible cere-
bral vasoconstriction syndrome are best treated in a stroke
unit even if they do not have parenchymal lesions.
Stroke Unit Design
The observed benefits are apparent for a wide variety of stroke
services, including stroke centers, acute stroke units, combined
acute and rehabilitation stroke units, rehabilitation stroke
units admitting patients after a delay of 1 or 2 weeks, and
mobile stroke teams.
A stroke center consists of a comprehensive stroke service
that offers the infrastructure to bring patients as quickly as
possible to the stroke center. It provides immediate diagnosis
and treatment, as well as early rehabilitation, and refers
patients to the appropriate further treatment, rehabilitation,
and secondary prevention. A stroke center offers 24-hour
availability of laboratory, radiological, neurosurgical, and car-
diologic services (Box 53-1). Stroke centers need a large catch-
ment area, and most often, they are part of a large teaching
hospital located in a metropolitan area. A primary stroke
center (PSC) has the necessary staffing, infrastructure, and
programs to stabilize and treat most acute stroke patients.3 A
comprehensive stroke center (CSC) is defined as a facility or
system with the necessary personnel, infrastructure, expertise,