Which Model of Stroke Unit Is Better for Stroke Patient Management?

Abstract

The increasing prevalence of cerebrovascular diseases has made urgent the need to develop timely and effective treatment strategies to tackle this health problem. Stroke units (SUs) appear to be the ideal setting where the management of acute stroke patients, including specific treatments as thrombolysis, may be optimized. Which model of SU gives the best results is still an unsettled issue. The more intensive and timely multidisciplinary approach to the acute phase of stroke, the management of medical complications, and the earlier and more focused rehabilitation, are likely the most qualifying aspects of our Neurovascular treatment unit.

Full text

Clinical and Experimental Hypertension, 28:377-382, 2006
Copyright © Taylor & Francis Group, LLC
ISSN: 1064-1963 print / 1525-6006 onlitie
DOI: 10.1080/10641960600549728
Which Model of Stroke Unit Is Better for Stroke
Patient Management?
SVETLANA LORENZANO, ALESSIA ANZINI, MANUELA
DE
MICHELE, ANNE FALCOU, SILVIA FAUSTI, CRISTINA
GORI, ALESSANDRA MANCINI, CRISTINA CAVALLETTI,
CARLO COLOSIMO, MARCO FIORELLI, MARIA LUISA
SACCHETTI, CORRADO ARGENTINO, AND DANILO TONI
Neurovascular Treatment Unit, Department of Neurological Sciences, University
of Rome, "La Sapienza," Rome, Itaty
The increasing prevalence of cerebrovascular diseases has made urgent the need to
develop timely and effective treatment strategies to tackle this health problem. Stroke
units (SUs) appear to be the ideal setting where the management of acute stroke
patients, including specific treatments as thrombolysis, may be
optimized.
Which
model of SU gives the best results is still an unsettled issue. The more intensive and
timely multidisciplinary approach to the acute phase of stroke, the management of
medical complications, and the earlier and more focused rehabilitation, are likely the
most qualifying aspects of our Neurovascular treatment unit.
Introduction
In the past decades the progressive ageing of world population, particularly in the industri-
alized western countries, has led to an increasing prevalence of cerebrovascutar diseases.
As one of the leading factors of mortality and the most important cause of morbidity and
long-term disability, acute stroke represents a major public health problem, imposing an
enormous social and economic burden (t,2). Therefore, the development of timely and
effective treatment strategies to tackle this crucial problem is now considered a high priority
issue.
The promising results of thrombolysis trials (3-7) have contributed to replacing the
past nihilistic attitude that considered ischemic stroke as an untreatable disease. By showing
that clinical outcome may be improved significantly by restoring adequate blood flow
within the first few hours of
stroke,
these studies boosted the concept that stroke is a medical
emergency that requires immediate hospitalization.
Address correspondence to Svctlana Lorenzano, Neurovascular Treatment Unit, Department of
Neurological Sciences, University of Rome, "La Sapienza" Viale dell'Universita 30, 00185 Rome,
Italy; E-mail: svetlana.lorenzano@uniromal.it
377

378 S. Lorenzano et al.
Stroke units (SUs) appear to be the ideal setting where this changed approach to
stroke patient care, including specific treatments as thrombolysis, may be optimized. The
first meta-analysis of all randomized controlled trials published in 1993 demonstrated the
superiority of SU care over conventional treatment of stroke patients (8). Subsequently,
these results were confirmed by the Stroke Unit Trialists' Collaboration meta-analysis
(9-11) that showed a significant reduction in morbidity and length of
stay.
Results showed
a 18% relative reduction in mortality, a 29% reduction in death or dependence, and a 25%
reduction in combined outcomes of death or need of institutional care, for patients treated
in a SU in comparison with those admitted to general medical wards. These results were
evident irrespective of sex, age, and severity of stroke. Moreover, there was an absolute
risk reduction of
3%
in all causes of mortality and in the need for nursing home care, and a
6% increase in the number of independent survivors (11).
Therefore, in terms of number of patients needed to treat (NNT) to save 1 patient
from death/dependence, SU care is as efficacious as intravenous (i.v.) thrombolysis given
within 6 hr of stroke onset (NNT 18), and it is inferior only to i.v. thombolysis administered
within 3 hr after symptom onset (NNT 8). However, while pharmacological reperfusion
may only be applied to a selected minority of acute ischemic stroke patients, SU treatment
might virtually benefit all stroke patients, and hence might have a larger impact for
stroke care in general (13, 14). In addition, it is noteworthy that some studies evaluating
the outcome of patients managed in SUs concluded that the positive effects of SU care
were still measurable up to several years following initial stroke treatment and appeared to
continue for at least 10 years (15-18, 9).
The reasons why SU care is more effective than conventional care are not definitely
clarified. Among the factors likely influencing good outcome we cite (19): well-coordinated
multidisciplinary management; stabilization of physiological parameters (20); thrombolysis
in selected patients (21); early administration of acetilsalicilic acid (22); use of anticoagulants
in patients with atrial fibrillation (13); and early mobilization (17). The evidence is so
strong that if stroke units were more widely available, stroke burden on patients and their
relatives could be highly decrease with significant social and economic implications.
However, translation of these research findings into clinical practice is very difficult without
concomitant implementation of SU care model.
Different types of SUs have been created throughout Europe (23, 24). The European
Stroke Initiative (EUSI) Recommendations for stroke management (12) define three
categories of SUs according to a more or less intensive approach:
1.
Acute SU that similarly to a coronary care unit for ischemic cardiopathy offers a more
intensive setting for acute stroke care where patients stay less than a week, with rapid
discharge to home, when it is possible, or rapid transfer to others wards.
2.
Combined acute and rehabilitation SU where the acute treatment is integrated with
rehabilitation for several weeks if necessary.
3.
Rehabilitation SU where patients are admitted for rehabilitation 1 or 2 weeks after
symptom onset, i.e., after clinical stabilization, with a length of stay of several weeks or
months if necessary.
The abovementioned meta-analysis of the Stroke Unit Trialists' Collaboration (9-11)
included mainly randomized controlled trials performed in combined acute SUs and in
rehabilitation SUs, while only
1
study was performed in an acute SU. Which model of SU
gives the best results is still an unsettled issue.
Our Neurovascular Treatment Unit (NTU) in Rome is an acute stroke unit with 6
monitored bed localized in an emergency department (ED). There are 8 neurologists

Stroke Unit Model 379
trained in stroke management and computed tomography (CT) reading on duty around
the clock offering neurological consultations to all the ED; a multidisciplinary staff
(neurosurgeons, vascular surgeons, cardiologists, anesthetists, and nutritionists) is available,
nurses and nonmedical staff are shared with the ED. Patients are continuously monitored
for electrocardiogram (ECG), heart rate, blood pressure, breathing, oxygen saturation,
body temperature, and hydroelectrolite balance. There is a rapid and preferential access to
neuroimaging diagnostic tools, Doppler ultrasonography of extra- and intracranial vessels,
echocardiography and other ED diagnostic services (radiology, nuclear medicine).
The mean length of stay is 48-72 hr, subsequently patients who cannot be discharged
home are transferred to other wards (neurological department stoke unit, neurology, vascular
surgery, neurosurgery, internal medicine).
Being localized in the ED, the NTU bas to share diagnostic resources with other
emergencies and in order to expedit early interventions for acute stroke patients diagnostic-
therapeutic pathways are defined. We differentiate emergent pathways, aimed at giving
tailored revascularization therapies, and urgent pathways aimed at defining the underlying
ethiopathogenic mechanism to assign timely the most appropriate secondary prevention
therapy.
Emergent Diagnostic-Therapeutic Pathways
On admission to the ED, a detailed neurological assessment is made by means of the
National Institute of Health Stroke Scale (NIHSS) score quantify the severity of neurological
deficit, while no differentiation of stroke subtype is attempted since this is not reliable on
simple clinical grounds (25). Whatever the degree of neurological deficit, patients
undergo CT to differentiate cerebral ischaemia from parenchymal hemorrhage, tumor, or
other focal lesions. In case of cerebral hemorrhage a neurosurgical consultation is required
and if there is not a surgical indication, the patient is admitted in the NTU. Ischemic stroke
patients with very severe deficit (stuporous or comatose) at hospital entry, after consultation
with the resuscitation
staff,
are admitted in the NTU to stabilize their conditions and
perform the examinations necessary for ethiopathogenic diagnosis and secondary prevention
(see below).
If the neurological deficit is slight to moderately severe (NIHSS score between 5 and
25),
the clinical picture is suggestive for a carotid territory stroke, the delay between onset
of symptoms and chnical observation is less than 3 hr, and the CT shows no or very limited
early signs, the patient undergoes extra- and intracranial Doppler flow study, eventually
supplemented, in case of doubts, by magnetic resonance (MR) or CT angiography. The
next step is emergent therapy that, in case of symptomatic internal carotid artery (ICA)
occlusion and patency of the ipsilateral middle cerebral artery (MCA), may be carotid
endarterectomy. Instead, in case of ICA patency or nonsignificant ICA plaques, the choice
is i.v. rt-PA irrespective of the demonstration of symptomatic MCA occlusion by (TCD),
considering the low sensitivity of TCD in detecting distal MCA branch occlusions.
However, in case of MCA patency at TCD and rapid clinical improvement, we restrain
from giving thrombolysis.
If the neurological examination suggests a diagnosis of posterior circulation stroke,
and ultrasounds, eventually completed by MR or CT angiography, detect a basilar artery
occlusion, intra-arterial tbrombolysis or, alternatively, i.v. heparin are given. When sinus
venous thrombosis is diagnosed by clinical and instrumental examinations, i.v. heparin is
given (with a target aPTT of 1.5-2 times baseline values) together with warfarin (target
INR 2 to 3). Finally, in case ultrasound examinations detect an artery dissection, confirmed

380 S. Lorenzano et al.
by MR or CT angiography, anticoagulant treatment with i.v. heparin is started followed by
oral anticoagulants.
Urgent Diagnostic-Therapeutic Pathways
These apply not only to all acute ischemic stroke patients but also to transient ischemic
attacks (TIAs), those we do not discharge immediately given the high risk of having a
stroke in the following 48 hrs (26). After entry CT, to which TIA patients also are submitted
to exclude other possible causes of a transient neurological deficit, all patients undergo
a Doppler flow study that allows us to differentiate four subgroups:
1.
Patients with definite large artery stroke, as those having a symptomatic carotid or basilar
artery severe stenosis or occlusion, whose treatment has already been discussed above.
2.
Patients with probable large artery stroke, as those with complicated (i.e., ulcerated) plaques
determining a 40% to 60% stenosis of ICA ispsilateral to the affected hemisphere.
3.
Patients with possible large artery stroke, as those with noncomplicated carotid plaques
determining a 40% to 60% stenosis.
4.
Patients without large artery stroke, as those with small nonstenosing carotid plaques or
without plaques.
In the groups 2 (after discussion with cardiologists), 3, and 4, we proceed with cardio-
logical examinations, to look for cardiac sources of emboli.
In patients with chronic atrial fibrillation (CAF), we start oral anticoagulants if there are
not contraindications. When anticoagulation may be risky, we perform transoesophageal
echocardiography (TEE) to evaluate the presence of intracardiac thrombi. Patients, with-
out CAF but with past medical history of cardiopathy and older than 45 years, undergo
first transthoracic echocardiography and, if no cardiac condition at risk of embolization is
found, they undergo TEE. TEE is the first choice examination in patients with past medical
history of cardiopathy and younger than 45 years and in all those without past medical
history of cardiopathy irrespective of age.
If a definite cardiac source of emboli is detected, oral anticoagulant therapy is started; if
no cardiac source is found, a hematological screening is performed to look for prothrombotic
states including genetic research. Moreover, surgical consultation is again required for
patients with probable large artery stroke.
Continuous Monitoring and Generai Management
During the whole stay in the NTU, patients undergo continuous monitoring of physiological
parameters (body temperature, oxygen saturation, blood pressure, and ECG) whose alter-
ations were more frequent in the acute phase of stroke and to influence the fate of the
ischemic penumbra and the clinical neurological overall clinical stabilization of the acute
stroke patients. In agreement with these observations, recent studies show that admitting
acute stroke patients to a stroke care monitoring unit rather than to a conventional stroke
unit can reduce mortality and poor outcome at 3-month follow-up (27) and that intensive
monitoring influences stroke patient outcome at discharge (19).
Early Rehabilitation
In our NTU an early rehabilitation program is instituted and tailored to the general clinical
condition of the acute stroke patient. In more severe patients, when an active training is

Stroke Unit Model 381
impossible, passive mobilization is used to prevent contractions and joint pain, deep
venous thrombosis, and pulmonary embolism and to reduce the risk of bedsores and
pneumonia that derives from immobilization. Cooperating patients actively participate
to the rehabilitation program that subsequently will be continued in a rehabilitation center
or in outpatient clinics when the patient returns at home.
Conclusion
A more intensive and timely multidisciplinary approach to the acute phase of stroke, the
management of medical complications, and an earlier and more focused rehabilitation
may be the most qualifying aspects of our NTU. We are now analyzing its efficiency in
terms of percent of patients with cerebrovascular disease entering our hospital admitted to
the NTU, and its efficacy in terms of number of dead or dependent patients in comparison
with those admitted to the NTU. The results of this analysis will be used for further
implementation of the model.
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