Tamer Belal Lecturer of neurology Mansoura University Tamer Belal Lecturer of neurology Mansoura University Stroke Unit : Many Questions, Some answers.

Tamer BelalLecturer of neurologyMansoura University

Stroke Unit : Many Questions, Some answers

Stroke is the 3rd most common cause of death, after heart attacks and cancer. Stroke is both common and serious.

It has been estimated that in 1990 stroke caused 4.4 million deaths world wide. Within most western countries a typical district of 250,000 people might expect more than 500 new strokes per year , of whom a half will have died or remain physically dependent one year later.

General information about stroke

Because so many survivors remain disabled, stroke related disability is common and its prevalence has been estimated at over 6/1000 in the general population

In addition to its impact on the health of the population, stroke also imposes a huge cost on health services. Almost 5% of all health services costs in the UK and over 3% of the Dutch annual health care budget is attributed to stroke care


In the UK, stroke accounts for almost 6% of all hospital costs and figures from other western countries are likely to be at least as great. Further more, since the costs of caring for disabled survivors are likely to dominate the lifetime costs of stroke, the financial burden to society as a whole is likely to be a huge


In developed and developing countries , stroke is a common disease with a large impact on the health of the population.

In the united states, data from stroke study indicated that the incidence of stroke is approximately 700,000cases per year. Of these approximately 500,000 cases are first strokes and 200,000 cases are recurrent strokes.

The age-adjusted annual incidence rates for first stroke are 167 per 100,000 population for white males and 138 per 100,000 population for white females. The age-adjusted rates in black and Japanese American men and women in the united states are approximately twice those in white.

Epidemiology of stroke

Incidence

The most reliable international stroke incidence data are from the world health organization (WHO); MONICA study. This project reported standardized data from 18 population in 10 countries (including eastern and western European countries, Russia and China) between 1985 and 1987 .

Age standardized stroke incidence rate varied widely, from 101 to 285 in men and from 47 to 198 in women ( all rate pert 100,000 population), with the highest rates in Russia and Finland and the lowest in Italy. In general, rates were higher in eastern than western Europe in men than in women (Male: female range 1.2:2.4). Recurrent strokes accounted for 18-22% of total reported stroke .

Incidence


The American Heart Association estimated that there are approximately 4.7 million stroke survivors in the united states. Many of these individuals are elderly and require long-term institutionalized care. Data indicate that the number of non institutionalized stroke survivors in the united states is approximately 2.4 million.

Prevalence


Stroke Risk Factors

Non-Modifiable Risk FactorsAge, Sex, Race or Ethnicity,Family history

Modifiable Risk Factors

Ischemic stroke Risk Factors

Non Modifiable Risk Factors Age

Sex

Race or Ethnicity

Family History

Well documented modifiable risk factors(Intervention of proven benefit) Hypertension

Atrial fibrillation

Smoking

Diabetes

Hyperlipidemia

Carotid stenosis

Sickle cell disease

Less well documented modifiable risk factors(observational studies, benefit of intervention unproven)Cardiac Myocardial infarction Left ventricular dysfunction Valvular heart diseases Left ventricular hypertrophy Patent foramen ovale Atrial septal defect Mitral annular calcification Mitral valve strands

Aortic arch atheroma

Physical inactivity

Poor diet

Lipoprotein (a)

Excessive alcohol consumption

Antiphospholipid syndrome

Ischemic stroke Risk Factors (cont,)

Less well documented modifiable risk factors(observational studies, benefit of intervention unproven)Hyperhomocyseinemia

Hypercoagulable states

Hormone replacement therapy

Oral contraceptive pill

Hyperfibrinogenemia

Drug abuse

Fibromuscular dysplasia

Migraine

Chronic inflammation/infection

Ischemic stroke Risk Factors (cont,)

Intracerebral hemorrhage Risk FactorsNon modifiable Age

Race or ethnicity

Apo lipoprotein E ε2 or ε4 allele

Cerebral amyloid angiopathyModifiable Hypertension

Alcohol

Ischemic stroke

Coagulaopthy

Warfarin and Aspirin use

Other anticoagulants and anti fibrinolytics

Cigarette smoking

Vascuilitis and vascular malformation

Sympathomimetic drugs (including cocaine)

Intracerebral tumors

Subarachnoid Hemorrhage Risk FactorsSaccular

aneurysms Other Causes

Non Modifiable Family historyAneurysm sizeAneurysm location prior hx of bleedingFemale genderADPKDEhler- DanlosA-V malformationMoyamoya disease Aortic coarcitationFibromuscular dysplasia

Modifiable Cigarette smokingHypertensionCocaine abuse

TraumaMycotic aneurysms Arteriosclerotic aneurysmsArterial dissection (vertebral arteries)

The main stroke Risk Factors include

Stroke Main Risk Factors High blood pressure

Cardiac dysrythmias

Smoking

Diabetes

Lipometabolism disorders

Overweight

Lack of exercise

Arteriosclerosis

Arteriosclerosis ( hardening of the arteries) is the foremost risk factor because many of the risk factors mentioned above encourage its development.

Age is also a risk factor : about 75% of strokes strike those over 65; the rate for those over 75 is three times as high as that of the 65-75 year-olds.

The main stroke Risk Factors include

Why is a stroke an emergency?Similar to a heart attack, a stroke occurs when the blockage of an artery causes a circulatory disorder in the brain. Due to lack of oxygen and blood this leads to the death of nerve cells and to neurological breakdown such as paralysis, numbness, speech and vision impairment and , in severe cases, to reduced consciousness as well as coma.

Complicated biochemical functions take place as a consequence of the circulatory disorder. The early intervention of an experienced team of doctors and therapists can stop and even reverse some of the changes taking place. However, it is necessary that diagnosis and treatment begin within the first 6 hours after the stroke. Nevertheless for the following reasons, this is often not possible

Some of those affected are not adequately informed about the symptoms of a stroke and thus inform the doctor too late. In addition, it is often difficult to recognize the symptoms of a stroke because there is no pain and the paralysis makes it difficult to recognize the loss of function.

Hospital organizational procedures are not yet optimal everywhere, thus sometimes causing an unnecessary loss of time between diagnosis and treatment.

Not all doctors are aware that an acute stroke is emergency which should be admitted to the hospital immediately

Why is a stroke an emergency?

Symptoms of stroke

A lame and / or numb feeling on one side of the body, especially in the face or arm.

Sudden vision problems, especially in one eye and / or double images

A sudden, severe headache

Sudden loss of the ability to speak or difficulties in understanding speech

Sudden dizziness and unsteady gait

Emergency management

In a way the task of the Stroke Unit begins outside the clinic: emergency doctors, rescue services, general practioners and patients as well as their families should all know that there is a nearby Stroke Unit open round-the-clock. All those concerned with strokes must be aware how crucial it is that a stroke victim be admitted mere hours after the attack. An emergency concept for the city or region must be developed so that Stroke Units operate efficiently.

Very early , intensive qualified treatment has been proven to substantially improve the starting point for patient rehabilitation. In addition to the specialized acute handling of the stroke patient, better public education as well as improved instruction of medical staff and emergency services can achieve a great deal. A survey carried out by the Minden Clinic has verified that comprehensive information campaigns shorten the time for admission, thus improving the effectiveness of the intensive therapies


At all information gatherings it is fundamentally important to emphasize the necessary for a true cooperation among all concerned parties as well as the significance of acting quickly. It is imperative that all those concerned have knowledge of the contact people and immediate care facilities outside the clinics.

In order to achieve admission as swift and trouble-free as possible for those who have just suffered a stroke, patients with symptoms corresponding to stroke should be brought directly to the Stroke Unit . Ideally, emergency doctors and rescue attendants are in a position, after appropriate training, to single outpatients.


An admissions doctors specialized in stroke, who will immediately supply the necessary diagnostic setting on the basis of the prevailing symptoms, must be on 24-hour call within the clinic. In the Stroke Unit the causes of stroke will be clarified swiftly through the interdisciplinary cooperation of neurologists, Neuroradiologist, neurosurgeons and internists. Ideally, appropriate therapy can begin as early as one to two hours after stroke. The earlier the therapy starts the more effectively it can be. This must be perfectly clear to all those concerned, both within and outside the clinic.


Diagnostic procedures in acute stroke patients

First level

Blood pressureHeart rateBody temperatureRoutine laboratory testsCoagulation statusChest X-rayECGCT scan/ MRIDoppler ultrasonography (Extra- and transcranial)

Second level

Cardiological evaluation (transthoracic/transoesophageal echocardiography, Holter)Laboratory tests: complete biochemical and hematological tests, coagulation status, immunology, serology and /or microbiology.CSF: Cytochemistry, immunological, serological and/ or microbiological examinationMRA, helical TCAngiographySPECT/PETEEG ( if seizures are suspected)Histological studies .

Diagnostic procedures in acute stroke patients

General management of acute stroke patient

Support of vital functions and prevention of general complicationAir way support and ventilationCardiac monitoring and careObservation of water and electrolytes abnormalitiesMaintenance of adequate nutritional statusBlood glucose level measurementBlood pressure monitoring Frequent position changes to prevent bed sores and muscle contracturesEarly physical therapy and rehabilitationUrinary careControl of fever and early diagnosis and treatment of infectionsUse of sedation

Treatment of acute neurological complications

Cerebral edema and increased intracranial pressureSeizuresHemorrhagic conversionHydrocephalus

General management of acute stroke patient

The Stroke Unit Story

The Stroke Unit storyMany studies over the last 50 years have attempted to evaluate different models of stroke care. We will attempt to trace the development of stroke units.

Some of the first studies of organization of stroke care come from Northern Irland during 1950s. Adams reported experiences from the establishment of a Stroke Rehabilitation Unit within a department of geriatric medicine which indicated that the proportion of patients regaining sufficient functional independence to return home was increased after development of this new service. They also observed a reduction in the number of patients who died within the first two months of their stroke.

During 1960s , further observational studies suggested that organized stroke care, focused around a Stroke Rehabilitation Team based within a stroke unit, could result in improvement in the recovery of stroke patients.

Definition of a Stroke Unit

The Stroke Unit story

During these early investigations into the organization of stroke care a number of the principles and components of stroke unit care become established and the first definition of “Stroke Unit” were published. Stroke Units were variously defined as:

A team of specialists who are knowledgeable about the care of the stroke patients and who consult throughout a hospital whenever a patient may be.

A special area of a hospital that provides beds for stroke patients who are cared for by a team of specialties

A geographic location within the hospital designated for stroke and stroke-like patients who are in need of rehabilitation services and skilled professional care that such a unit can provide.


These early studies also established that most Stroke Units were staffed by A core multidisciplinary team which usually comprise:

¤ Medical ¤ Nursing ¤ Physiotherapy ¤ Occupational therapy ¤ Speech and language therapy ¤ Social work staff

Some early stroke units also involved other disciplines such as ¤ Dieticians ¤ Neurologists ¤ Ophthalmologists ¤ Chaplains ¤ Neuropsychologists ¤ Audiologists.




It also become recognized that these multidisciplinary groups developed coordinated policies and procedure to formulate and execute an integrated rehabilitation plan tailored to the individual patient problems and needs. The main advantage of having specialized units for stroke patients was said to be that it provided the opportunities to develop these collaborative policies for stroke rehabilitation.

Stroke Intensive Care Unit:


During the early years of developing stroke rehabilitation units an alternative movement, mainly based in the United States, was setting up and evaluating intensive care units for stroke patients.

These stroke intensive care units were comparable to coronary care units but unlike them, they never become widely established.

The original rationale was that- A high intensity in nursing inputs- Specialist medical investigations- Close Monitoring - Standardized procedures for diagnosis ,investigations and management would reduce early stroke mortality

Follow up studies failed to show any impact in mortality and morbidity, but there did appear to be a reduction in post stroke complications.

Other studies published around the same time also failed to show any convincing benefit from this type of Stroke Unit

Combined Acute and Rehabilitation Care Unit ( Acute Rehabilitation Unit)


With the declining interest in Stroke intensive care units, new approaches were developed in 1970s and 1980s. In particular researchers experimented with models of care where stroke patients were recruited early after their stroke but could receive a prolonged period of rehabilitation if necessary i.e Combined Acute and Rehabilitation Care, sometimes referred to as “Acute Rehabilitation Unit” examples appeared from North America, British and Scandinavia.

The rationale for these units was that stroke patients should receive the bulk of their care within a specialist area . Acknowledging the principles that rehabilitation in its broadest sense should start very early and that continuity of care is important.

Stroke Rehabilitation Unit


During this period there were also some reports of Stroke Rehabilitation Unit where patients were admitted after initial delay of one or two weeks after stroke onset. The philosophy of care in this services was similar to that in “Acute Rehabilitation Unit” although this model inevitably introduced a delay in applying these rehabilitation principles and reduced continuity of care.

Mobile Stroke Teams


Which attempt to bring coordinated multidisciplinary care to patients housed in a variety of non specialized words, were also described and evaluated in 1980s. Comparing both types of service, it was found an important advances of having patients in one place (SU) is that nursing staff can play a greater part in the rehabilitation process. Coordinating the care of patients scattered across a variety of wards is difficult and stroke patients managed in acute areas have no compete for nursing time with others who are perceived as having more urgent needs(For example chest pain) . Potentially important aspects of rehabilitation such as regular toileting to maintain continence and dignity may be seen as having a lesser priority when nursing resources are limited

“Landmarks” in the history of stroke unit careYear Statements

1950 First published report of organized stroke care

1962 First published RCT of a system of stroke rehabilitation

1970 Reports (no RCTs) of stroke intensive care unit

1970s Early definition and description of a “stroke unit”

1980 First large (>300 patients) RCT of a stroke unit shows only short term benefits

1985 RCT of a mobile stroke team

1988 King`s Fund Consensus Conference statement criticizes stroke services

1990 Small systematic review suggest possible benefits of stroke unit care

1991 RCT of a stroke unit provides convincing evidence of benefit

1993 First RCT of an acute stroke unit (intervening only in the first few days)

1993 Systematic review (10 RCT) suggests stroke unit care may prevent premature deaths

1995 Pan European Consensus Meeting supports organized stroke unit care

1997 Updated systematic review (18 RCT) shows a reduction in dependency

RCT : Randomized controlled trial

Non systematic selection of studies that compared models of care provision for stroke

Intensive Care Stroke Unit

No differences in mortalityReduction in complicationsTrend toward reduction in long stay hospitalization

Intermediate Care Stroke Unit

Reduction in medium stay hospitalizationReduction in hospitalization in long-stay centersReduction in mortalityBetter functional status Patient follow up for between 5 and 10 years: persistent benefit in mortality and functional status

Stroke TeamsReduction in medium stay hospitalizationReduction in mortality (decrease urinary infection)No significant differences in mortality at 6 weeks or at 12 months

Stroke Unit Vs Neurology wards

Reduction in hospital case facilityShorter length of stay

Non systematic selection of studies that compared models of care provision for stroke:

Stroke Unit Vs Neurology wards

Reduction in mortality at 3,6 and 12 monthsShorter length of stayReduction in medium stay hospitalizationReduction in complicationsBetter functional status at dischargeReduction in long-stay hospitalizationReduction in health costsConsistent benefits with respect to functionHigher rates of adherence to key processers of care in SU than other models

Non systematic selection of studies that compared models of care provision for stroke:

Stroke Unit

Stroke Unit

By the end of 1980s, there appeared to be some consensus based on the results of several small randomized trials that stroke unit care may speed up recovery after stroke.

Subsequently the concept of SU evolved from Acute, no ICUs characterized by a systemization of care provision for the

patients and that involved trained personnel, Pre-established criteria, with special attention being paid to the acute

phase treatment Early functional rehabilitation and early return to society .

This implied establishment a systematic diagnosis and precise therapy as well as an efficacious multidisciplinary approach .

In 1990s, interest in SUs was renewed following the publication of several studies comparing SUs with general medical wards that demonstrated the benefits in terms of mortality, functional recovery and in the rates of chronic institutionalization.

Also, Several meta-analysis confirmed the efficacy of SUs not only with the respect to early mortality (28% reduction within the first 4 months) but also that 1 year ( 21% reduction) which means that the number needed to treat to prevent one death was 33, to prevent one patient being unable to live at home was20 and to prevent one patient failing to regain independence was 20.

Stroke Unit

Several categories of SUs have also been defined mainly based on admission policy (“Acute admission units”, which admitted patients at stroke onset; “Delayed admission units”, which admitted patients after a delay of at least one week, and that are mainly focused on rehabilitation ) .

Acute SUs are defined as those areas dedicated (Non or semi-intensive) during the acute phase, and once stabilized , the patient is transferred to the general neurology ward, where the diagnostic-therapeutic process continues up until discharge from the hospital , or transferred to rehabilitation unit.

Stroke Unit

To date, there exist some variability in the medical departments in which the SU established: geriatric medicine, General medicine, Neurology and rehabilitation medicine. Although all these possibilities shared the multidisciplinary team-care approach, neurology and general medicine are more focused on acute and more disease- specific approaches and geriatric and rehabilitation medicine on a more generic disability approach.

Stroke Unit

Although, in several countries stroke expertise may reside within other hospital departments (eg, general and geriatric medicine), mainly depending on the health policy and on the different medical specialization developing and availability, acute SUs are recommended to be situated in a specific area within the neurology department of the hospital and with dedicated beds. It should be of multidisciplinary structured coordinated by a neurologist specializing in cerebrovascular diseases, and with special trained support personnel.

There need to be predefined criteria of admission, explicit diagnosis and treatment protocols and work programs coordinated with other specialties such as cardiology, neuroradiology, neurosurgery, vascular surgery, rehabilitation and geriatrics

Stroke Unit

The staff set-up of 6 bed stroke unitThe success of rehabilitation therapy in the SU depends substantially on a soundly functioning multi-professional team. The minimum set up of the team should be as follows:

1 neurologist (always available)1 internist (available when needed)1 neuroradiologist (available when needed)10 nurses

For rehabilitation purposes enough of the following personnel, based on the size of the Stroke Unit should be available:

physical therapistspeech therapistoccupational therapistsocial workerssecretary

Color doppler-assisted duplex imaging

Echocardiography Computed tomography

Patient/Stroke Unit

MonitoringCerebral angiographyECG/ Laboratory

Relatives

Physical Therapy

Doctors

Patient

Nursing Staff

Occupational Therapy

Speech Therapy

Stroke Unit Area and Equipment requirements

A 6 bed facility is the minimum requirement for a catchment area of 750,000 to 1 million inhabitants. Each bed must be equipped with a monitoring system; and an additional central monitoring system is desirable. In the event that there is no intensive care unit in the clinic , artificial respiration equipment must also be available for those patients whose condition worsens after admittance making intubation necessary

A Stroke Unit must be able to make the following examinations: Computed tomography on a 24-hour stand-by basis Cerebral angiography on a 24-hour stand-by basis Extracranial and transcranial Doppler sonography on a 24-hour stand-by

basis Color Doppler-assisted imaging (CDDI) ultrasonography on call ECG Trans-oesophageal echocardiography Blood gas analysis, blood sugar and electrolyte determination (at the unit)

A laboratory on a 24-hour stand-by basis is indispensable as well as sufficient perfusion and electronic infusion devices


Basic Monitoring ECG Continuous blood pressure measurement Pulse oximetry Respiration monitoring

Special Monitoring TC Doppler Long-term embolism detection EEG monitoring Monitoring of respiratory disorders

Special Options Possibilities for systemic or local thrombolysis therapy Possibilities for acute ventricle drainage and/ or decompression operation Possibilities for carrying out therapy studies.


PREHOSPITAL GENERAL PRACTIONER/EMERGENCY PHYSICIANS Air way support Blood pressure control Avoid glucose solutions Urgent transfer to hospital

STROKE

HOSPITAL EMERGENCY PHYSICIANS/NEUROLOGIST (Available 24 h)

Diagnosis (First level) Support of vital function Specific treatment

NEUROLOGY DEPARTMENT NEUROLOGIST (Stroke) Diagnosis (second level) General management specific treatment

EMERGENCY ROOM

STROKE UNIT

STROKE TEAM

Acute Stroke management

STROKE

HOSPITAL

EMERGENCY ROOM

NEUROLOGY

STROKE UNIT2-5 DAYS

NEUROLOGY WARD

REHABILITATION

NURSING HOME

HOME FAMILY DOCTORS

NEUROLOGY OUTPATIENT

Nursing

Functional organization of Stroke unit within a hospital

and health care system

Which patients can be admittedThe following are specially suited:

Patients whose symptoms are very recent for reasons that therapeutic measures are most effective within the first 6 hours

Patients who need a swift diagnostic classification (ischemia, hemorrhage, subarachnoid hemorrhage)

Patients who need other illnesses ruled out Patients having strokes whose origins are rare Patients whose conditions threaten to become worse. Patients whose condition fluctuate and who have secondary

deterioration Patients who have serious concomitant diseases (extreme changes in

diabetes, unstable blood pressure, fever) Patients who were admitted on the basis of warning signals and need

to be monitored

Seriously affected stroke patients should be admitted to a neurological intensive care unit. This applies especially when they must have artificial respiration and suffer extreme disturbances in conscousiousness

Immediate treatment at the Stroke Unit-What does it mean for those affected ?

The following results have been derived from several controlled Stroke Unit studies:

Shorter in-patients time in the hospital as well as in rehabilitation facilities

Fewer secondary complications

A decrease in both short-term and 1- year mortality

Better results from therapy as compared to a stay in a normal ward

What comes after stroke unit

Most patients will probably have to be treated at the Stroke Unit for a few days only. The unstable period of the illness is often offered by then. Some of the patients can be moved to a normal neurological ward. Other patients benefit more from being transferred to a rehabilitation facility. The patients leave the Stroke Unit with an individual designed therapy program which should be set-up as follows:

Medical treatment Treatment for concomitant diseases Advice for preventing another stroke Physical therapy Occupational and speech therapy

Furthermore, family members should be included while the patient is still at the SU. Of special importance are those family members who will be taking over the care of the stroke patients after he/or she has been discharged from the hospital or rehabilitation facility. They must be informed early on about care and therapy and should receive instructions from professional personnel on how to deal with the patient`s disability.

The patient should be mobilized as early as possible and as much as possible.

Early patient mobilization prevent secondary complications and , apart from that , increases self-esteem

What comes after stroke unit

Thank You

Tamer Belal Lecturer of neurology Mansoura University Tamer Belal Lecturer of neurology Mansoura University Stroke Unit : Many Questions, Some answers.

Documents

incidence of stroke

stroke study

answers stroke

stroke accounts

lifetime costs of stroke

total reported stroke

stroke related disability

general population