Comprehensive Stroke Centers: Recognizing the Need for Complex Stroke Care and Interventional Radiology's Contribution

Abstract

Stroke is the leading cause of long-term disability and ranks fourth among all causes of death, accounting for 1 in every 19 deaths in the United States.1 In 2009, approximately 795,000 people had a new or recurrent stroke. The estimated direct and indirect medical cost of stroke during that year was $38.6 billion; the cumulative direct and indirect cost of stroke care between now and 2050 are projected to exceed $1.5 trillion. Predominantly, on the basis of the National Institute of Neurological Disorders and Stroke (NINDS) recombinant tissue plasminogen activator (rt-PA or tPA) trial, intravenous (IV) tPA quickly became the mainstay of acute ischemic stroke (AIS) treatment, and in 1996, the US Food and Drug Administration (FDA) approved IV tPA for the treatment of AIS within 3 hours of symptom onset.2 Recognizing that the time sensitive and complex nature of treating patients with AIS required an organizational approach to care, The Joint Commission (TJC) developed Advanced Disease-Specific Care Certification standards for Primary Stroke Centers (PSCs). Since 2003, when TJC began certifying PSCs, over 1,000 have been certified nationwide in the United States.3 Over the last decade, new treatments and technology for the treatment of stroke patients has increased the complexity of stroke care. In addition, the focus of PSCs was on care for ischemic stroke patients. It has been long recognized that care for hemorrhagic stroke patients is equally, if not more, complex. Thus, drawing on the evidence-based recommended requirements from the Brain Attack Coalition (BAC) and American Stroke Association, a thorough literature review and a technical advisory panel that included experts from multiple specialties related to stroke, TJC established standards for Comprehensive Stroke Center (CSC) certification, which became effective on September 1, 2012.4,5 This distinct certification is the eighth Advanced Disease-Specific Care Certification offered by TJC. TJC CSCs will typically be elite academic medical centers or tertiary care facilities. PSCs will continue to represent a wide range of hospitals that offer standard stroke care, use tPA, and often have a designated stroke unit. A complex stroke patient requires advanced diagnostic imaging and treatment procedures by specially trained physicians and other health-care providers.4 Large complex ischemic strokes may be further defined as those needing endovascular therapies, hemicraniectomies, management of systemic disease with multiorgan involvement, or monitoring and/or management of increased intracranial pressure. Complex intracerebral hemorrhages may be defined as those needing intensive care unit (ICU) and/or neurosurgical intervention, while complex subarachnoid hemorrhages (SAH) may require these services and/or vasospasm treatment. A CSC is a hospital that has the necessary personnel, expertise, infrastructure, and programs to care for complex stroke patients. Many advocate for a “hub and spoke” model, where the CSC acts as a resource for expertise and education for other centers in the region. Interventional management of the complex stroke patient is an integral part of CSC certification. As a result, guidelines have been established to help facilitate the care of patients receiving interventional management.6,7 TJC certification requirements are detailed in the “Advanced Disease-Specific Care Certification Requirements for Comprehensive Stroke Center.”5 Key requirements specific to interventional management will be summarized followed by considerations of endovascular stroke therapy and examples of process improvement.