The imperative to develop dedicated stroke centers.

Abstract

OLDER PRACTITIONERS (INCLUDING ONE OF THE AUthors of this Editorial) will recall the days when patients with stroke were either treated at home or admitted to the hospital for compassionate observation. Neurologists made efforts to localize lesions and confirm functional areas of the brain and brainstem and described many vascular syndromes. Because the individual patient gained little, if anything, from these exercises, there was a public and professional aura of therapeutic helplessness surrounding stroke. Fortunately, those days are over. Optimism about the benefits of treatment coupled with a sense of urgency to deal quickly with every patient with stroke has swept away that nihilism. Coronary care units were introduced in the 1950s and spread rapidly because they saved lives. These units provided the models for intensive care units concentrating on respiratory enhancement, later for the introduction of trauma units, and eventually for strokeunits. In the late1970s theearliestobservational stroke units produced useful data on stroke cause, prognostic indicators, and the effect of cerebral ischemic lesions on cardiac function. Even before specific interventions to diminish theextentofpermanentbraindysfunctionbecameavailable, good general medical care and measures to stabilize cardiac functionprovidedbyknowledgeable staff resulted inearlier discharge and fewer deaths. Bed sores and contractures were prevented, attention to the airway reduced the occurrence of pneumonia from aspiration, and cardiac monitoring detected serious arrhythmias, all of which contributed to reducing disability and death. Early rehabilitation was encouraged and, among other benefits, the incidence of deep vein thrombosis was diminished through the use of antithrombotics. The benefits of stroke units have been evaluated in an increasing number of studies. The Cochrane Collaboration meta-analysis of more than 3500 patients in 20 trials comparing stroke units with general care units indicates that stroke unit care results in significant reductions in death (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.710.97), death or dependency (OR, 0.75; 95% CI, 0.65-0.87), and death or institutionalization (OR, 0.76; 95% CI, 0.65-0.90). Compared with conventional care on a general medical ward, care in an organized stroke unit reduces death and dependency with an absolute risk reduction of 5.6%. The number needed to be treated (NNT) in the stroke unit compared with a general medical setting is only 18. The ideal stroke unit provides multidisciplinary care to ensure normalization of physiological variables including temperature, fluid and electrolyte balance, blood glucose levels, and blood pressure; to promote early mobilization, physiotherapy, appropriate nutrition; and possibly to prevent depression. The impact of dedicated stroke units on the stroke population depends on how well these units are staffed and on their availability, accessibility, and cost. Until recently, 2 obstacles limited the widespread adoption of dedicated stroke units. First, few neurologists and other professionals were interested in stroke. Second, no known therapy had a positive effect on reducing the amount of ultimate brain damage. Despite benefits proven for expert general management, an indifferent approach to acute stroke care remained commonplace. Indifference changed to excited anticipation with the publication of the National Institute of Neurological Disorders and Stroke trial demonstrating benefit of tissue-type plasminogen activator (tPA) for patients with acute ischemic stroke. Careful scrutiny of the results by North American and more recently European agencies led quickly to the approval of tPA for use within 3 hours of the onset of the first symptoms of ischemic stroke. Guidelines to ensure proper application of tPA were developed. As an immediate result of this trial an urgent need has arisen to improve public and professional education about stroke, institute systems of stroke care, and improve early access to an increased number of stroke units. The dramatic change in outlook for as many as 10% of patients in the early stages of ischemic stroke quite suddenly requires the service side of medicine to develop a stroke infrastructure. In this issue of THE JOURNAL, the Brain Attack Coalition, representing several key US medical organizations, discusses the challenge of improving stroke care. A series of