Comprehensive Stroke Units Research Articles

Clinical, imaging, and management features of symptomatic carotid web: Insight from CAROWEB registry.

Although carotid web (CaW) is increasingly diagnosed as a cause of cryptogenic stroke, data are still limited to monocentric small sample cohort. To broaden knowledge on symptomatic CaW, CAROWEB registry has been recently implemented. In a large cohort of symptomatic CaW patients, we described epidemiologic characteristics, admission clinical and imaging features, and the current management including the secondary preventive strategy choice made in comprehensive French Stroke Units. CAROWEB is an ongoing French observational multicenter registry enrolling consecutive CaW patients diagnosed after an ipsilateral ischemic stroke (IS) or transient ischemic attack (TIA). Submitted cases were validated by two experienced neurologist and neuroradiologist. Clinical, imaging, and management features were collected for this study. Between June 2019 and December 2021, 244 cases were submitted by 14 centers, 42 rejected, and 202 included (IS, 91.6%; TIA, 7.9%; retinal infarction, 0.5%; mean age, 50.8 ± 12.2 years; female, 62.9%; Caucasian, 47.5%; Afro-Caribbean, 20.3%). IS patients showed median (interquartile range (IQR)) admission National Institutes of Health Stroke Scale (NIHSS) score, 8 (2-15); intracranial artery occlusion, 71.8%; ipsilateral chronic cerebral infarction (CCI), 16.3%; and reperfusion treatment, 57.3%. CaW was not identified during the mechanical thrombectomy procedure in 30 of 85 (35.3%) patients. Secondary prevention was invasive in 55.6% (stenting, n = 80; surgery, n = 30). In multivariable analysis, the invasive therapeutic option was associated with ipsilateral CCI (odds ratio (OR): 4.24 (1.27-14.2), p = 0.019) and inversely associated with risk factors (OR: 0.47 (0.24-0.91), p = 0.025) and admission NIHSS score (OR: 0.93 (0.89-0.97), p = 0.001). CaW must be considered in all ethnic groups including Caucasians. Secondary prevention is heterogeneous in large French Stroke Centers. The absence of risk factors, milder severity strokes, and ipsilateral CCI were predictive variables of secondary invasive treatment. The high rate of invasive treatment suggests that medical treatment alone is deemed ineffective to avoid recurrence and emphasize the need of randomized trials.

Clinical outcomes of delayed mechanical thrombectomy: Descriptive analysis and development of a screening tool.

Limited data guide the selection of patients with large vessel occlusion ischaemic stroke who may benefit from referral to a distant tertiary centre for mechanical thrombectomy (MT). We aimed to characterize this population, describe clinical outcomes and develop a screening system to identify patients most likely to benfit from delayed mechanical thrombectomy (MT). We undertook a retrospective cohort analysis enrolling patients transferred from regional sites to one of two MT comprehensive stroke units with a time from non-contrast computed tomography (NCCT) of the brain to reperfusion of 4 h or more. We describe Alberta Stroke Programme Early Computed Tomography Score (ASPECTS), National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) in our patients and compare these patients to those in extended-time-window trials. Lastly, we developed and validated a scoring model to help clinicians identify appropriate patients based on variables associated with poor outcomes. We included 563 patients, 46% of whom received thrombolysis; the median (interquartile range [IQR]) ASPECTS was 8 (7-10) and the median (IQR) NIHSS score was 16 (11-20). The median (IQR) symptom to mechanical reperfusion time was 390(300-580)min. Eight patients (1%) had a symptomatic haemorrhage. We achieved good clinical outcome (defined as mRS score ≤2) in 299 patients (54%). Age, diabetes, NIHSS score and ASPECTS were used to create a weighted scoring system with a validated area under the curve of 0.83 (95% confidence interval 0.74-0.92). Our study shows, in highly selected patients, that delayed MT many hours after baseline NCCT is associated with good clinical outcomes. However, older patients with diabetes, high NIHSS score and low ASPECTS may not benefit from transfer to a hub centre many hours away for MT in this model of care.

Assessment instruments used for self-report of pain in hospitalized stroke patients with communication problems: a scoping review.

The objective of this scoping review was to identify assessment instruments used for the self-report of pain by hospitalized patients who have had a stroke and who have communication problems. Pain assessment in various patient groups has received considerable attention, and a variety of pain assessment instruments exists. Nevertheless, there is a lack of consensus regarding which pain assessment instruments are used for self-report of pain in stroke patients with communication problems. This review included articles that focused on hospitalized adults who have had a stroke, have communication problems attributable to a stroke, and describe the use of an assessment instrument for the self-report of pain. The scoping review considered systematic reviews, quantitative and qualitative studies, and mixed method studies. Ten databases were searched from inception to August 2020, using Embase as the key information source (it yielded 424 papers). Hand-searching of the references of the included articles yielded an additional 12 papers. Papers written in any language were considered. A data extraction table was created to record relevant information in line with the goals and results of each article, the sample studied, and the pain assessment instrument used. Ten papers were included in the review, most of which were descriptive studies. Most papers were from the United Kingdom and the United States. The most common communication problem in stroke patients was aphasia. The participants received care in various hospital settings (eg, rehabilitation units, comprehensive stroke units, palliative care). Eleven assessment instruments were identified. In most cases, the assessment instruments focused on assessing pain presence and pain intensity. The most frequently used unidimensional pain intensity instrument was the numerical rating scale. Four instruments were multidimensional, of which two assessed health-related quality of life, including pain. The most thorough pain assessment instrument was the ShoulderQ, which contains 10 verbal questions and three visual vertical graphic rating scales that focus on the assessment of stroke-related shoulder pain. A range of both unidimensional and multidimensional self-report pain instruments was identified; however, of all the possible communication problems, most studies focused solely on patients with mild to moderate aphasia. Therefore, further research is recommended, including studies that also enroll patients with various stroke-related communication problems other than aphasia. In addition, the instruments should be translated for research in non-Western countries. Finally, apart from descriptive studies, experimental research with a robust randomized controlled trial design is needed to examine the effect of pain-inducing procedures on the perceived pain in patients with stroke-related communication problems.

Cost analysis of early rehabilitation after stroke in comprehensive cerebrovascular centres in the Czech Republic.

The paper analyses real-world data on cost of treatment in patients after stroke hospitalized in early rehabilitation units within comprehensive stroke centres in the Czech Republic. This is the first study of the kind in the Czech Republic, while such information is extremely rare worldwide. Stroke treatment witnessed a dramatic development in the last years, when the main progress was due to establishment of specialized (comprehensive) stroke units incorporating also early rehabilitation. There is a general agreement among clinicians that early rehabilitation is beneficial for patients after stroke. Costs of early rehabilitation after stroke were calculated by the micro-costing method alongside a pragmatic study in three Czech hospitals. Patients were transferred to specialized early rehabilitation units usually on 7th to 14th day after stroke onset and received four hours of interprofessional rehabilitation per day. The analysis of data collected during the prospective observational research of 87 patients proved significant differences between patients. The average costs of hospitalization were determined to be CZK 5,104 (EUR 194) per one day of intensive rehabilitation in seriously affected patients early after stroke. These costs differed significantly between hospitals (p-value < 0.001); the structure of direct costs was quite stable, though. About 60% of these costs were due to nursing and overhead, while no more than 15% were consumed by therapists. The treatment of patients after stroke in specialized stroke units proved to be beneficial for the patients increasing the number of those re-integrated in family and community life.

MRI as a first-line imaging modality in acute ischemic stroke: a sustainable concept.

Background:Computed tomography (CT) scans are the first-line imaging technique in acute stroke patients based on the argument of rapid feasibility. Using magnetic resonance imaging (MRI) as the first-line imaging technique is the exception to the rule, although it provides much more diagnostic information and avoids exposure to radiation. We evaluated whether an MRI-based acute stroke concept is fast, suitable, and useful to improve recanalization rates and patient outcomes.Methods:We performed a retrospective observational cohort study comparing patients treated at a comprehensive stroke center (Ulm/Germany) applying an MRI-based acute stroke concept with patients recorded in a large comprehensive stroke registry in Baden-Württemberg (Germany). We analyzed the quality indicators of acute stroke treatment, patient’s outcome, and the rate of transient ischemic attack (TIA) at discharge.Results:A total of 2182 patients from Ulm and 82,760 patients from the Baden-Württemberg (BW) stroke registry (including 29,575 patients of comprehensive stroke centers (BWc)) were included. Intravenous thrombolysis rate was higher in Ulm than in BW or the BWc stroke centers (Ulm 27.4% versus BW 20.9% versus BWc 26.1; p < 0.01), while a door-to-needle time <30 min could be achieved more frequently (Ulm 73.6% versus BW 44.1% versus BWc 47.1%; p < 0.01). Thrombectomy rate in patients with a proximal vascular occlusion was higher (Ulm 69.2% versus BW 50.7% versus BWc 59.3; p < 0.01). The number of TIA diagnoses was lower (Ulm 16.2% versus BW 24.6% versus BWc 19.9%; p < 0.01). More patients showed a shift to a favorable outcome (Ulm 21.1% versus BW 16.9% versus BWc 15.3; p < 0.01). Complication rates were similar.Conclusions:The MRI-based acute stroke concept is suitable, fast and seems to be beneficial. The time-dependent quality indicators were better both in comparison to all stroke units and to the comprehensive stroke units in the area. Based on the MRI concept, high rates of recanalization procedures and fewer TIA diagnoses could be observed. In addition, there was a clear trend towards an improved clinical outcome. A clinical trial comparing the effects of CT and MRI as the primary imaging technique in otherwise identical stroke unit settings is warranted.

Stroke Thrombectomy in Patients with COVID-19: Initial Experience in 13 Cases.

We performed a retrospective review in both comprehensive stroke units of a region affected early by the coronavirus disease 2019 (COVID-19) pandemic, between March 1 and April 26, 2020, including patients with COVID-19 who underwent mechanical thrombectomy for ischemic stroke. We identified 13 cases, representing 38.2% of 34 thrombectomies performed during this period. We observed increased mortality and a high incidence of thrombotic complications during hospitalization. Given the high rate of infected patients, systematic use of full personal protection measures seems justified.

Overview of endovascular thrombectomy accessibility gap for acute ischemic stroke in Asia: A multi-national survey.

Endovascular thrombectomy revolutionized the treatment of acute ischemic stroke. Nevertheless, access to endovascular thrombectomy is limited in many parts of the world. Asia holds 60% of the world's population and its countries carry some of the highest stroke disease burden. To understand the availability of endovascular thrombectomy and intravenous thrombolysis in this region, we interviewed stroke neurologists and neuro-interventionists of 19 Asian countries, and found a large disparity in access to endovascular thrombectomy and intravenous thrombolysis between high- and low-income countries. Lack of neuro-interventionists, comprehensive stroke units, stroke triage systems and high treatment cost are the major obstacles to wider accessibility of endovascular thrombectomy, especially among developing countries. The potential solutions to provide equitable access to stroke revascularization therapy are discussed.

Changes in survival and characteristics among older stroke unit patients—1994 versus 2012

ObjectivesTreatment on organized stroke units (SUs) improves survival after stroke, and stroke mortality has decreased worldwide in recent decades; however, little is known of survival trends among SU patients specifically. This study investigates changes in survival and characteristics of older stroke patients receiving SU treatment.Materials & MethodsWe compared 3‐year all‐cause mortality and baseline characteristics in two cohorts of stroke patients aged ≥60 consecutively admitted to the same comprehensive SU in 1994 (n = 271) and 2012 (n = 546).ResultsThree‐year survival was 53.9% in 1994 and 56.0% in 2012, and adjusted hazard ratio (HR) was 0.99 (95% CI: 0.77–1.28). Adjusted 30‐day case fatality was slightly higher in 2012, 18.9% versus 16.2%, HR 1.68 (95% CI: 1.14–2.47). There were no significant between‐cohort differences in survival beyond 30 days. Patients in 2012 were older (mean age: 78.8 vs. 76.7 years) and more often admitted from nursing homes. There were higher rates of atrial fibrillation (33.7% vs. 21.4%) and malignancy (19.2% vs. 8.9%), and prescription of antiplatelets (46.9% vs. 26.2%) and warfarin (16.3% vs. 5.5%) at admission. Stroke severity was significantly milder in 2012, proportion with mild stroke 66.1% versus 44.3%.ConclusionsThree‐year survival in older Norwegian stroke patients treated on an SU remained stable despite improved treatment in the last decades. Differences in background characteristics may explain this lack of difference; patients in 2012 were older, more often living in supported care, and had higher prestroke comorbidity; however, their strokes were milder and risk factors more often treated.

Neurological Critical Care Services' Influence Following Large Hemispheric Infarction and Their Impact on Resource Utilization.

Acute ischemic stroke (AIS) is the fourth leading cause of death in the US. Numerous studies have demonstrated the use of comprehensive stroke units and neurological intensive care units (NICU) in improving outcomes after stroke. We hypothesized that an expanded neurocritical care (NCC) service would decrease resource utilization in patients with LHI. Retrospective data from consecutive admissions of large hemispheric infarction (LHI) patients requiring mechanical ventilation were acquired from the hospital medical records. Between 2011-2013, there were 187 consecutive patients admitted to the Jefferson Hospital for Neuroscience (Philadelphia, USA) with AIS and acute respiratory failure. Our intention was to determine the number of tracheostomies done over time. The primary outcome measure was the number of tracheostomies over time. Secondary outcomes were, ventilator-free days (Vfd), total hospital charges, intensive care unit length of stay (ICU-LOS), and total hospital length of stay (hospital-LOS), including ICU LOS. Hospital charges were log-transformed to meet assumptions of normality and homoscedasticity of residual variance terms. Generalized Linear Models were used and ORs and 95% CIs calculated. The significance level was set at α = 0.05. Of the 73 patients included in this analysis, 33% required a tracheostomy. There was a decrease in the number of tracheostomies undertaken since 2011. (OR 0.8; 95% CI 0.6-0.9: p=0.02).Lower Vfd were seen in tracheostomized patients (OR 0.11; 95%CI 0.1-0.26: p<0.0001). The log-hospital charges decreased over time but not significantly (OR 0.9; 95%CI 0.78-1.07: p=0.2) and (OR 0.99; 95%CI 0.85-1.16: p=0.8) from 2012 to 2013 respectively.The ICU-LOS at 23 days vs 10 days (p=0.01) and hospital-LOS at 33 days vs 11 days (p=0.008) were higher in tracheostomized patients. The data suggest that in LHI-patients requiring mechanical ventilation, a dedicated NCC service reduces the overall need for tracheostomy, increases Vfd, and decreases ICU and hospital-LOS.

Neurological Critical Care Services’ Influence Following Large Hemispheric Infarction and Their Impact on Resource Utilization

Abstract Introduction: Acute ischemic stroke (AIS) is the fourth leading cause of death in the US. Numerous studies have demonstrated the use of comprehensive stroke units and neurological intensive care units (NICU) in improving outcomes after stroke. We hypothesized that an expanded neurocritical care (NCC) service would decrease resource utilization in patients with LHI. Methods: Retrospective data from consecutive admissions of large hemispheric infarction (LHI) patients requiring mechanical ventilation were acquired from the hospital medical records. Between 2011-2013, there were 187 consecutive patients admitted to the Jefferson Hospital for Neuroscience (Philadelphia, USA) with AIS and acute respiratory failure. Our intention was to determine the number of tracheostomies done over time. The primary outcome measure was the number of tracheostomies over time. Secondary outcomes were, ventilator-free days (Vfd), total hospital charges, intensive care unit length of stay (ICU-LOS), and total hospital length of stay (hospital-LOS), including ICU LOS. Hospital charges were log-transformed to meet assumptions of normality and homoscedasticity of residual variance terms. Generalized Linear Models were used and ORs and 95% CIs calculated. The significance level was set at α = 0.05. Results: Of the 73 patients included in this analysis, 33% required a tracheostomy. There was a decrease in the number of tracheostomies undertaken since 2011. (OR 0.8; 95% CI 0.6-0.9: p=0.02). Lower Vfd were seen in tracheostomized patients (OR 0.11; 95%CI 0.1-0.26: p&lt;0.0001). The log-hospital charges decreased over time but not significantly (OR 0.9; 95%CI 0.78-1.07: p=0.2) and (OR 0.99; 95%CI 0.85-1.16: p=0.8) from 2012 to 2013 respectively. The ICU-LOS at 23 days vs 10 days (p=0.01) and hospital-LOS at 33 days vs 11 days (p=0.008) were higher in tracheostomized patients. Conclusion: The data suggest that in LHI-patients requiring mechanical ventilation, a dedicated NCC service reduces the overall need for tracheostomy, increases Vfd, and decreases ICU and hospital-LOS.

Stroke-Associated Pneumonia Risk Score: Validity in a French Stroke Unit

Stroke-associated pneumonia is a leading cause of in-hospital death and post-stroke outcome. Screening patients at high risk is one of the main challenges in acute stroke units. Several screening tests have been developed, but their feasibility and validity still remain unclear. The aim of our study was to evaluate the validity of four risk scores (Pneumonia score, A2DS2, ISAN score, and AIS-APS) in a population of ischemic stroke patients admitted in a French stroke unit. Consecutive ischemic stroke patients admitted to a stroke unit were retrospectively analyzed. Data that allowed to retrospectively calculate the different pneumonia risk scores were recorded. Sensitivity and specificity of each score were assessed for in-hospital stroke-associated pneumonia and mortality. The qualitative and quantitative accuracy and utility of each diagnostic screening test were assessed by measuring the Youden Index and the Clinical Utility Index. Complete data were available for only 1960 patients. Pneumonia was observed in 8.6% of patients. Sensitivity and specificity were, respectively, .583 and .907 for Pneumonia score, .744 and .796 for A2DS2, and .696 and .812 for ISAN score. Data were insufficient to test AIS-APS. Stroke-associated pneumonia risk scores had an excellent negative Clinical Utility Index (.77-.87) to screen for in-hospital risk of pneumonia after acute ischemic stroke. All scores might be useful and applied to screen stroke-associated pneumonia in stroke patients treated in French comprehensive stroke units.

A new era of endovascular treatment for acute ischemic stroke: what are the implications for stroke care in Brazil?

.First, these exciting results were obtained at high-volume comprehensive stroke centers with large ex -perience with stroke therapy with TPA (including telemed-icine) and full-time stroke teams (with a stroke neurolo-gist), angiography suite and multimodal neuroimaging. The reproducibility of their results in our healthcare sys-tem requires organizing efficient stroke networks, able to identify candidates for EVT and promptly refer them to comprehensive stroke care center. This poses a special challenge in Brazil, given its continental dimensions, geo-economical disparities, and paucity of such comprehen-sive stroke units. We also need to train a new generation of stroke neurologists and interventionalists.Secondly, the underlying selection paradigm differed widely among trials, from being extremely restrictive in se-lecting patients (

Compensatory care: The elephant in the in-patient rehabilitation room

International Journal of Therapy and RehabilitationVol. 20, No. 4 CommentCompensatory care: The elephant in the in-patient rehabilitation roomJulie PryorJulie PryorSearch for more papers by this authorJulie PryorPublished Online:5 Jun 2014https://doi.org/10.12968/ijtr.2013.20.4.178AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Burton CR, Fisher A, Green TL (2009) The organisational context of nursing care in stroke units: A case study approach. Int J Nurs Stud 46(1): 85–94 Crossref, Google ScholarDonnelly JP, Donnelly K, Grohman KK (2005) A multi-perspective concept mapping study of problems associated with traumatic brain injury. Brain Inj 19(13): 1077–1085 Crossref, Google ScholarGraham SK, Cameron ID (2008) A survey of rehabilitation services in Australia. Austr Health Rev 32(3): 392–399 Crossref, Google ScholarKearney PM, Lever S (2010) Rehabilitation nursing: invisible and underappreciated therapy. Int J Ther Rehabil 17(8): 394–395 Link, Google ScholarKirkevold M (1997) The role of nursing in the rehabilitation of acute stroke patients: Towards a unified theoretical perspective. ANS Adv Nurs Sci 19(4): 55–64 Crossref, Google ScholarMcPherson K (2006) Rehabilitation nursing – a final frontier? Int J Nurs Stud 43(7): 787–9 Crossref, Google ScholarNSW Health (2011) Rehabilitation redesign project Final Report version 1.4. Sydney: NSW Health. Google ScholarOzer MN (1999) Patient participation in the management of stroke rehabilitation. Topics Stroke Rehabil 6(1): 43–59 Google ScholarPryor J (2005) Nursing's role in rehabilitation: A review of the research literature. J Austr Rehabil Nurs Assoc 8(3): 8–13 Google ScholarPryor J, Dean S (2012) The person in context. In Dean SSeigert RTaylor W. editors. Interprofessional rehabilitation: a person centred approach. Chichester, UK: Wiley-Blackwell. p.135–165 Crossref, Google ScholarPryor J, O'Connell B (2009) Incongruence between nurses' and patients' understandings and expectations of rehabilitation. J Clin Nurs 18(12): 1766–74 Crossref, Google ScholarSt-Germain D, Boivin B, Fougeyrollas P (2011) The Caring-Disability Creation Process Model: a new way of combining ‘care’ in nursing and ‘rehabilitation’ for better quality of services and patient safety, Disabil Rehabil 33(21–22): 2105–2113 Crossref, Google ScholarWade D (2005) Describing rehabilitation interventions. Clin Rehabil 19(8): 811–8 Crossref, Google ScholarWest T, Langhorne P, Bernhardt J (2013) How do comprehensive and acute stroke units differ? A critical review. Int J Ther Rehabil 20(1): 41–52 Link, Google Scholar FiguresReferencesRelatedDetails 2 April 2013Volume 20Issue 4ISSN (online): 1759-779X Metrics History Published online 5 June 2014 Published in print 2 April 2013 Information© MA Healthcare LimitedPDF download

How do comprehensive and acute stroke units differ? A critical review

Background: Stroke unit care is advocated for all acute stroke patients. Varying models of stroke unit care exist and there is a need to identify how these models differ and how these differences may affect patient outcomes. This review explores the difference between the comprehensive stroke unit model, which includes rehabilitation, and the acute stroke unit model, which does not. Content: A review of descriptive information regarding comprehensive and acute stroke units was performed to determine the differences in the underlying components of care. Conclusion: A greater emphasis on acute medical care appears to exist in the acute stroke unit, with higher levels of nurse staffing, earlier assessment and investigation, more intensive physiological monitoring and an increased use of thrombolysis and anti-platelet therapy. In contrast, the availability of a period of rehabilitation in the comprehensive stroke unit appears to create a greater emphasis on rehabilitation, even in the acute phase, with greater involvement of gerontologists, rehabilitation physicians and allied health professionals, increased multidisciplinary staff education and training, greater patient and carer participation in rehabilitation, and early mobilisation protocols.

Preferences, barriers and facilitators for establishing comprehensive stroke units: a multidisciplinary survey

To determine the preferences of multidisciplinary stroke clinicians for models of inpatient stroke unit care and perceived barriers to establishing a comprehensive stroke unit (CSU) model (acute and rehabilitation care in the same ward). Written questionnaires distributed and completed at multidisciplinary stroke unit case conferences in NSW, Australia. Twenty hospitals with 22 stroke units were surveyed, 13 acute stroke units, 7 rehabilitation stroke units, 2 CSUs. Two hundred and twenty-eight respondents: 99 (43.4%) allied health, 72 (31.6%) nurses and 57 (25.0%) doctors. One hundred and fifty-one respondents (67.0%) thought CSU to be the best model. Seventy-three % of doctors and 79% of allied health preferred CSU v. 57% of nurses (P=0.041). Of doctors, rehabilitation specialists were most likely to favour comprehensive model (84.2%) and neurologists least (57.0%). The main perceived advantages of CSU were reduced cost and improved functional outcomes; perceived disadvantages were increased workload and unwell patients unable to participate in rehabilitation. Main perceived barriers to establishing CSU were lack of space, money, staffing and time. Although most current stroke unit care in NSW is based on the traditional model of acute and rehabilitation components in separate wards or hospitals, the majority of multidisciplinary stroke team clinicians believe CSU is the optimum model. What is known about the topic? Stroke unit care is known to improve survival and dependency but the optimum model of care is unproven, despite some small studies suggesting that the CSU model may result in better outcomes. What does this paper add? This paper is the first to survey stroke clinicians from various disciplines and types of unit, to determine their preferences for stroke unit model. What are the implications for practitioners? A majority of clinicians expressed a preference for the CSU model, suggesting that most would be comfortable caring for patients in both acute and rehabilitation phases of stroke care if further such units are established.

Comprehensive Stroke Units: A Review of Comparative Evidence and Experience

Stroke unit care offers significant benefits in survival and dependency when compared to general medical ward. Most stroke units are either acute or rehabilitation, but comprehensive (combined acute and rehabilitation) model (comprehensive stroke unit) is less common. To examine different levels of evidence of comprehensive stroke unit compared to other organized inpatient stroke care and share local experience of comprehensive stroke units. Cochrane Library and Medline (1980 to December 2010) review of English language articles comparing stroke units to alternative forms of stroke care delivery, different types of stroke unit models, and differences in processes of care within different stroke unit models. Different levels of comparative evidence of comprehensive stroke units to other models of stroke units are collected. There are no randomized controlled trials directly comparing comprehensive stroke units to other stroke unit models (either acute or rehabilitation). Comprehensive stroke units are associated with reduced length of stay and greatest reduction in combined death and dependency in a meta-analysis study when compared to other stroke unit models. Comprehensive stroke units also have better length of stay and functional outcome when compared to acute or rehabilitation stroke unit models in a cross-sectional study, and better length of stay in a 'before-and-after' comparative study. Components of stroke unit care that improve outcome are multifactorial and most probably include early mobilization. A comprehensive stroke unit model has been successfully implemented in metropolitan and rural hospital settings. Comprehensive stroke units are associated with reductions in length of stay and combined death and dependency and improved functional outcomes compared to other stroke unit models. A comprehensive stroke unit model is worth considering as the preferred model of stroke unit care in the planning and delivery of metropolitan and rural stroke services.

Ｓｔｒｏｋｅ Ｕｎｉｔの現状と課題：急性期脳卒中診療体制に関する全国アンケート調査から

Guideline for Stroke Treatment 2004 published in Japan strongly recommended that acute stroke patients should be managed in dedicated stroke care unit or stroke unit. We conducted a nation-wide survey of all hospitals providing acute stroke care. We sent a questionnaire to 7, 835 hospitals and obtained 2, 603 answers (33.2%). According to the meta-analysis by Stroke Unit Trialists' Collaboration, service organizations were classified into five categories as a hierarchy in descending order as follows ; acute stroke units, comprehensive stroke units, mixed rehabilitation ward, mobile stroke team, and general medical ward. Only 8.3% of hospitals had organized stroke units (acute stroke units ; 0.9%, comprehensive stroke units ; 7.4%), and 63.8% of hospitals managed acute stroke patients in general medical words. The categorization of stroke service organizations was highly correlated with the number of patients admitted in a year. We compared performance levels of the key elements recommended for establishing primary stroke centers by the Brain Attack Coalition among the five categories, such as acute stroke teams, stroke units, written care protocols, and an integrated emergency response system, availability and interpretation of computed tomography scans 24 hours everyday, access to neurosurgeon within 2 hours and rapid laboratory testing. Currently there are very few hospitals with performance levels required for the primary stroke center. More importantly, measures were taken for the quality improvement of stroke care only by 6.5% of hospitals. Intravenous thrombolytic therapy is now widely available in Japan. Establishment of clearly defined stroke units or stroke care units is urgently needed.

Unidades de tratamiento del ataque cerebrovascular (UTAC) en Chile

Stroke is a major public health problem in Chile, with an incidence similar to that of many industrialized nations, it accounts for 10% of all deaths and ranks 5th in number of healthy years of life lost to a disease. Organized inpatient care for stroke patients has been shown in systematic reviews of randomized clinical trials to be effective in preventing death, disability and institutional care, without increasing length of stay compared to usual care. Organized stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in a dedicated ward (stroke ward) of which there are various possible models; acute stroke units which accept patients acutely but discharge early (usually within 7 days). This could include an "intensive" model of care with continuous monitoring and high nurse staffing levels; comprehensive (i.e. combined acute and rehabilitation) stroke units which accept patients acutely but also provide rehabilitation for at least several weeks if necessary. The way in which stroke units affect outcome is through reduction of complications of immobility and probably non specific neuroprotection. Stroke units should deliver high quality evidence based interventions to all eligible patients and should maintain high standards of care through staff training, guidelines and protocols, audit and quality assurance. Given that stroke is one of the fifty six health priorities in the health reform, inpatient stroke care should be delivered through stroke units organized in hospitals throughout Chile.