Organization of Stroke Care: Education, Stroke Units and Rehabilitation

Acute stroke is increasingly recognised as one of the leading factors of morbidity and mortality worldwide. Its economical burden is among the highest of all diseases. Ischaemic stroke is by far the most frequent subtype of acute stroke. More than 80% of all stroke patients suffer from focal ischaemia [Bonita, 1992]. Over the past decades, acute stroke has increasingly been recognised as a medical emergency. Acute, post-acute and rehabilitation care of stroke patients in specialised wards as well as revascularising therapies have been proven to be effective in acute ischaemic stroke.There have been several publications of guidelines or consensus papers over the past years [Asplund et al., 1993; Brainin et al., 1997; Aboderin et al., 1996; Adams et al., 1994; The European Ad Hoc Consensus Group, 1996; 1997; Billier et al., 1998; Einhäupl et al., 1999; Feinberg et al., 1994; Gorelick et al., 1999; Report on Pan European Consensus Meeting on Stroke Management, 1995; WHO Task Force on Stroke and other Cerebrovascular Disorders, 1989]. This series of recommendations is proposed by the European Stroke Initiative, the common body of three major European neurological or stroke-related societies, the European Neurological Society ENS, the European Federation of Neurological Society EFNS and the European Stroke Council, which also represents the European Stroke Conference. In these recommendations, the authors provide both an overview of established or widely used therapeutic strategies as well as an evaluation of involving, but not yet proven strategies. Table 1 gives the definitions for levels of evidence used in these recommendations.Despite the high mortality and morbidity of stroke, many patients and relatives do not recognize the symptoms of stroke or realise that seeking treatment is urgent. Various factors are responsible for delay in patient referral to hospital. The National Stroke Association estimates that 40% of people in the USA do not know the warning signs of stroke, and only 1% know that stroke is a leading cause of death [Gorelick et al., 1999]. In Germany, it is estimated that only 5% of the population are aware of the warning signs of stroke compared with 50% who know about myocardial ischaemia.Reasons for this shortcoming include a poor awareness of stroke by the victim or family, reluctance to seek immediate medical help, incorrect diagnosis by the paramedical service and rating stroke as a non-emergency by medical personnel and the family physician. These facts emphasise the need for an ongoing education program. The benefits of media campaigns to raise awareness of stroke have been documented in a number of studies [The European Ad Hoc Consensus Group, 1996; Alberts et al., 1992; Barsan et al., 1993; 1994]. Education programs can be extensive and involve radio and television interviews, newspaper articles, lectures to local and regional primary care and emergency department physicians, and mailings to local physicians. The aims of public education initiatives are to enable and encourage the general population to recognise immediately the symptoms of stroke, to realise that urgent medical atttention is needed, and to use the emergency transportation services and immediately go to the correct hospital. Primary contact with general practitioners (GPs) may cause delays and prevent early institution of adequate therapy. Teaching the public about symptoms and signs of stroke is one of the highest priorities of public medical education.Professional groups who must be motivated in stroke care include emergency medicine physicians and technicians, other specialists, nurses, GPs and paramedical personnel. In many European countries neurologists are nowadays most interested in the care of stroke patients. Stroke units are frequently part of neurology departments. However, internists, geriatricians, GPs and emergency medicine physicians may also be responsible for treating stroke patients. Actually, due to the low number of neurologists or other stroke physicians in some European countries, many stroke patients are still not seen by a physician with special expertise in stroke management. Primary care physicians are not a target group for education campaigns at present, though increasing their general level of understanding of stroke is important, as they will be responsible for continuing the secondary prevention instituted after the acute phase.Inaccurate initial diagnosis represents a major problem. Ambulance dispatchers may have a false-positive assessment rate of up to 50%, and even in trained paramedics, this rate is about 25% [Kothari et al., 1997]. However, this result can be improved by adequate training [Kothari et al., 1999].Paramedics and physicians also need to be trained in the recognition of symptoms and signs of acute stroke and the necessity of immediate transportation to an adequately equipped unit. The medical personnel should be trained in recognising the acute presentations of ischaemic stroke and should be able to cope with the early complications after stroke. It should be noted here that there is no reliable way to differentiate between intracranial parenchymal haemorrhage and ischaemic stroke by clinical symptoms alone. Some signs of subarachnoid haemorrhage, another presentation of acute stroke, however, may allow for early suspicion of this stroke subtype. Emergency medical personal should be trained to conduct a focussed medical examination that includes level of consciousness, presence of focal weakness, presence of seizure activity and the presence of aphasia or other cognitive disturbances. They need to be informed that fluctuating or stuttering courses and even early clearing of systems are of special importance. They need to learn about the complexity of stroke presentation and its differential diagnosis in order to understand why early involvement of specialists in this field is desirable. It is particularly important that these groups learn that they are important and competent partners in providing acute stroke care.Successful stroke care begins with recognising stroke as a medical emergency like acute myocardial infarction (MI) or severe trauma and, even more importantly, recognising that a patient presenting as a medical emergency has a stroke [Adams et al., 1994; The European Ad Hoc Consensus Group, 1996; Kothari et al., 1999]. There is wide-spread consensus among stroke physicians that the best way to provide early stroke care is to call the emergency medical system immediately and to get transported to an institution, where stroke care can be provided on an adequate level. The corresponding emergency numbers should be called immediately, if stroke is suspected.Cost considerations provide another incentive to regard stroke as an emergency. The total cost of stroke is about USD 30 billion/year in the USA and USD 1.9 billion/year in Sweden; in Canada the direct costs alone for 285 stroke patients were USD 6.6 million over a 2-year period. In Sweden, the cost of stroke patients from stroke to death have been calculated to be 73.000 USD, while in Finland it is 60.000 USD [Kaste et al., 1998]. Increasing the proportion of stroke patients with a favourable outcome will decrease costs, particularly the direct costs, which represent about 80% of the total costs [Kaste et al., 1998; Wade et al., 1985].The initial evaluation of the stroke patients includes the assessment and breathing and circulation. Differential diagnoses that need to be considered are coma of other origin, trauma, drug overdose, post-seizure state or metabolic disorders. After ischaemic stroke, only very few patients develop depression in consciousness within the first 24 h. With early loss of consciousness, a diagnosis of an intracranial haemorrhage or one of the other differential diagnosis mentioned before is more probable [Hacke et al., 1995].In the emergency room, stroke patients need to be tested for hemiparesis, aphasia, hemianopia, dysarthria, disturbance of coordination including ataxia and poor balance, double vision and oculomotor disturbances, nausea, vomiting, headache and neck stiffness. Stroke can present with different syndromes, depending on the part of the brain that is injured by ischemia. However, special syndromes are more frequent than others and should be recognised.Stroke patients should be treated in specialised centres [Stroke Unit Trialist’s Collaboration, 1997]. Such a centre is defined by both trained personnel and the capability to perform diagnostic studies without undue time delay. Minimum requirements of such centres are listed in table 2. They include 24-hour availability of CT scanning, stroke physicians and other specialised personel.Stroke centres or stroke units are no stand-alone solutions. They can only work optimally if a well-established referral and rehabilitation network is [The European Ad Hoc Consensus Group, This also includes with primary care physicians in primary and secondary acute stroke it is that all stroke patients are to the best equipped to provide the most acute stroke This may not be the hospital. of patients may from care or stroke care if they are and treated may be and is by the Stroke of the the of and the European Ad Hoc Consensus time for treatment of patients with acute brain infarction is considered to be In some special may a treatment but this is the not the et al., a for immediate treatment has the past few years for which an emergency care or stroke may be for many acute stroke of acute stroke at different levels of patient management. acute assessment of neurological and treatment of The of special treatment strategies may be ongoing before the on the subtype of acute stroke has been is the most important the first and after acute stroke even the one with symptoms must be recognised as an medical patient et al., 1994; and Adams et al., 1994]. The patient has to be transported to an emergency and the physician must the ischaemic stroke patient as a or only a of the stroke patients present with a but most have some in of the in the early treatment of acute stroke is to patients who need immediate and treatment from who can be in a stroke or which may complications secondary treatment such a infarction or stroke, and medical such as myocardial and must be recognised assessment of stroke on the and neurological and use and of diagnostic is of stroke patients nowadays the the emergency or unit. different is if the patient in the within the first few after stroke compared with patients who for 24 after stroke. In the first the neurological examination has to be focussed on the of and of stroke. such as or must be recognised and is the therapeutic in a patient may be for stroke are a for patient can be used to that the are They should be for in the management. These should be by the stroke care in with other and can be for The for in levels or should be on an patient The use of has been to the of and cost patient and the of complications and early within the include that of patients in general medical of to early rating of stroke as by of treatment for stroke and of a or another physician with special expertise in stroke in the emergency et al., 1996; et al., initial examination includes of breathing assessment of and and of if for clinical and studies are and a is are clinical are After the emergency which in part will be by emergency or other the should perform a neurological The examination is if by a medical on factors and in a of drug trauma or may important initial is to a infarction from or subarachnoid haemorrhage CT or is particularly urgent in the patient with a level of consciousness to the there are the clinical of haemorrhage are and level of of is that acute stroke with level of consciousness or headache is proven However, and initial or infarction may present with a clinical not from and adequate is an important part of general emergency In stroke may be by in the or is of special with patients with consciousness et al., In acute stroke, early in and early due to consciousness are However, patients with and or haemorrhage or stroke may develop early In an should be considered et al., it that patients with severe stroke are with They should be treated with for the acute the patient is the diagnostic is and the patient has been to the [Hacke et al., are frequently with the the physician must acute and for or of these may to stroke and may stroke and are a and a of stroke patients may have low at the time of stroke The examination of the stroke patient includes assessment of the presence of or a in the Acute stroke, ischaemic or to a in the first and after stroke. nowadays that should not be treated in the first after stroke. However, there are no to or time of and which to use for should be used only in in the early acute ischaemic stroke and for or it is that in the early after stroke, should only be treated if the on or if the [Adams et al., 1994]. for the treatment of such from to In that may be over a can be best [Hacke et al., is some stroke patients This is of special in the of of or is the cause of of and, in a few also may be the treatment of and The of in the acute is to and to is best treated with or are best if there is no is the for an which is in the treatment of acute stroke [Adams et al., 1994; et al., 1995; The European Ad Hoc Consensus Group, and et al., There are that a high level at is to neurological outcome after stroke et al., 1994]. are after acute stroke. part of the after stroke, it to be to include treatment the general treatment recommendations after stroke. for have not been In some a of has been should be of can also neurological focal levels must be in patient presenting with symptoms and signs of acute stroke. of the level of or by or may neurological due to [Adams et al., 1994; The European Ad Hoc Consensus Group, for the treatment of no should be used in the early or stroke also outcome after stroke et al., 1996; et al., 1998]. of body is 1 and to patients with severe acute stroke not in patients with ischaemic stroke if they do not have levels and are to differentiate the of acute stroke, brain haemorrhage, subarachnoid haemorrhage, to other brain to get an about the cause of brain to provide a for of the stroke and to or complications of stroke that may Table the that may be for early evaluation of patients with acute CT between and ischaemic stroke. CT signs of early ischaemia can be as early as after stroke but they may develop over are immediately, but they may in the first and a CT may CT also to other neurological that may be with stroke. In CT may subarachnoid in the of with very or that a or may be by In examination of the should be This is the only for a in the evaluation of acute extensive early signs in the first after stroke a very ischaemia with a of secondary haemorrhage or of CT or in the may be In is more it has not yet the level of a in most should be in all stroke patients of the high of in stroke patients. Stroke and acute myocardial infarction may stroke may cause and is the of studies are frequently in stroke centres They include not only or of the but also They are used to state of or studies include and to for but these studies are not in the However, it to be to have these studies in the first 24 after stroke of such and has been in series and in some However, these major that are not in a of 1 CT is the most important diagnostic in patients with stroke. evaluation of and and is in the of acute stroke patients. This also includes and of the and intracranial and special and studies for of stroke should be early after stroke, but should not delay general or care should in a stroke unit. on the Stroke Unit Trialist’s an in a in death or of and a 25% in death or need of care for patients treated in a stroke in to a general medical In a of patients treated in the acute and state and mortality by compared to general The Stroke compared the of stroke treatment in et al., In stroke treatment in a stroke and in the stroke treatment not and need of in patients treated in the stroke of by in the stroke unit. mortality et al., et al., 1997; et al., is for patients treated in stroke stroke is a or part of a that or care of stroke patients. The and the to treatment and care the stroke unit. The of such a are and and The of a stroke in of is not Stroke units with as as have outcome after stroke care is of et al., 1994]. of the patients to a stroke with the of will be to a in their from the Stroke Unit Trialist’s that all of from treatment and rehabilitation in stroke and and stroke and patients with and severe stroke care should be to a of and there is in no evidence to of on the of or on stroke the and patients most from stroke units et al., units are in several The acute stroke patients and continuing for treatment several but than 1 the acute and rehabilitation stroke patients and continuing treatment and rehabilitation for several or if the rehabilitation stroke patients after a delay of 1 or and continuing treatment and rehabilitation for several or if a stroke stroke care and treatment to stroke patients at a of Such are established in where stroke units are not only the acute and rehabilitation stroke and the rehabilitation stroke have proven in of mortality and of is for the acute stroke units without as well as for the stroke why patients in stroke units do than patients with care is not treated in stroke units do not more or than stroke patients treated in wards et al., 1999; et al., However, are common in stroke and the personnel more aware of et al., and in The most of a stroke compared to a however, prevention of time to of and early rehabilitation et al., 1997]. These are the for the proven of mortality of patients treated in stroke to rehabilitation including care very early on is a very important of an effective stroke unit. The of the of a stroke such as a trained education and involvement of are as yet not but be of importance. of a stroke is not to a medical Stroke units by internists, geriatricians, neurologists or specialists in rehabilitation medicine may be effective [Stroke Unit Trialist’s Collaboration, however, care in neurology wards has proven [Kaste et al., 1995].In stroke is increasingly considered as an acute medical emergency with the need for immediate and This has been on the that the patients from immediate diagnostic treatment and prevention of medical of stroke as a medical emergency has been well on the of stroke treatment including immediate in the the the and rehabilitation the the series et al., 1996; et al., about of the stroke patients within within and within of the stroke. transportation than patients a with a network compared with patients without such a patients with a at the than patients who alone. with severe including than patients with about stroke symptoms also of as stroke patients a to of stroke in including first and stroke, from to This is for the most part due to in the and the of the The with of the stroke patients are than years of [Kaste et al., 1998]. The of in this group of patients from outcome with total to and and to no at of the stroke patients have neurological that and one will can the number of patients who are after stroke. The physician is early on about the of outcome of a Table which may in of stroke patients need rehabilitation of a stroke victim is as as This that the patient should immediately be to a with such not only for acute diagnosis and but also for early The of the rehabilitation on the of the patient and the of the the patient is the rehabilitation is to prevent and and to prevent for the patient is after With one can also the of and on the are the of several a at the patient consciousness and is able to or if the patient has a level of consciousness from the of the patient is to an part in the rehabilitation need to be in for more than 1 or after the they have a major decrease in the level of and the of and the of In patients and stroke patients who must be for more than a or or should be After or most patients who are can be of with and in a or for a part of the initial of stroke has the patients should be for the of and a rehabilitation for should be The assessment of the includes evaluation of including cognitive such as aphasia, the of weakness, loss and that the to to rehabilitation include of to and to at and the need for care stroke to provide adequate rehabilitation for stroke includes the who is interested in and trained for the in stroke a trained in stroke an in a with in a to stroke and a with the of stroke patients [Adams et al., most treating stroke patients do not have all these trained stroke The of the stroke and can be in most and they can provide a rehabilitation if they it as a all stroke patients have for The factors listed in table are for outcome after The more of the for poor outcome the patient the is for there is a local of rehabilitation the should be to patients who are most to be able to of the The and stroke patients are who most et al., The of neurological that are used to outcome are for groups of patients. the in outcome may be In of it is that a of the rehabilitation should be to a for This is particularly a patient who is to have no rehabilitation to treatment and or the assessment of a stroke patient by the of the stroke rehabilitation a rehabilitation will be The of the patient to be on a by the different a the of the stroke should and the of stroke patients. there be a in of the of the rehabilitation the for for to be and if The patients and the of their family should be of the stroke They should be the of stroke and the of the family also need to be not to the patient in order to the of the rehabilitation as the should to the from to and the to their best in The or a should the with the patient to the at in order to the from [Kaste et al., as it is that the patient a rehabilitation than can be provided within the acute they should be to a special rehabilitation if such a is the patient is to a rehabilitation it is of the that all of the stroke of the to the stroke of the rehabilitation [Kaste et al., After the rehabilitation can be over by the rehabilitation if one This the of the patient to the rehabilitation and the to The of the rehabilitation in the acute the of the stroke and stroke rehabilitation The acute of the rehabilitation should not than is for a This is and more than 24 of neurological the first after the of This is also the time for however, should be as as in the neurological is most of the in neurological has and the rehabilitation has to an the stroke patient a rehabilitation This is to that the which has been the acute rehabilitation is the outcome of a patient be in an more rehabilitation is needed, and it is to the patient for a more rehabilitation of the rehabilitation for patients with stroke are by the patient can and by the of in The of is and there is no to the of of stroke patients [Kaste et al., of The most used to the of a stroke patient is the it is far from it is one with which is which is an important and it for not only between patients but also between and The clinical of a can be by the It is a which gives an of the of a It is used in the of stroke patients and gives an to different strategies in stroke after stroke is With the for or the et al., the of a patient can be but they include some which are not for patients with stroke. they are not for reliable assessment of stroke patients with major depression is present, it should be The treatment of depression not only the of of the treated patients more in rehabilitation than do who are not treated for do not the neurological but patients can and more is the that the of patients are able to be at and do not from compared patients who were treated and by a stroke with patients in a stroke [Kaste et al., stroke patients treated by a stroke were able to the on an more and were more in 1 after the of stroke. outcome of stroke is of in both and such can be with stroke and not by is by from the of et al., Finland and et al., 1 patient should have to evaluation for rehabilitation should be early after stroke services should be provided by a

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