There is convincing evidence from a large number of randomized controlled trials (RCTs) that the outcomes of stroke patients managed in dedicated stroke units are better than those of patients managed in general medical or neurological wards [1–3]. Stroke units are the essential part of the chain of recovery and form the backbone of prehospital, in-hospital, and post-hospital care, that is, from home back to home.
In addition to stroke unit care, intravenous (i.v.) thrombolysis, mechanical thrombectomy, and hemicraniectomy have been shown to improve the outcome of stroke patients. The acute therapies and interventions in stroke are described in Chapters 19–21. The basic functions of the stroke unit, mainly covered in other chapters of this book, are etiological diagnostic workup (Chapters 2–5 and 9–17), general management and proactive prevention of complications (Chapters 22 and 23), secondary prevention of stroke and other vascular endpoints (Chapter 24), and early rehabilitation (Chapter 25).
The purpose of this chapter is to characterize the chain of recovery of acute stroke patients from emergency phone call to acute stroke unit, including clinical evaluation of the patient and aspects of general stroke management that can be optimally delivered in stroke units, in light of current guidelines.
Prehospital Care and Referral
According to the European Stroke Organisation (ESO) , emergency care of the acute stroke victim depends on a four-step chain: (1) rapid recognition of, and reaction to, stroke signs and transient ischemic attacks (TIAs); (2) immediate emergency medical service (EMS) contact and priority EMS dispatch; (3) priority transport with prenotification to the receiving hospital; and (4) timely and competent in-hospital treatment at the emergency department (ED).
The general emergency phone number (112 in most European countries, 911 in the United States) is the first link in the chain of survival and recovery for acute stroke patients. National stroke-awareness campaigns always emphasize the importance of recognizing the symptoms of acute stroke and calling the emergency number immediately before doing anything else. This is usually done by a family member, since the stroke patient is unable to make the call him-/herself. There is class II level B evidence that educational programs to increase awareness of stroke at the population level are beneficial, and the same holds true for EMS professionals – both paramedics and physicians .
EMS transport to and arrival at the ED increase the likelihood of a patient presenting within the 4.5-hour time window allowing i.v. thrombolysis and/or mechanical thrombectomy to be considered, compared to private physician referral and self-transport, and significantly reduce the time from symptom onset to CT evaluation [6, 7]. Failure to use the emergency number is the most common and most devastating error, with regard to the possibility of timely recanalization therapy. Delays during acute stroke management have been identified at the population level (due to failure to recognize the symptoms of stroke and calling the emergency number), at the level of the emergency services and emergency physicians (due to a failure to implement stroke code), and at the hospital level (due to delays in in-hospital logistics and neuroimaging) [8, 9].
To optimize stroke identification, prehospital professionals should use a prehospital stroke screening instrument that has been prospectively evaluated for sensitivity, specificity, reproducibility, and validity. Such instruments include the Los Angeles Prehospital Stroke Screen (LAPSS), the Cincinnati Prehospital Stroke Scale (CPSS, or Face-Arm-Speech-Test [FAST]), and the Melbourne Ambulance Stroke Screen (MASS), which all have been reported to have a sensitivity exceeding 90% [10–14]. The electronic validated algorithm of questions should be used during the emergency phone call.
The stroke code is activated immediately when stroke is suspected . Using a predefined protocol, the patient will be transported to the stroke center, which will be notified in advance. Prehospital notification of an inbound stroke patient has been demonstrated to shorten the delay from ED arrival to initial neurological assessment and initial brain imaging, and to increase the proportion of patients treated with recombinant tissue plasminogen activator (rtPA) or mechanical thrombectomy .
Physicians, nurses, CT/MR technologists, and pharmacists are able to utilize early notification to mobilize necessary resources for the patient. This is called the “stroke alarm” at the ED. Stroke alarm also means that the patient has a priority for CT and emergency laboratory evaluation. The ESO Guidelines include a class II level B recommendation for immediate EMS contact, priority EMS dispatch, and priority transport with prenotification of the receiving hospital, and a class III level B recommendation that suspected stroke victims should be transported without delay to the nearest medical center with a stroke unit that can provide ultra-early treatment . In current guidelines, there is also a class III level B recommendation for immediate ED triage; clinical, laboratory, and imaging evaluation; accurate diagnosis; and therapeutic decision and administration of appropriate treatments at the receiving hospital .
In-hospital delays may account for at least 16% of total time lost between stroke onset and recanalization therapy. Reasons for in-hospital delays are a failure to identify stroke as emergency, inefficient in-hospital transport, delayed medical assessment and imaging, and uncertainty in administering thrombolysis [16, 17]. In Helsinki, the ED reorganization of acute stroke care has been shown to result in reduced delays in acute stroke treatment, i.e. shorter door-to-rtPA times. The present mean door-to-needle time is 20 minutes, which is based on almost 2 000 patients treated . The main components of the reorganization were:
ED with written protocols for stroke patients
ED prenotification by the EMS
ED rebuild with easy-access CT
digital patient records, including digital imaging system (PACS) .
In remote and rural areas helicopter transfer should be considered to improve access to treatment (class III level C) . Telemedicine is also a feasible, valid, and reliable means of facilitating thrombolysis for patients in distant or rural hospitals, where timely air or ground transportation is not feasible (class II level B). The quality of treatment, complication rates, and short- and long-term outcomes are similar for acute stroke patients treated with rtPA via a telemedicine consultation at local hospitals and those treated in academic centers [18–20].
As an alternative, stroke treatment in a specialized ambulance, staffed with a neurologist, paramedic, and radiographer and equipped with a CT scanner, point-of-care laboratory, and a teleradiology system, appears to be feasible and without safety concerns [21, 22].
Its effectiveness in reducing call-to-needle times needs to be scrutinized in a prospective controlled study. Further, the cost-effectiveness of this approach and its utility in different urban scenarios should also be addressed in further studies.
To ensure that a stroke patient presents within the time window allowing thrombolysis to be considered, several pre-admission conditions have to be guaranteed:
awareness of stroke at the population level with rapid recognition of and reaction to stroke signs and TIAs
EMS transport to the ED
prehospital notification of the stroke patient
ED reorganization with easy-access CT.
Stroke Unit Care
Striking discrepancies in infrastructure and quality of stroke care, but also in costs and outcome, have been identified in Europe , indicating the urgent need for a common and agreed concept of well-organized, evidence-based stroke care in European countries, and for standardized, methodologically sound regional or national audits of stroke care . Three basic principles of organized stroke unit care have been proven to be highly effective in terms of improved outcome (fewer deaths, less dependency). They include (1) a dedicated stroke ward, (2) a multiprofessional team approach, and (3) a system of comprehensive stroke unit care. All three principles are based on evidence level I .
Dedicated stroke ward care means that acute stroke patients are treated in a geographically defined area of the hospital admitting exclusively stroke and TIA patients and not patients with other disorders. The outcomes of stroke and TIA patients managed in dedicated stroke units are better than those of patients managed in general medical or neurological wards , and the benefit of organized stroke unit care covers all groups of stroke patients, including ischemic  and hemorrhagic stroke . There is also no indication that age or sex limits the benefits of organized stroke unit care. Indeed, elderly patients and those with severe stroke benefit most from stroke unit care [1, 25]. The benefits of stroke unit care may decline over time elapsed since stroke onset, and preferably stroke patients should be admitted acutely, but patients should not be excluded from stroke unit care simply because of delayed presentation, particularly if the patient requires closer attention that cannot be provided in general wards. There is also sufficient evidence that the benefits seen in stroke unit trials are replicated in routine practice, as long as these evidence-based principles of organized stroke unit care are considered in daily routine .
The multiprofessional team approach implicates that stroke units must be staffed with physicians, nurses, physiotherapists, occupational therapists, speech and swallowing therapists, neuropsychologists where available, and social workers (including a case manager) with special interest, training, and expertise in stroke care. The physicians are neurologists or internists provided that their focus is stroke care and that they are specifically trained in stroke medicine. Likewise, comprehensive stroke unit care means that acute stroke management, that is, diagnostic workup and treatment, is seamlessly combined with early mobilization and rehabilitation and secondary prevention, according to the needs of the patient (out of bed within 24-hour principle).
There are many types of stroke units including acute stroke units, combined acute and rehabilitation stroke units, and rehabilitation stroke units admitting patients after a delay of 1–2 weeks [1, 2]. The ESO has recently defined the essential components and facilities for ESO Stroke Units , which are shown in Box 18.1. Accordingly, the stroke unit criteria are organized (1) to ensure vital functions, (2) to provide early diagnostic investigations, (3) to allow basic surveillance and (4) stroke-specific therapeutic interventions, (5) to perform general therapeutic and diagnostic interventions, (6) to start secondary prevention, and (7) to combine this with multiprofessional early mobilization and rehabilitation procedures. Both the First  and Second Helsingborg Declaration , and the guidelines by the ESO , recommend that all stroke patients should have access to care in specialized stroke units. However, an ESO survey published in 2007 showed that only one in seven stroke patients in Europe has admission to stroke unit care, and 42% of them were treated in hospitals that had neither facilities nor expertise to provide good care for stroke patients . An update of this survey, to take a new picture of stroke management in Europe, is urgently needed.
|Departments and clinics||Multiprofessional stroke unit|
Inpatient rehabilitation (in-house)
Outpatient rehabilitation available
Collaboration with outside rehabilitation center
Stroke outpatient clinic
|Staff available||Stroke-trained physician|
|Investigations available||Brain CT scan 24/7|
CT priority for stroke patients Extracranial duplex sonography
|Hyperacute interventions||Intravenous rtPA protocols|
Access to hemicraniectomy*
Access to surgery for hematoma
Access to intra-arterial interventions*
|Stroke unit interventions||Agreed written protocols for common problems|
|Stroke unit monitoring||Monitoring of heart rate|
Monitoring of oxygen saturation
Monitoring of blood pressure
Monitoring of breathing
Monitoring of temperature
|Stroke unit assessment||Early rehabilitation assessment** |
Food and fluid management
Speech therapy start <2 days
Physiotherapy start <2 days
Dysphagia management (swallowing screened on admission)
Skilled stroke nursing
|Stroke unit multiprofessional team care||Coordinated multiprofessional stroke unit care (care in a discrete area in the hospital, staffed by a specialist stroke multiprofessional team with regular multiprofessional meetings for planning care)|
Early discharge planning
|Interventions: other||Access to surgery for aneurysms|
Access to carotid surgery
* Access means not necessarily on-site, but defined partnership with a providing institution.
** By an appropriately trained professional.
Stroke care organization at the receiving hospital makes a difference in the rate of successfully thrombolyzed and/or thrombectomized patients. A randomized controlled trial compared the time from emergency call to therapy decision between mobile stroke unit and regular hospital interventions. The study was stopped early because the mobile stroke unit reduced the median time from alarm to therapy decision from 76 to 35 minutes . This treatment approach showed similar benefits in reducing the delay from alarm to end of CT, alarm to end of laboratory analysis, and to intravenous thrombolysis for eligible ischemic stroke patients.
According to the ESO, the stroke unit criteria are organized to
ensure vital functions
provide early diagnostic investigations
allow basic surveillance and stroke-specific therapeutic interventions
perform general therapeutic and diagnostic interventions
start secondary prevention
combine this with multiprofessional early mobilization and rehabilitation procedures.
Early Activities at a Stroke Unit
The time window for treatment of patients with acute stroke is narrow and requires well-organized services at the ED and acute stroke unit. The points which must be kept in mind include:
acute emergency management of stroke requires parallel processes at different levels of patient management
acute assessment of neurological and vital functions parallels treatment of acutely life-threatening conditions
the selection of special treatment strategies does not require the subtype of acute ischemic stroke to have been defined.
Time is the most important factor, especially the first minutes and hours after stroke onset. During those hours the following tasks need to be performed:
differentiate between different types of stroke (either ischemic or hemorrhagic)
assess the underlying cause of brain ischemia
identify concurrent diseases or complications associated with stroke
rule out other brain diseases