In 2005, the BAC developed recommendations for the establishment of CSCs [2]. These recommendations emphasized that service needs to deliver specialized care and included the following key components: (1) personnel with expertise, (2) diagnostic techniques, (3) surgical and interventional therapies, (4) infrastructure, and (5) educational/research programs (Table 1.3) [2]. The CSCs are the highest-level and well-equipped hospitals which can treat all types of stokes. The CSCs require infrastructures, highly qualified specialists, and specialized process for diagnosis and treatment of complex stroke patients who needed a high level of medical and surgical care, specialized intensive care unit (ICU) facilities such as neuroscience ICU, specialized tests, or intervention treatments. Moreover, the trained and expertise stroke team must be available 24/7 for surgical treatment or intervention therapies. Some stroke patients could benefit from CSCs treatment, those with stroke caused by unusual etiologies and demanding specialized testing, or multispecialty management. In addition, CSC would be to act as a resource center for other facilities in their region, such as PSCs. The CSCs could receive patients initially treated at a PSC and provide expertise about the diagnosis and management of particular patients, guidance for patient triage, and educational resource for other hospitals and healthcare professionals at a given geographical area [2]. In 2011, the American Heart Association (AHA)/American Stroke Association (ASA) proposed a set of metrics and related data elements covering the major aspects of specialized care for patients with ischemic stroke and nontraumatic subarachnoid and intracerebral hemorrhages at CSCs [6].

The BAC outlined the organization of stroke centers in a hospital network or geographical area in a consensus statement for CSCs [2]. In the current healthcare environment, hospital networks and systems are continuing to grow. Within such a network or system, one approach to acute stroke care might be to designate some hospitals as PSCs and others as CSCs (Fig. 1.1).

In 2003, the AHA/ASA and The Joint Commission (TJC) convened and agreed on a certification process for stroke through a Disease-Specific Certification program, including a voluntary evaluation process driven by demonstration of a consistent approach to the measurement of clinical outcomes and minimum standards for stroke care [7]. The three major requirements were necessary for Primary Stroke Center Certification. These three requirements were in compliance with the use of evidence-based guidelines, implementation of TJC standards, and measurement of clinical outcomes [7]. The stroke performance measures were developed to improve the quality of stroke. The stroke performance measures in ischemic stroke included deep venous thrombosis prophylaxis, acute treatment such as antithrombotic therapy and anticoagulation therapy at discharge in patients with atrial fibrillation, dysphagia screening, stroke education, smoking cessation advice/counseling, risk factor modification, and rehabilitation [8]. Furthermore, a subset of these stroke performance measures was included for hemorrhagic stroke patients [5]. In 2009, the stroke 8-measure set was approved as a core measure set (Table 1.4) [8].