Any patient with acute stroke should be admitted to a hospital stroke unit as soon as possible. There is robust evidence that stroke patients who receive organized inpatient care in a defined acute stroke unit (ASU) are more likely to be alive, independent, and living at home 1 year after the stroke. This is currently the single most effective management strategy that should be used routinely in all hospitals that admit patients with acute stroke. All patients with acute stroke, irrespective of age, stroke severity, or other considerations, should be admitted to the ASU for the initial evaluation and treatment. In the United States, the accreditation of hospitals as primary stroke centers and comprehensive stroke centers provides a method to recognize those hospitals that have met numerous care metrics and have the resources to provide the highest level of care for a spectrum of cerebrovascular disorders that require hospitalization. In general, stroke units provide dedicated beds for the management of stroke patients, along with designated staffing including a specialist physician (stroke subspecialty neurologist, or other physician with training and experience in stroke medicine), nurses with an interest and expertise in stroke, physiotherapists, occupational therapist(s), social worker, and speech and language therapist. It is also desirable to have a designated stroke unit director (clinical pharmacologist, dietitian, and neuropsychologist. Separate from stroke center accreditation issues, there are three major types of stroke units: (1) ASU for acute care only (the average length of stay in such units is usually a few days); (2) stroke unit that provides both acute care and rehabilitation (the average length of stay in such units usually ranges from several days to a few weeks); and (3) stroke team without a designated stroke unit. Current evidence shows superiority of the first two types of ASUs. The key element of ASUs
is a coordinated expert interdisciplinary team working in a geographically based setting with regular team meetings and close monitoring of stroke care quality metrics. The tasks of the team are to establish an accurate diagnosis, observe vital signs, maintain homeostasis, provide acute treatment, prevent complications, implement early rehabilitation and initiate secondary prevention strategies, and develop the most appropriate discharge and rehabilitation plan.

On the basis of the existing evidence, the Joint Commission in the United States has suggested 10 core stroke performance measures for primary stroke centers. The stroke measures include (1) venous thromboembolism prophylaxis (patients with stroke will receive prophylaxis or have documentation regarding why it was not used); (2) antithrombotic use at discharge (patients with ischemic stroke will be prescribed an antithrombotic medication at discharge); (3) anticoagulant use for atrial fibrillation/flutter (patients with ischemic stroke and atrial fibrillation or atrial flutter will be prescribed an anticoagulant unless specific contraindications exist); (4) use of thrombolytic therapy (initiation of intravenous alteplase [tissue plasminogen activator] within 3 hours of symptom onset in eligible patients); (5) antithrombotic therapy by the end of hospital day 2 unless contraindications exist for patients with ischemic stroke; (6) statin medication use recommendation at hospital discharge (patients with ischemic stroke and atherosclerotic cardiovascular disease will be prescribed a statin unless contraindications exist); (7) provision of stroke education (patients with ischemic or hemorrhagic stroke, and/or their caregivers, will receive education materials regarding a spectrum of issues related to stroke prevention, symptom recognition, evaluation, and management); (8) rehabilitation assessment (patients will be assessed for and receive rehabilitation services); (9) door to transfer times to another hospital depending on stroke type (there will be timely transfer of patients with ischemic or hemorrhagic stroke to the hospital with the higher level stroke care, when transfer is indicated); and (10) National Institutes of Health Stroke Scale (NIHSS) use (the NIHSS will be measured before and after undergoing a recanalization procedure or within 12 hours of arrival for those not undergoing such a procedure).

In general, outpatient evaluation and management may be considered for the following patients with TIA: (1) patients with a single TIA after 1 week of presentation; (2) patients with a TIA (or multiple TIAs) within 2 weeks of presentation, if the TIAs are unassociated with a probable cardioembolic source, if there is no evidence of a high-grade arterial stenosis as the probable cause, if there is no evidence of increasingly severe or frequent events, if the deficit associated with the event(s) was mild, and if the duration was not more than 60 minutes; (3) those who have had TIA or cerebral infarction more than 2 weeks before presentation; (4) those who have had recent ischemic cerebrovascular events that presented with transient monocular blindness alone and no evidence of carotid stenosis; (5) those who have had an intracerebral hemorrhage more than 30 days before presentation; (6) those who have chronic cerebrovascular disease, such as asymptomatic carotid or vertebral artery stenosis, asymptomatic and unruptured intracranial aneurysm, arteriovenous malformation, or cavernous malformation; and (7) those who refuse to be hospitalized. It is recommended that evaluation and management of these TIA patients be undertaken in acute outpatient TIA clinics with expedited access to all neuroimaging and laboratory tests required.