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Treatment of stroke on an intensive stroke unit: a novel concept
J Treib1, M T Grauer, R Woessner
1Department of Neurology, Westpfalz-Klinikum GmbH, Germany. jtreib@westpfalz-klinikum.de
Insights
Intensive stroke units improve patient outcomes and reduce long-term costs by providing specialized, early rehabilitation. This approach optimizes care in the critical first 3-4 days post-stroke, challenging outdated therapeutic nihilism.
Area of Science:
- Neurology
- Intensive Care Medicine
- Public Health
Background:
- Stroke is a leading cause of death and disability in industrialized nations, posing significant healthcare and societal costs.
- Demographic shifts are increasing the importance and impact of stroke.
- Despite advancements, therapeutic nihilism persists among some patients and physicians.
Purpose of the Study:
- To introduce and advocate for the concept of "intensive stroke units" in Germany for optimal acute stroke care.
- To improve patient outcomes, reduce long-term morbidity, and decrease healthcare costs associated with stroke.
- To foster research into new pathophysiological-based therapeutic concepts and approaches for stroke management.
Main Methods:
- Implementation of "intensive stroke units" providing specialized care for the first 3-4 days post-stroke.
- Utilizing advanced diagnostic tools including magnetic resonance imaging (MRI), positron emission tomography (PET), computed tomography (CT), and echocardiography.
- Employing intensive monitoring of vital signs and cerebral function, alongside early mobilization and specific acute management strategies.
Main Results:
- Early rehabilitation in specialized stroke units significantly improves long-term outcomes.
- Intensive monitoring and management minimize complications.
- Specific therapies tailored to underlying pathophysiology can be initiated.
Conclusions:
- Intensive stroke units offer a superior model for acute stroke care, improving patient prognosis and reducing long-term healthcare burdens.
- The early hours (3-6 hours) post-stroke are critical for intervention.
- While not universally adopted, the principles of intensive stroke care are based on sound pathophysiological reasoning and warrant further consideration.
Abstract:
In industrialised nations stroke ranks as number three among causes of death and is the most frequent cause of disability in old age. Demographic changes will result in stroke gaining increasing importance for individuals as well as for society as a whole. Stroke is already a major cost factor for healthcare and social security systems because of its high long-term costs. Therapeutic nihilism, although still widespread among patients and some physicians, is no longer justified. Long-term outcome after stroke can be significantly improved by providing therapy in wards specialised in early rehabilitation, so-called 'stroke units'. Recent magnetic resonance imaging (MRI) and positron emission tomography (PET) studies, as well as lysis therapy studies have shown that the first 3-6 h are crucially important. For this reason, the concept of "intensive stroke units" also called "intensive care stroke units" has been implemented in Germany. The goal of an intensive stroke unit is the optimal care of stroke patients under intensive care conditions for the first 3-4 days with the aim of improving outcome, long-term morbidity, and reducing long-term healthcare costs. Another important objective is the development and research of new therapeutic concepts and approaches that are based on pathophysiological considerations. A further goal is the initiation of specific therapies depending on the suspected underlying pathophysiology, for example, local or systemic thrombolysis, full-dose heparinisation, platelet aggregation inhibitors, oral anticoagulants, neuroprotective agents, decompression craniotomy, sympathomimetically supported volume therapy and hypothermia. A final objective is to minimise the number of complications through intensive monitoring. Basic acute management includes optimal oxygen supply, rapid normalisation of blood glucose and body temperature, volume therapy, maintaining a high blood pressure and cardiac output to improve remaining cerebral perfusion in the presence of ischaemically impaired autoregulation, treating cerebral oedema, prophylaxis of thrombosis, and early mobilisation. Rapid and easy access to computerised tomography (CT), MRI, Doppler and duplex scanning of the brain-supplying blood vessels, and echocardiography is essential. The ready availability of intensive care monitoring (blood pressure, electrocardiography, central venous pressure, transcranial Doppler (TCD), TCD embolism detection, cerebral pressure, electroencephalography and cardiac output is also imperative. We would like to stress at this point that this manuscript is a personal view describing stroke care in Germany. Many of the principles described have not been widely adopted elsewhere, perhaps in part due to a lack of available facilities. However, many of our recommendations are based on logical principles and thus, we feel, bear further scrutiny.