Randomized controlled study of stroke unit care versus stroke team care in different stroke subtypes

The benefits of stroke unit management may vary according to stroke subtype. A post hoc analysis of the influence of stroke subtype on stroke unit effectiveness was undertaken by using prospective data collected in a randomized controlled trial.

Two hundred sixty-seven patients with moderately severe ischemic stroke (164 with large-vessel infarcts and 103 with lacunar infarcts) were randomly allocated to treatment in stroke units or in general medical wards with specialist stroke team support. Mortality, institutionalization, neurological, functional, and quality-of-life scores and resource use were assessed at 3 and again at 12 months after stroke onset. An intention-to-treat analysis was undertaken, and logistic regression was used to evaluate the independent effect of stroke unit intervention.

Stroke team-supported management was associated with higher mortality (odds ratio [OR] 4.9, 95% CI 1.3 to 18.6) and higher mortality or institutionalization (OR 2.9, 95% CI 1.1 to 7.4) at 3 months (OR 3.6, 95% CI 1.5 to 8.7) and at 1 year (OR 2.8, 95% CI 1.3 to 6.2) in patients with large-vessel infarcts. In contrast, there were no significant differences in outcome in patients with lacunar strokes managed in the stroke unit or by the stroke team. In patients with lacunar strokes, stroke unit care was associated with a longer length of hospital stay (18 versus 13.5 days for stroke unit care versus stroke team care, respectively; P<0.01) and significantly greater use of therapy.

Stroke units improve the outcome in patients with large-vessel infarcts but not in those with lacunar syndromes. For lacunar strokes, stroke unit management may be associated with higher initial health costs for equivalent benefit.