Treatment in acute stroke- stroke unit in

mandatory

dr. Semuel A Wagiu, Sp.S

Mechanical thrombectomy  stroke treatment
armamentarium
1990er years  stroke unit treatment is an evidence-
based proven effective treatment in acute stroke
Essential components of a successful stroke unit
treatment  stroke team approach, early mobilization,
early secondary stroke prevention, regulation of blood
pressure, blood glucose levels and especially testing of
swallowing function, and respectively its treatment.
 Older Stroke unit studies……..

Langhorne, Williams, Gilchrist, and Howie (1993)  that comprehensive

treatment results in a main decrease in mortality.
Jørgensen et al. (1995)  that morbidity was dramatically reduced after
Stroke unit care
Indredavik, Slørdahl, Bakke, Rokseth, & Håheim (1997)Five and 10 years
later patients treated in the Stroke unit had remained significantly more
often at home, and demonstrated less mortality
 Recent Stroke unit studies…….

The most recent meta analysis (Stroke Unit Trialists’ Collabora-tion, 2013) came
from the Cochrane Stroke Group  comparing Stroke unit care with an
alternative service
Stroke unit care showed reduction in the OR after a period of 1 year of 0.87 for
death, for dependency from institutionalized care of 0.78 and for death or
dependency of 0.79
Stroke unit treatment results in an almost 22% increase in better survival and
less disability
Stroke unit in intracerebral hemorrhage…………

Stroke unit treatment is also effective in intracerebral hemor- rhage

Stroke unit care reduced death or dependency (OR 0.81; 95% CI, 0.471–
0.92; P = 0.0009) with no difference in benefit between patients with
intracerebral hemorrhage (0.79; 95% CI, 0.61–1.00) and patients with
ischemic stroke (0.82; 95% CI, 0.70–0.97).
 Population-based approach……….

There were 41,692 index stroke events; 79% were admitted to a Stroke unit at
some point during their hospital stay and 21% were cared for in a general
ward. The adjusted OR for survival at 7 days was 3.11 (95% CI 2.71–3.56)
and at 1 year 1.43 (95% CI 1.34–1.54) while the adjusted OR for being
discharged at home was 1.19 (95% CI 1.11–1.28) for Stroke unit care.
What area effective parts in Stroke unit
treatment…???

Cardiac
Monitoring

Blood
Hypovolemia
Pressure

Stroke Unit
Treatment

Airway
Hypovolemia Support And
Ventilatory

Sources Of
Supplement
Hyperthermi
al Oxygen
a
 Keep it easy and simple …???
Turner et al., (2015b) reported the effectiveness of a care bundle
achieving 4 evidence-based components in a Scotland-wide population with
ischemic stroke.
Achieving a care bundle for ischemic stroke is associated with reduced
mortality at 30 days and 6 months and increased likelihood of discharge to
usual residence at 6 months.
 Better organized is better………….

Three Stroke Care processes were associated with reduced mortality:

review by a stroke consultant within 24 h of admission (OR 0.86, 95% CI
0.78–0.96), nutrition screening and formal swallow assessment within 72 h
(OR 0.83, 95% CI 0.72–0.96), and antiplatelet therapy and adequate fluid
and nutrition for first the 72 h (OR 0.55, 95% CI 0.49–0.61).
Patients admitted to stroke services with higher levels of organization were
more likely to receive high quality care as measured by audited process
measures of acute stroke care. Those patients receiving high quality care
had a reduced risk of death in the first 30 days after stroke.
 Early mobilization……..
Patients spent 30% of time in bed, 46% of time in sitting out of bed, and 20%
of time in higher motor activities such as transferring, standing, walking, or
climbing stairs.
Patients with mild, moderate, and severe stroke spent 79%, 59%, and 31%
of observed time sitting out of bed or engaged in higher motor activities,
respectively.
This study shows that it is possible for acute stroke patients to spend most of
the active day out of bed and to engage in higher motor activities up to 20%
of the time
Believing that early mobilization is an important part of Stroke unit care has
been substantially challenged by the AVERT Trial Collaboration group et al
Fewer patients in the very early mobilization group had a favorable outcome
than those in the usual care group (n = 480 [46%] vs n = 525 [50%]; OR
0.73, 95% CI 0.59–0.90; P = 0.004). 88 (8%) patients died in the very early
mobilization group compared with 72 (7%) patients in the usual care group
(OR 1.34, 95% CI 0.93–1.93, P = 0.113).
 Level of hospital care………….

Most stroke service which offer all various treatment options are located within
university hospitals or large hospitals which are referral hospitals within defined
areas.
Tamm et alll from Canada shows that even in community hospitals which offer
only very basic stroke care, the effect of an approach incorporating Stroke unit
treatment is effective
Patient mortality decreased signifi-cantly from 17.1% to 8.3% (OR 0.54; 95% CI
0.31–0.95) after Stroke unit implementation, whereas it remained 19% at the
control hospital
Stroke unit also increased the odds that patients would be discharged home
independently (OR, 2.17; 95% CI, 1.49–3.15; P < 0.001) without increasing
length of stay.
Economical impact of Stroke unit treatment……

Quality and costs are not independent variables, but high quality requires
substantial costs.
Cox proportional hazards models were used to estimate hazard ratios (HRs)
of 30-d post-admission mortality, adjusted for case mix, organization,
staffing, and care quality variables.
There was a dose-response relationship between weekend nurse/bed ratios
and mortality risk, with the highest risk of death observed in stroke services
with the lowest nurse/bed ratios
Stroke unit Treatment is associated with reduced health care system costs.
 Do Stroke units need neurologists….?

The proportion of death and dependency after 3 months was significantly

improved for patients in the SI-SU compared to MST-ICU (P < 0.001; aOR =
0.45; 95% CI: 0.31–0.65).
The shift analysis of the modified Rankin Scale (mRS) distribution showed
significant shift to a lower mRS in the SI-SU group, P < 0.001.
The proportion of mortality in patients after 3 months also differed between
the MST-ICU and the SI-SU (P < 0.05), but after adjusting for confounders
this association was not significant (aOR = 0.59; 95% CI: 0.31–1.13).
The proportion of patients with excellent outcome was higher in the SI-SU
(59.4 vs 44.9%, P < 0.001) but the relationship was no more significant after
adjustment (aOR = 1.17; 95% CI: 0.87–1.5).
Stroke unit treatment under
neurological guidance is much better
than just with an neurologist in the
team.