In the scientific literature, there is unanimous consensus that hospitalization in stroke unit (SU) is the most important treatment for the generality of stroke patients. The benefit in terms of better long-term outcome of acute stroke patients admitted into SU versus conventional wards has been previously demonstrated in several randomized trials and their meta-analysis [
1]. Two Italian observational follow-up studies confirmed SU patient management as predictor of good outcome in a real-world setting, across all age ranges and clinical characteristics [
2,
3]. In this regard, both European and Italian guidelines suggest transporting all cases of suspected stroke to the emergency room of the nearest hospital provided with SU [
4,
5]. The Act number 70/2015 by the Italian government identified specific skills that contribute to a classification of stroke unit (Table
1). First level SU are characterized by the presence of at least one dedicated neurologist, a committed nursing staff, at least one bed with continuous monitoring, and the possibility of carrying out intravenous thrombolytic therapy (IVT) and connection with a 2nd level stroke center. Second level SU must treat at least 500 stroke cases/year, have dedicated staff 24 h a day, have neuroradiology active 24/7, and be able to perform mechanical thrombectomy in emergency (Table
1). The evidence is that stroke care involves management by a dedicated stroke team consisting of vascular neurologist, neurosurgeon, neurointerventionist, radiologist, anesthesiologist, specialized nurses, other trained medical personnel, and rehabilitation facilities. It also requires the availability of cutting-edge technology at their disposal. Since this requires high costs and it is impossible to have all these facilities in every hospital in a given area, the government Act 70/2015 identified a “hub and spoke” stroke network. According to this model, a single hospital staffed by specialized physicians and with the appropriate high-technology infrastructure forms the hub (second level emergency departments—EDs), while other hospitals providing less complex forms of care act as the spoke (first level EDs). The Act number 70/2015 states also that a first level SU must be located in a first level ED, with a catchment area of between 150,000 and 300,000 inhabitants, and a second level SU must be located in the second level EDs, with a catchment area of between 600,000 and 1,200,000 inhabitants. Made these premises, the need in Italy for first level stroke centers is 240 and for second level stroke centers is 60, which should be adequately and rationally distributed throughout the national territory. Referring to the “Notebooks of the Ministry of Health on the Organization of Stroke Assistance: The Stroke Units” n.2 of March–April 2010, the need for dedicated beds is about 8 beds in SU every 150–300,000 inhabitants, corresponding to about 1 bed every 19,000 inhabitants.
Table 1
Classification of stroke unit as defined by the current Act 70/2015 of the Italian health government
First level stroke unit | Multiprofessional competences into hospital |
Dedicated neurologist and nurses |
One bed with continuous monitoring, at least |
Early rehabilitation |
Intravenous thrombolysis |
Neurosurgical on-call availability (also in other hospital) |
Neurosonology with Doppler ultrasound and echocardiography 24/7 availability of CT scan and CT angiography (at least 16 multislices) and/or MR (also with DWI) and MR angiography |
Linking with second level stroke units and rehabilitation units |
Second level stroke unit | The same as first level and: |
500 admissions/year at least |
24/4 neuroradiology with CT (64 multislices) and CT angiography, MR with DW and PW images and MR angiography |
Endovascular interventional unit |
24/7 neurosurgery |
24/7 vascular surgery |
Cerebral angiography |
Intra-arterial thrombolysis (urgency), mechanical thrombectomy (urgency), extra- and intracranial stenting |
Urgent embolization of arteriovenous malformations and aneurisms, endarterectomy |
Decompressive hemicraniectomy |
Aneurismal clipping |