Do stroke units save lives?

doi:10.1016/0140-6736(93)92813-9

The Lancet

Volume 342, Issue 8868, 14 August 1993, Pages 395-398

https://doi.org/10.1016/0140-6736(93)92813-9 Get rights and content

Abstract

Management of stroke patients in specialist stroke units hastens recovery but is not believed to influence mortality. We did a statistical overview of randomised controlled trials reported between 1962 and 1993 in which the management of stroke patients in a specialist unit was compared with that in general wards. We identified 10 trials, 8 of which used a strict randomisation procedure. 1586 stroke patients were included; 766 were allocated to a stroke unit and 820 to general wards. The odds ratio (stroke unit vs general wards) for mortality within the first 4 months (median follow-up 3 months) after the stroke was 0·72 (95% Cl 0·56-0·92), consistent with a reduction in mortality of 28% (2p < 0·01). This reduction persisted (odds ratio 0·79, 95% Cl 0·63-0·99, 2p<0 05) when calculated for mortality during the first 12 months. The findings were not significantly altered if the analysis was limited to studies that used a formal randomisation procedure. We conclude that management of stroke patients in a stroke unit is associated with a sustained reduction in mortality.

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Cited by (572)

Medical demography at stroke centers: Current situation in France
2024, Revue Neurologique
Following the 2010–2014 French national stroke action plan, the number of stroke center (SC) has gradually increased in France, allowing a homogeneous coverage and access to neurovascular care in organized and territorially defined structures. However, operational difficulties within SCs have been progressively reported over the last few years. The objective of this study was to identify the medical staff shortages in SC that may contribute to these difficulties.
A survey on the medical staffing level as of January 1, 2021 was sent to all French SC managers. Specific questions related on vacancies, need of interim medical staff, and participation in out-of-hour healthcare services.
Among the 139 SC managers contacted, 122 (88%) filled in the questionnaire. Analysis of the data showed that over 879 physician positions opened, 163 (18.5%) remained vacant for a mean of two years, and that in 51 SCs (41.9%), more than two positions were unfilled. In 13 of these 51 SCs, the out-of-hour healthcare services relied on less than four practitioners, defining a critical situation, and three other SCs had to close temporarily (2) or permanently (1). Moreover, 39.2% of SCs with at least one vacancy used interim physicians, for a median period of 12.5 weeks/year (IQR 5–18).
This study highlights the significant medical staff shortage in French SCs. In the absence of urgent measures, more SCs will close, jeopardizing the regional network and access to care for stroke patients.
Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization–Lancet Neurology Commission
2023, The Lancet Neurology
Perspectives for the treatment of acute cerebral infarcts
2023, Bulletin de l'Academie Nationale de Medecine
Identifier les pistes d’amélioration du traitement de l’ischémie cérébrale aiguë.
Nous avons évalué : (i) l’accès en France aux traitements validés, et comparé à l’Allemagne et l’Italie ; (ii) les pistes d’amélioration des stratégies actuellement disponibles ; (iii) les stratégies nécessitant d’être évaluées.
Nous avons identifié 4 pistes : augmenter la proportion de patients traités conformément aux évidences scientifiques. La France a (i) un déficit en lits de soins intensifs neurovasculaires par rapport à l’Allemagne et l’Italie (13,5 par million d’habitants vs 29,9 et 23,2), et en centres de thrombectomie (0,6 par million d’habitants vs 1,8 et 1,0) ; (ii) un déficit de thrombolyse intraveineuse (TIV) (203 par million d’habitants vs 402) et de thrombectomie mécanique (TM) (104 vs 194) par rapport à l’Allemagne ; et (iii) une hétérogénéité territoriale importante en lits de soins intensifs neurovasculaires, TIV et TM ; réduire les contre-indications à la TIV aux seuls patients à très haut risque hémorragique ; sélectionner les candidats à une reperfusion sur l’état du parenchyme plutôt que sur les délais ; explorer des stratégies nouvelles : (i) prise en charge préhospitalière (UNV mobiles, régulation) ; (ii) TIV par ténecteplase ou rt-PA à dose réduite ; (iii) amélioration de thrombectomie (indications et technique) ; (iv) neuroprotection, dont certaines pistes n’ont pas encore été explorées ; et (v) favoriser la récupération fonctionnelle précoce.
Il existe une marge de progression importante dans le traitement de l’ischémie cérébrale aiguë, qui repose en partie sur des mesures déjà accessibles.
To identify targets to improve the treatment of acute cerebral ischemia.
We assessed (i) access to validated strategies in France and compared with Germany and Italy; (ii) avenues for improvement of currently available strategies; and (iii) strategies that still need to be evaluated.
We identified 4 avenues: increase the proportion of patients treated according to current scientific evidence. France has (i) a deficit in neurovascular intensive care beds compared to Germany and Italy (13.5 per million inhabitants vs. 29.9 and 23.2), and in mechanical thrombectomy (MT) centres (0.6 per million inhabitants vs. 1.8 and 1.0); (ii) compared to Germany, a deficit in intravenous thrombolysis (IVT) (203 per million inhabitants vs. 402) and MT (104 vs. 194); and (iii) an important territorial heterogeneity for intensive neurovascular beds, IVT and MT; reduce contraindications to IVT only to those patients at very high bleeding risk; select candidates for reperfusion based on the cerebral criteria rather than on delays; explore new strategies: (i) pre-hospital management (mobile stroke units, regulation); (ii) thrombolysis with tenecteplase or with low dose rt-PA; (iii) improved thrombectomy (indications and technique); (iv) neuroprotection, some avenues of which have not yet been explored; and (vii) ptomoteearly functional recovery.
There is significant room for improvement in the treatment of acute cerebral ischaemia, based in part on already available measures.
Nanotechnology assisted biomarker analysis to rehabilitate acute ischemic stroke patients by early detection
2022, Process Biochemistry
Ischemic stroke is the second highest global cause for disability, due to the reduction or interruption of blood flow to the part of brain. This leads the disruption of oxygen and nutrients supply to the brain tissue and makes the damage or dying to the brain cells. Early identification of stroke is possible for the rehabilitation with reducing the damage of the brain and avoids other complications. At the same time identifying the stroke at its acute phase is still challenging. Currently various imaging methods such as Magnetic resonance imaging and computed tomography are in use to predict and analyze the condition of stroke by cross section imaging of brain and head. However, accurate identification of stoke is questionable by these imaging techniques. So that, along with imaging, additional blood-based biomarker analysis to identify the stroke at earlier stage helps to get a precise conclusion on the medical status of the patient. This review has discussed on blood biomarkers for determining stroke and diagnosis by nanotechnology implemented biosensors towards the rehabilitation of acute ischemic stroke patients.
Has secondary neurovascular drug prevention specificities?
2021, Bulletin de l'Academie Nationale de Medecine
La prévention secondaire médicamenteuse post accident vasculaire cérébral (AVC) fait appel aux mêmes médicaments que la pathologie coronaire, mais la spécificité d’organe influence certaines indications : (i) les AVC sont des pathologies plus hétérogènes que la pathologie coronaire, et chaque sous type d’ischémie et d’hémorragie cérébrale expose à un risque évolutif différent, qui va modifier la balance bénéfice/risque et influencer le choix du traitement ; (ii) le cerveau peut saigner, la transformation hémorragique faisant partie de l’histoire naturelle de l’ischémie cérébrale ; ce risque est une limite à l’utilisation de traitements thrombolytiques et anticoagulants ; (iii) Les troubles cognitifs sont fréquents et influencent la tolérance aux médicaments. Pour ces raisons dans les ischémies cérébrales cardioemboliques, l’introduction des anticoagulants est souvent différée de quelques jours, et dans les ischémies secondaires à l’athérosclérose, lorsque la combinaison aspirine-clopidogrel est indiquée, elle ne doit pas être poursuivie plus de 3 semaines.
Secondary drug prevention after stroke uses the same drugs as for secondary prevention after a coronary event, but the brain has specificities that influences certain indications : (i) strokes are heterogeneous diseases and all subtypes of ischaemic strokes or of intracerebral haemorrhage have their own evolution over time, that will influence the risk/benefit ratio of any drug therapy; (ii) the brain may bleed and haemorrhagic transformation is part of the natural history of all brain infarcts; this risk is a limitation for thrombolysis and oral anticoagulation; (iii) cognitive impairments are frequent after stroke and may influence the safety profile of treatments. For these reasons in cardio-embolic strokes oral anticoagulation is usually delayed for a few days, and in ischemic events due to atherosclerosis, the combination of aspirin plus clopidogrel, when indicated, should not be prescribed for more than 3 weeks.
Access to mechanical thrombectomy for cerebral ischaemia: A population-based study in the North-of-France
2019, Revue Neurologique
Citation Excerpt :
Mechanical thrombectomy (MT) is of major importance in the management of patients with acute cerebral ischaemia [1], beside stroke unit care [2], aspirin [3,4], intravenous thrombolysis (IVT) with recombinant tissue-plasminogen activator (rt-PA) [5–7], and decompressive surgery [8].
Hospitals admitting acute strokes should offer access to mechanical thrombectomy (MT), but local organisations are still based on facilities available before MT was proven effective. MT rates and outcomes at population levels are needed to adapt organisations. We evaluated rates of MT and outcomes in inhabitants from the North-of-France (NoF) area.
We prospectively evaluated rates of MT and outcomes of patients at 3 months, good outcomes being defined as a modified Rankin scale (mRS) 0 to 2 or like the pre-stroke mRS.
During the study period (2016–2017), 666 patients underwent MT (454, 68.1% associated with intravenous thrombolysis [IVT]). Besides, 1595 other patients received IVT alone. The rate of MT was 81 (95% confidence interval [CI] 72–90) per million inhabitants-year, ranging from 36 to 108 between districts. The rate of IVT was 249 (95% CI 234–264) per million inhabitants-year, ranging from 155 to 268. After 3 months, 279 (41.9%) patients who underwent MT had good outcomes, and 167 (25.1%) had died. Patients living outside the district of Lille where the only MT centre is, were less likely to have good outcomes at 3 months, after adjustment on age, sex, baseline severity, and delay.
The rate of MT is one of the highest reported up to now, even in low-rate districts, but outcomes were significantly worse in patients living outside the district of Lille, and this is not only explained by the delay.

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ArticlesDo stroke units save lives?

Abstract

Lancet

Lancet

J Chron Dis

J Chron Dis

Psychol Bull

Stroke intensive care units: objectives and results

Stroke

Management of acute stroke in the elderly: preliminary results of a controlled trial

BMJ

Management of acute stroke in the elderly: follow-up of a controlled trial

BMJ

Benefit of stroke unit: a randomised controlled trial

Stroke

Stroke rehabilitation units: concepts, evaluation, and unresolved issues

Stroke

Clinical epidemiology of stroke

Does an intensive-care stroke unit reduce the early case-fatality rate of ischaemic stroke?

Stroke

Evaluation of stroke rehabilitation by randomised controlled studies: a review

Acta Neurol Sand

Remedial therapy after stroke: a randomised controlled trial

BMJ

The Bradford community stroke trial: results at six months

BMJ

Articles
Do stroke units save lives?