Aging Begins at 30

The Need for Stroke Care Units

Creation Date: June 2000
Last Revision Date: June 2000
Peer Review Status: Internally Peer Reviewed

A neurologist stated in the Lancet "If I had a stroke---I will aim to bypass my family doctor and organize immediate transport to (the) hospital that has expressed interest in stroke, and preferably (with) an acute stroke unit." He then related a sophisticated personal living-will on his own treatment.

First strokes occur in about 4 out of 1,000 people aged 45 to 84. About 20% of stroke patients die within 30 days and 40% of survivors remain dependent. Strokes recur about 5% yearly. Stroke patients also have a 3% yearly risk of serious coronary heart disease. Stroke mortality has fallen in most countries. It is the third most common cause of death after heart attacks and cancers.

A stroke is indicated by a sudden brain malfunction because of a clot blocked brain artery in 80%. A blood vessel bleed into the brain (intracerebral hemorrhage) occurs in 12%. About 8% of strokes are from bleeding into the fluid around the brain (subarachnoid hemorrhage). Only by a brain CAT scan can these types be accurately differentiated. Unless blood flow and cell nutrition are quickly restored, damage will be irreversible.

Coronary Care Units came in the 1950s, trauma units in the 1960s. Now it is time for Stroke Units. A weighted analysis of prior studies (3,500 stroke patients in 20 trials) showed that patients who received stroke unit care compared to general-treatment patients had significant (15%) reduction in death, dependency and institutionalization.

Clot dissolving treatment is very helpful and cost effective. Approved by the FDA in 1996, it is done with a naturally occurring anticoagulant "tissue-type plasminogen activator" or tPA. Ten percent of the dose is given immediately into the brain circulation and 90% over the next hour. For every six patients who receive tPA treatment, one more will return to normal or have minimal disability but the treatment is not without risk.

A stroke unit is staffed by neurologists, radiologists, neurosurgeons, specially trained nurses, physical, occupational and speech therapists and laboratory workers available around the clock.

First responders such as police officers, firefighters and emergency medical technicians must be aware of the urgency of treatment. To be effective, the clot dissolvers must be given within 3 hours of stroke onset. Caregivers should be at the patient's bedside within 15 minutes and scans completed and read within 45 minutes. Door arrival to tPA injection time should not exceed 60 minutes. The annual team cost varies up to $200,000 which can be recouped by lessening stroke hospitalization by one day.

About 750,000 new and recurrent strokes occur yearly. Stroke patient lifetime costs exceed $90,000 for ischemic strokes and $250,000 for subarachnoid bleeds. Presently about 20% of hospitals have specialized stroke treatment units. In a recent issue of JAMA a "Brain Attack Coalition" of stroke experts urged the establishment of Stroke Units throughout the United States.

Specialized training reaps benefits. Neurologists have lower three-month death rates (16%) than internists (23%) and this is better than family physicians (25%); all significant differences. Research will continue to improve results.

The neurologist writing in the Lancet about his own care ended with "Above all, I should like to be cared for by someone trained and interested in this common life threatening disease."

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See related Patient Topics Brain and Nervous System, Heart and Circulation, Seniors' Health or Stroke.

See related Provider Topics Brain and Nervous System, Heart and Circulation, Seniors' Health or Stroke.

All contents copyright © 1992-2004 the Author(s) and The University of Iowa. All rights reserved.

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