Neurological acute stroke care: the role of European neurology

In 1995 the EFNS has made stroke treatment and prevention a major policy issue and established a Task Force to develop guidelines for acute neurological stroke care for use by neurologists throughout Europe and to be modified according to local and national requirements. This Task Force report supplements recommendations and treatment guidelines previously published. It focuses on the need of adapting neurological hospital services to immediate stroke care and sets up lines of argumentation and organisational recommendations compiled on various levels of evidence. Due to the increase of aging populations across Europe the socioeconomic and health burden of stroke will increase in many countries within the next decades. In addition, acute stroke mortality differs greatly among European countries being the highest in many countries of Eastern Europe and lowest in many of the Western nations. This implies that management of acute stroke varies in intensity and quality and a uniform improvement of care can be achieved in many countries by involving more neurologists. The viability of ischemic brain tissue may extend up to 18 or even 24 hours but experimental and human stroke research shows that the earlier the intervention takes place the more likely the outcome is favourable. Thrombolysis has been recommended for use within a therapeutic time window of up to 3 hours following the onset of stroke, a time window of up to 6 hours is currently being tested. Neuroprotection drugs are being tested for time windows up to 12 hours. Factors delaying early hospital referral as well as factors delaying in‐hospital management can be overcome if neurologists participate in public education programmes that propagate early recognition of symptoms and advocate emergency hospitalization. Training programmes for medical and paramedical staff can improve initial diagnosis of stroke. Organizational structures within the hospital are recommended that allow neurologists to react quickly and have access to all investigations on an emergency basis. It is important to have an early accurate diagnosis of the stroke as various subtypes have different frequencies with which complications and associated comorbidities occur, have varying rates and patterns of worsening and recurrence. It is essential to establish neurological stroke units for acute care wherever possible. Such units have been shown to be effective but their elements and components making them most efficacious are still not well known. Neurological acute stroke units have the primary aim of initiating stroke treatment on an emergency basis and of clarifying the stroke cause. Ready availability of CT, neurosonological investigations, ECG, echocardiography, and laboratory tests including coagulation is mandatory. Cardiac monitoring as well as monitoring of blood pressure, blood gases, body temperature and blood glucose should be performed immediately upon hospital arrival. When available, arteriography, MRI, EEG monitoring, and new brain imaging techniques should be used. An acute stroke unit should consist of 6 (4–8) beds. Depending on the severity of stroke, case‐mix and complication rates such a unit can serve a population between 200,000 and 400,000 inhabitants and treat 350 to 800 strokes per year. After stabilisation, referral to a non‐intensive stroke rehabilitation unit is recommended. In larger hospitals where a stroke unit cannot be installed easily it is recommended to set up a mobile neurological acute stroke team that is available at emergency departments. Neurologists should be able to take up the history of the patient from the paramedics immediately upon arrival, make the first assessment and follow the patient to other departments. Seamless management includes early neurorehabilitation, the use of a stroke pathway and access to all investigations in order to perform therapies on an emergency basis.