Background and Purpose: Precise mechanisms underlying the effectiveness of the stroke unit (SU) are not fully established. Studies that compare monitored stroke units (semi-intensive type, SI-SU) versus an intensive care unit (ICU)-based mobile stroke team (MST-ICU) are lacking. Although inequalities in access to stroke unit care are globally improving, acute stroke patients may be admitted to Intensive Care Units for monitoring and followed by a mobile stroke team in hospital's lacking an SU with continuous cardiovascular monitoring. We aimed at comparing the stroke outcome between SI-SU and MST-ICU and hypothesized that the benefits of SI-SU are driven by additional elements other than cardiovascular monitoring, which is equally offered in both care systems. Methods: In a single-center setting, we compared the unfavorable outcomes (dependency and mortality) at 3 months in consecutive patients with ischemic stroke or spontaneous intracerebral hemorrhage admitted to a stroke unit with semi-intensive monitoring (SI-SU) to a cohort of stroke patients hospitalized in an ICU and followed by a mobile stroke team (MST-ICU) during an equal observation period of 27 months. Secondary objectives included comparing mortality and the proportion of patients with excellent outcomes (modified Rankin Score (mRS) 0-1). Equal cardiovascular monitoring was offered in patients admitted in both SI-SU and MST-ICU. Results: 458 patients were treated in the SI-SU and compared to the MST-ICU (n = 370) cohort. 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 mRS distribution showed significant shift to the 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). Conclusions: Our study shows that moving from a stroke team in a monitored setting (ICU) to an organized stroke unit leads to a significant reduction in the 3 months unfavorable outcome in patients with an acute ischemic or hemorrhagic stroke. Cardiovascular monitoring is indispensable, but benefits of a semi-intensive Stroke Unit are driven by additional elements beyond intensive cardiovascular monitoring. This observation supports the ongoing development of Stroke Centers for efficient stroke care.

1.
Donnan GA, Fisher M, Macleod M, Davis SM: Stroke. Lancet 2008;371:1612-1623.
2.
Seenan P, Long M, Langhorne P: Stroke units in their natural habitat: systematic review of observational studies. Stroke 2007;38:1886-1892.
3.
Candelise L, Gattinoni M, Bersano A, Micieli G, Sterzi R, Morabito A: Stroke-unit care for acute stroke patients: an observational follow-up study. Lancet 2007;369:299-305.
4.
Langhorne P, Dey P, Woodman M, Kalra L, Wood-Dauphinee S, Patel N, et al: Is stroke unit care portable? A systematic review of the clinical trials. Age Ageing 2005;34:324-330.
5.
Douglas VC, Tong DC, Gillum LA, Zhao S, Brass LM, Dostal J, et al: Do the Brain Attack Coalition's criteria for stroke centers improve care for ischemic stroke? Neurology 2005;64:422-427.
6.
Steiner T: Stroke unit design: intensive monitoring should be a routine procedure. Stroke 2004;35:1018-1019.
7.
Walter A, Seidel G, Thie A, Raspe H: Semi-intensive stroke unit versus conventional care in acute ischemic stroke or TIA - a prospective study in Germany. J Neurol Sci 2009;287:131-137.
8.
Sulter G, Elting JW, Langedijk M, Maurits NM, De Keyser J: Admitting acute ischemic stroke patients to a stroke care monitoring unit versus a conventional stroke unit: a randomized pilot study. Stroke 2003;34:101-104.
9.
Cavallini A, Micieli G, Marcheselli S, Quaglini S: Role of monitoring in management of acute ischemic stroke patients. Stroke 2003;34:2599-2603.
10.
Glader EL, Edlund H, Sukhova M, Asplund K, Norrving B, Eriksson M: Reduced inequality in access to stroke unit care over time: a 15-year follow-up of socioeconomic disparities in Sweden. Cerebrovasc Dis 2013;36:407-411.
11.
Ringelstein EB, Chamorro A, Kaste M, Langhorne P, Leys D, Lyrer P, et al: European Stroke Organisation recommendations to establish a stroke unit and stroke center. Stroke 2013;44:828-840.
12.
Stroke Unit Trialists' Collaboration: Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2013;9:CD000197.
13.
European Stroke Organisation (ESO) Executive Committee; ESO Writing Committee: Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008;25:457-507.
14.
Lyrer P, Michel P, Arnold M, Hungerbühler H, Gralla J, Humm A, et al: Stroke Units und Stroke Centers in der Schweiz: Richtlinien und Anforderungsprofil. Schweiz Med Forum 2012;12:918-922.
15.
Sulter G, Steen C, De Keyser J: Use of the Barthel index and modified Rankin scale in acute stroke trials. Stroke 1999;30:1538-1541.
16.
Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J: Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988;19:604-607.
17.
Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al: Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993;24:35-41.
18.
Ringelstein EB, Zeumer H, Schneider R: Contribution of computer tomography of the brain to differential typology and differential therapy of ischemic cerebral infarct. Fortschr Neurol Psychiatr 1985;53:315-336.
19.
Savitz SI, Lew R, Bluhmki E, Hacke W, Fisher M: Shift analysis versus dichotomization of the modified Rankin scale outcome scores in the NINDS and ECASS-II trials. Stroke 2007;38:3205-3212.
20.
Gattringer T, Niederkorn K, Seyfang L, Seifert-Held T, Simmet N, Ferrari J, et al: Myocardial infarction as a complication in acute stroke: results from the Austrian stroke unit registry. Cerebrovasc Dis 2014;37:147-152.
21.
Silva Y, Puigdemont M, Castellanos M, Serena J, Suñer RM, García MM, et al: Semi-intensive monitoring in acute stroke and long-term outcome. Cerebrovasc Dis 2005;19:23-30.
22.
De Jong G, van Raak L, Kessels F, Lodder J: Stroke subtype and mortality. A follow-up study in 998 patients with a first cerebral infarct. J Clin Epidemiol 2003;56:262-268.
23.
Saposnik G, Fang J, O'Donnell M, Hachinski V, Kapral MK, Hill MD: Escalating levels of access to in-hospital care and stroke mortality. Stroke 2008;39:2522-2530.
24.
Di Carlo A, Lamassa M, Wellwood I, Bovis F, Baldereschi M, Nencini P, et al: Stroke unit care in clinical practice: an observational study in the Florence center of the European Registers of Stroke (EROS) Project. Eur J Neurol 2011;18:686-694.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.