Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 50, Num. s1, 2002, pp. S64-S65

Neurology India, Vol. 50, (Suppl. 1), Dec, 2002, pp. S64-S65

Relevance of Stroke Units to Stroke Care : From Nihilism to Cautious Optimism

S.M. Hastak

Department of Neurology, Lilavati Hospital, Mumbai - 400 050, India.

Correspondence to : Dr. S.M. Hastak, Neurologist and Coordinator Stroke unit, Lilavati Hospital , Ali Yavar Jung, Mumbai - 400 050, India.

Code Number: ni02164

Summary

Many studies have shown definite reduction in the mortality and morbidity of patients treated in the stroke unit when compared to the general medical ward. The beneficial effect of treatment in a stroke unit is achieved in completely unselected patients independent of their age, sex, co-morbidity, and stroke severity. Better outcome has been atributed to prevention of serious events like aspiration, infection, electrolyte imbalance and consequent early mobilization. In India, at present, there are 8 to 10 stroke units which can serve as models for further expansion of acute stroke care.

Key words : Stroke units, Morbidity, Mortality, India.

Introduction

In spite of recent advances in the management of stroke it is not uncommon at any medical conference to hear someone say 'stroke treatment consists of masterly inactivity'. This can be described as therapeutic nihilism. The word nihilism is derived from a latin word nihil which means 'nothing'.¹ It is fortunate that stroke care is changing all over the world. As the level of care changes and interest in this field is activated mainly by thrombolysis, it is necessary to change our thinking so as to keep pace with the rest of the scientific world. Historically therapeutic nihilism is considered a trademark of a neurologist. Definition of stroke in the 1599 oxford english dictionary is 'stroke of God's hands'.² This led to the deduction that stroke was a divine intervention and human effort could not possibly change the outcome. In 1892 Osler stated that in cases of stroke 'the friends should at onset be frankly told that the chance of full recovery are slight'.³ This attitude of physicians has resulted in low interest and awareness amongst the community about stroke.With the advent of thrombolysis there is an urgent need to change gears and shed the nihilistic attitude of yesterday. The concept of stroke unit converts the therapeutic nihilistic to a cautious optimist.

Stroke unit - 'To have or not to have' - evidence based medicine

World Health Organization (WHO) estimated in the year 1990 that out of total 9.4 million deaths in India, 6,19,000 deaths were due to stroke. This means 1880 people die every day in India due to stroke.⁴ Stroke remains a major cause of mortality and morbidity in our country. A ten-year study by a Norwegian group,⁵ has shown definite reduction in the mortality and morbidity of patients treated in the stroke unit when compared to the general medical ward. They paid particular attention to immediate hydration with saline, detection and treatment of fever, oxygenation, control of blood sugar coupled with early mobilization. In a recent study done in London,⁶ stroke unit care improved outcome of patients with large vessel infarcts but not in those with lacunar syndromes. In a community based study done in Denmark,⁷ it was concluded that the 'beneficial effect of treatment in a stroke unit is achieved in completely unselected patients independent of their age, sex, comorbidity, and stroke severity. Those who had most severe strokes appear to benefit most. All patients with acute stroke should therefore have access to treatment and rehabilitation in a dedicated stroke unit'. It has also been shown that stroke unit care reduces the mortality and morbidity of patients with intra cerebral hemorrhage. The stroke unit Trialists' collaboration (1997),⁸ reported on nineteen trials conducted on the usefulness of stroke unit. These were all randomized trials comparing stroke unit care with contemporary conventional care. Total 3246 patients could provide data for this report. They concluded that 'organized inpatient stroke unit care probably benefits a wide range of stroke patients in a wide range of different ways, i.e. reducing death from secondary complication of stroke and reducing the need for institutional care though a reduction in disability'. It has been estimated that for every 1000 patients treated in a stroke unit there would be 180 fewer dead or dependent. The multi disciplinary team of the stroke unit consists of doctors, nurses, physiotherapists, occupational therapists and speech therapists. The involvement of the caretakers in the rehabilitation process and education is critical to the outcome. The Cochrane library in 2001 reviewed the stroke unit trials and concluded that these units help reduce mortality and morbidity after acute stroke.⁹

Stroke unit - the Indian experience : Dr. P.M. Dalal (1978) in Mumbai and later Dr. G. Arjundas (1980) in Chennai pioneered the concept of stroke unit / stroke team care.¹⁰ Both these units have reported a definite drop in mortality, in patients of stroke after setting up these facilities (Mumbai group 58% to 36% while Madras group 38% to 12%). It was felt that the formation of a stroke unit team helped prevent potentially serious events like aspiration, infection, electrolyte or water imbalance. The early mobilization of patients by the stroke team was an important component in preventing morbidity. In India at present there are 8 to 10 stroke units which could serve as models for further expansion of acute stroke care in the community.

Stroke unit a tool for the future

With the arrival of thrombolysis as a therapy to be delivered within the first 3 hours of acute stroke, there is an urgent need to organize stroke care in the form of a stroke unit. Thirty years ago acute coronary care units were introduced without an evidence base but they allowed trials to be mounted and created rapid advances in this field. Similarly, we believe that stroke unit / stroke team is a tool which can be properly utilized, even in our country with limited resources, to advance stroke care in the new millennium.

References

1. Dorland's Illustrated medical dictionary. Philadelphia, Pa, WB Saunders Co, 1981.
2. Schiller F : Concepts of stroke before and after Vichow. Med Hist 1970; 14 : 115-131.
3. Osler W : Principles and Practice of Medicine. D Appleton and Co, New York. 1892.
4. Prasad K : Epidemiology of cerebrovascular Disease in India, Recent Concepts in Stroke. Association of Physicians of India 1999.
5. Indredavik B, Bakke RPT, Slordahl SA et al : Stroke Unit treatment 10 Year Follow-up. Stroke 1999; 30 : 1524-1527
6. Evans A, Harraf F, Donaldson N et al : Randomized Controlled Study of stroke unit care versus stroke team care in different stroke subtypes. Stroke 2002; 33 : 449-455.
7. Jorgensen HS, Kammersgaard LP, Houth J et al : Who benefits from treatment and rehabilitation in a stroke unit? A community based study. Stroke 2000; 31 : 434-439.
8. Stroke Unit Trialists' Collaboration: How do stroke units improve patient outcomes? Stroke 1997; 28 : 2139-2144.
9. Stroke unit Trialists' collaboration: The Cocharane Library, Oxford. 2001; 4.
10. Arjundas D, Arjundas G : Stroke management. Post Graduate Medicine. Association of Physicians of India. 2001; 15.

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