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STROKE TREATMENT, MANAGEMENT AND REHABILITATION

The past decade has witnessed a dramatic change in treatment of acute stroke, leaving the era of an indifferent approach fi rmly behind. Equally as important as the development of particular emergency treatments, however, is the recognition that the organization of stroke services per se plays a key role in the provision of effective therapies and in improving the overall outcome after stroke.

An important advance in stroke management is the advent and development of specialized stroke services (stroke units) in the majority of developed countries. These services are organized as specialized hospital units focusing exclusively on stroke treatment. Evidence favours all strokes to be treated in stroke units regardless of the age of the patient and the severity and subtype of the stroke. Evidence from randomized trials shows that treatment in stroke units is very effective, especially when compared with treatment in general medical wards, geriatric wards or any other kind of hospital department in which no beds or specialized staff are exclusively dedicated to stroke care. The Stroke Unit Trialist’s Collaboration has shown that stroke units reduce early fatality (death within 12 weeks) by 28% and death by the end of one year follow-up by 17% (relative risk reduction). Stroke units also decrease disability and result in more discharges to home, rather than having patients institutionalized. In most European countries, the elements of comprehensive stroke unit care outlined by the Stroke Unit Trialists’ Collaboration have been adopted, and include assessment and monitoring, physiological management, early mobilization, skilled nursing care, and short-term multidisciplinary team rehabilitation services. Despite proven effi cacy and cost–effectiveness, stroke unit care remains underused in almost all parts of the world.

Ischaemic stroke is caused by interruption of the blood supply to a localized area of the brain. This results in cessation of oxygen and glucose supply to the brain with subsequent breakdown of the metabolic processes in the affected territory. The process of infarction may take several hours to complete, creating a time window during which it may be possible to facilitate restoration of blood supply to the ischaemic area and interrupt or reverse the process. Achieving this has been shown to minimize subsequent neurological defi cit, disability and secondary complications. Therefore the acute ischaemic stroke should be regarded as a treatable condition that requires urgent attention in the therapeutic window when the hypoxic tissue is still salvageable . Recent advances in management of ischaemic stroke imply implementation of thrombolytic therapy that restores circulation in zones of critical ischaemia thus allowing minimizing, or even reversing, the neurological defi cit. Thrombolysis is effective for strokes caused by acute cerebral ischaemia when given within three hours of symptom onset. Intravenous thrombolysis has been approved by regulatory agencies in many parts of the world and has been established or is in the build-up phase in many areas. The therapy is associated with a small but defi nitive increase in the risk of haemorrhagic intracerebral complications, which emphasize the need for careful patient selection. Currently less than 5% of all patients with stroke are treated with thrombolysis in most areas where the therapy has been implemented. One half to two thirds of all patients with stroke cannot even be considered for intravenous thrombolytic therapy within a three-hour window because of patient delays in seeking emergency care. Changing the patients’ behaviour in the event of acute suspected stroke remains a major challenge. Several studies are currently ongoing on the possibility to extend the current criteria for thrombolysis to larger patient groups including beyond the three-hour window.

In cases of acute stroke, aspirin is given as soon as CT or MRI has excluded intracranial haemorrhage. Immediate aspirin treatment slightly lowers the risk of early recurrent stroke and increases the chances of survival free of disability: about one fewer patient dies or is left dependent per 100 treated. However, because aspirin is applicable to so many stroke patients, it has the potential to have a substantial public health effect. Aspirin is also likely to reduce the risk of venous thromboembolism.

Heparins or heparinoids lower the risk of arterial and venous thromboembolism, but these benefi ts are offset by a similar-sized risk of symptomatic intracranial haemorrhage, and such therapy is therefore not generally recommended. For patients at high risk of deep venous thrombosis, low-dose subcutaneous heparin or graded compression stockings are currently being evaluated in clinical trials.

A recent trial did not confi rm superiority of surgical treatment over non-surgical management in cases of ICH, though appropriately selected patients with acute, spontaneous ICH may benefi t from urgent removal of the clot, particularly in the cerebellum. Selection criteria and choice of surgical procedure vary widely between centres.

Several advances are noted with endovascular treatment of intracranial aneurisms by detachable coils. Recent evidence suggests that endovascular intervention is at least as effective as open surgery, with fewer complications.

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