Organization of regional and local stroke resources: Methods to expedite acute management of stroke

Setting up An Acute Stroke Service

The administration of intravenous thrombolytic therapy to appropriate patients and the provision of care in a dedicated stroke unit setting form the pillars of evidence-based acute stroke care. Yet, the availability of these interventions remains variable around the world. Many challenges exist for physicians attempting to set up an acute stroke service for the first time. Based upon their experience in three countries, the authors propose 12 key steps in setting up a successful acute stroke service: identify the building blocks understand local funding mechanisms forge partnerships engage senior managers obtain training be inclusive adapt to local surroundings maintain a clinical focus be incremental capitalise on the enthusiasm of others lead from the front; and provide feedback.

The authors then examine some of the specific barriers that may be encountered and offer three historical examples of evidence-based interventions that were slow to be adopted. An acute stroke service is evidence-based and cost effective, yet the ability of patients to access such a service is variable, even in the developed world. By considering 12 common-sense steps, physicians and managers can maximise their chances of setting up a sustainable and successful acute stroke service.

Treating the acute stroke patient as an emergency: current practices and future opportunities

Developments in acute stroke therapy have followed advances in the understanding of the evolving pathophysiology in both ischaemic stroke and intracerebral haemorrhage (ICH). In ischaemic stroke, rapid reperfusion of the ischaemic penumbra with thrombolysis within 3 h of symptom onset is of proven benefit, but few patients currently receive therapy, mainly due to the short-time window and lack of stroke expertise. In ICH, a recent study indicated that a haemostatic agent can limit ongoing bleeding and improve outcomes when administered within 4 h of stroke onset. These advances in acute stroke therapy underlie the concept that 'time is brain' and that urgent intervention can limit cerebral damage. Neuroprotective therapy could offer the prospect of a greater proportion of stroke patients receiving treatment, potentially before imaging and even in the ambulance setting. Virtually all stroke patients would benefit from receiving multidisciplinary care in acute stroke units.

Telestroke: extending stroke expertise into underserved areas

Telestroke systems offer the opportunity to extend stroke-care expertise into rural and underserved areas. These systems are being used to give alteplase to patients with stroke in previously underserved areas safely, effectively, and rapidly. Telestroke will probably play a large part in improving the quality of stroke care and in enrolling patients into clinical trials in rural and community hospitals. One such telestroke system, REACH (remote evaluation of acute ischaemic stroke), is a low-cost, web-based system that allows the consultant to access the system from work, home, or on the road. REACH is presently being used to give alteplase and guide acute stroke care in eight rural community hospitals in Georgia.