European Journal of Neurology (1997),4,435-441 SPECIAL SECTION

Neurological acute stroke care: the role of Europeanneurology

European Federationof Neurological SocietiesTask Force

Correspondence to: Michael Brainin, Center for Neuroscience,Danube UniversityKrems, andDepatfment of Neurology, Landesne rvenklinik Gugging, Hauptstrasse 2, A-3400 Maria Gugging,Austria

In 1995the EFNS has made stroke treatment and prevention a major policy issue and established a Task Force to developguidelinesfor acute neurological stroke care for use by neurologists throughout Europe and to be modified according to localand national requirements. This Task Force report Supplementsrecommendations and treatment guidelinespreviouslypub-lished. It focuses on the need of adapting neurological hospital services to immediate stroke care and Sets up lines of argu-mentationand organisationalrecommendationscompiledon various levelsof evidence. Due to the increaseof agingpopulationsacross Europe the socioeconomic and health burden of stroke will increase in many countries within the next decades. Inaddition, acute stroke mortality differs greatly among European countries being the highest in many countries of EasternEurope and lowest in many of the Western nations. This implies that management of acute stroke varies in intensity andquality and a uniform improvement of care can be achieved in many countries by involving more neurologists. The viabilityof ischemicbrain tissue may extend up to 18or even 24 hours but experimental and human stroke research shows that theearlier the intervention takes place the more likely the outcome is favourable. Thrombolysis has been recommended for usewithin a therapeutic time window of up to 3hours following the onset of stroke, a time window of up to 6 hours is currentlybeing tested. Neuroprotection drugs are being tested for time windows up to 12hours. Factors delaying early hospital refer-ral as well as factors delaying in-hospital management can be overcome if neurologists participate in public education pro-grammes that propagate early recognition of symptoms and advocate emergency hospitalization. Training Programmes formedical and paramedical staff can improve initial diagnosis of stroke. Organizational structures within the hospital arerecommended that allow neurologists to react quickly and have access to all investigations on an emergency basis. It isimportant to have an early accurate diagnosis of the stroke as various subtypes have different frequencies with which com-plications and associated comorbidities occur, have varying rates and patterns of worsening and recurrence. It is essential toestablish neurological stroke units for acute care wherever possible. Such units have been shown to be effective but theirelements and components making them most efficacious are still not well known. Neurological acute stroke units have theprimary aim of initiating stroke treatment on an emergencybasis and of clarifying the stroke cause. Ready availabilityof CT,neurosonological investigations,ECG, echocardiography, and laboratory tests including coagulation is mandatory. Cardiacmonitoring as well as monitoring of blood pressure, blood gases, body temperature and blood glucose should be performedimmediately upon hospital arrival. When available, arteriography, MRI, EEG monitoring, and new brain imaging tech-niques should be used. An acute stroke unit should consist of 6 (4-8)beds. Depending on the severity of stroke, case-mix andcomplication rates such a unit can serve a population between 200,000 and 400,000 inhabitants and treat 350 to 800 strokesper year. After stabilisation, referral to a non-intensive stroke rehabilitation unit is recommended. In larger hospitals wherea stroke unit cannot be installed easily it is recommended to set up a mobile neurological acute stroke team that is availableat emergency departments. Neurologists should be able to take up the history of the patient from the paramedics immedi-ately upon arrival, make the first assessment and follow the patient to other departments. Seamlessmanagement includesearly neurorehabilitation, the use of a stroke pathway and access to all investigations in order to perform therapies on anemergencybasis.

INTRODUCTION:THE INCREASING BURDEN OFSTROKE

In Europe stroke is a leading cause of death and the mostcommon cause of severedisability in adults. In most West-

Participants of the European Federation of Neurological Societies Task

Force on neurological acute stroke: Michael Brainin, Austria (Chair);

Markku Kaste, Finland (Vice-Chair); Anna Czlonkowska, Poland; Hans-

ChristophDiener,Germany;Pavel Kavlach,Czech Republic;Tom Skyhoj

Olsen, Denmark; Danilo Toni, Italy;Graham Venables,United Kingdom.

ern European countries, death from stroke has declinedby 30-50% since 1975, but in the countries of EasternEurope stroke mortality has remained stable or slightlyincreased over the same period of time (Asplund, 1996; Khaw, 1996; Stegmayr et al., 1996).Despite the declinein mortality in Western Europe, the incidence of stroke isexpected to increase within the next few decades, mainlydue to a 30%growth in the elderly population, which will

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lead to an increase in the health burden of stroke withconsequent increases in economic costs. Lifetime costsof first-ever stroke are estimated at between US$40,000in the Netherlands and US$80,000 in Sweden, of whichhospitalcostsaccountfor45% in the firstyear after a stroke(Asplund et al., 1993; Bergman et al. , 1995); it is esti-mated that hospital costs will increase increase by 1.5%per year (Bergman et al., 1995). Across Europe, there-fore, with its ageing population, there is a pressing needto cope with this increase, and make stroke prevention and treatment a priority to reduce the growing health bur-den and lessen its socio-economic impact.

Improving acute stroke care along established and evi-dence-based principles is a substantial undertaking. The World Health Organization (WHO) Monitoring in Car-diovascular Disease (MONICA) project (Thorvaldsen etal., 1995) has demonstrated a large variation between countries in case fatality rates (the proportion of fatalitiesoccurring within 28 days after onsetof acute stroke), rang-ing from 15% in northern countries to 50%in some East-ern European states. The implications of these findings are that the quality of acute stroke care varies betweencountries and that an improvement in initial diagnosis, treatment and rehabilitation programmes will reduce case fatality rates.

EFNS TASK FORCE ON STROKE AND EXISTINGGUIDELINES

National neurological societieshave become increasingly aware of the need to address the problem of acute stroke care through consensus statements and training pro-grammes. In particular, there is a need to set up special-ized treatment facilities for the acute care of patients withstroke. In 1995 the European Federation of NeurologicalSocieties (EFNS) made stroke treatment and prevention a major policy issue. A Task Force on Neurological Acute Stroke Care was instructed to develop guidelines for the implementation of stroke management policies for use byneurologists in all European countries with the intention that these guidelinescould then be modified according tolocal and national requirements.

Other guidelines have focused on general issues ofstroke care, public awareness and educationprogrammesand treatment, rehabilitation and organizational issues. Anad hoc consensus group (European Ad Hoc ConsensusGroup, 1996, 1997) has compiled all available evidence about early intervention in acute stroke and laid down theprinciples of intensive care. A report from the American Heart Association has developed guidelines for the man-agement of patients with acute ischaemic stroke (Adamset al., 1994). This has been supplemented by a practice advisory document on thrombolytic therapy for acute is-chaemic strokeby the American Academy of Neurology

(American Academy of Neurology, 1996). The WHO/Eu-ropean Stroke Council “Helsingborg Declaration” (WorldHealth Organization/European Stroke Council, 1996) ad-dressed the need to develop specific acute care and reha-bilitation facilities in an organized fashion in order to re-duce mortality and disability. The present guidelines are intended to focus on the role of neurological services and neurologists in the acute care of people with stroke, and supplement already existing reports and guidelines.

NEUROLOGISTS MUST COPE WITH STROKE EMERGENCIESON A DAILY BASIS

Neurologists have played amajor part in experimental andclinical research into therapy of cerebrovascular diseases. Harrison et al. (197 1) first suggested that aspirin might reduce the frequency of transient ischaemicattacks. These observations opened the way for the first of many largerandomized trials of aspirin in both secondary prevention(Canadian Cooperative Study Croup, 1978) and, more recently, acute intervention trials in ischaemic stroke (In-ternational Stroke Trial Collaborative Group, 1997; Chi-nese Acute Stroke Trail Collaborative Group, 1997).

Data from both animal and human stroke research sug-gest that the earlierintervention takes place the more likely it is that the outcome will be favourable. Cerebral tissue may remain viable for up to 18-24h after acute ischae-mia, even if cerebralblood flow is below 22 ml/100 g per min, provided there is a high level of oxygen extractionand a high cerebral metabolic rate for oxygen (Baron etal., 1995). Thrombolyis is now recommended in NorthAmerica if undertaken within 3 h of the onset of stroke,and further clinical trials testing the efficacy of throm-bolysis are under way with a time window of up to 6 h.Neuroprotection trials presently test a therapeutic time win-dow up to 12 h.

Therefore, neurologists involved in the acute care ofstroke must now operate within organizational structures that allow them to react quickly, as therapeutic measures undertaken outside the appropriate time windows are less likely to be effective and may be harmful. The fact that neurologistsmust now cope with strokeemergencies on a daily basis represents a major turning point in clinical neurology.

TREATMENT DELAYS BOTH OUTSIDE ANDINSIDE THE HOSPITAL CAN BE AVOIDED

Various factors are responsible for delay in patient refer-ral to hospital. These include apoor awareness of the stroke by the victim or family, reluctance to seek emergency ormedical help, incorrect diagnosisby the paramedical serv-ice and rating stroke as a non-emergency by medical per-sonnel and the family physician. In Germany,only 5% of

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the population are aware of the warning signs of strokecompared with 50%who know about myocardial ischae-mia (A. Kottmaier, unpublished data). Jørgenson et al.(1996) showed that patients who had previously suffereda transient ischaemicattack underwent shorter admissiontimes when they experienced a stroke in comparison topatients with first-ever strokes not known to’have had atransient ischaemicattack. Ambulance staff are known tomake an incorrectdiagnosis in 50%of patients comparedwith 25% by paramedics (Kothari et al., 1995).

Because of these factors, traditional settings for thetreatment of patients with acute stroke may not be appro-priate. Neurologistsshould be involvedin the public edu-cation and training of paramedical staff, stress the impor-tance of awareness about stroke, the early recognition ofsymptoms and the need for emergency hospitalization.

Within the hospital, factorsdelaying early interventioninclude admission polices that require placement of pa-tients on general medical wards, lack of access to earlybrain-imaging facilities,the rating of strokeas non-urgentby hospital staff,non-existenttreatmentfacilitiesfor strokeat the point of admission and unavailabilityof a neurolo-gist in the emergency room. This may lead to delays inthe early recognition of stroke, prolonged ‘door to drug’ times, failure to use new treatment modalities, includingthrombolysis, and the introductionof early secondary pre-vention measure. Conditions other than stroke that pres-ent stroke-likesyndromes,such as hypoglycaemiaor sub-duralhaematoma,may be life-threatening,and non ischae-mic stroke may account for up to 25% of acute strokeadmissions(Bratina etal., 1995).Delay in imaging is com-mon (Andersonet al., 1995):despitea median arrivaltimeof 4.3 h for ischaemic stroke and 2 h for intracerebral orsubarachnoid haemorrhage, computed tomography (CT)was delayed by a median of 66 h for the former comparedwith a few hours by the intervention of the emergencystroke team (Bratina et al., 1995).

EARLYACCURATE DIAGNOSISCAN BEACHIEVED

Different stroke subtypes have different aetiologies, dif-fering frequencies with which complications and associ-ated comorbidities occur, differing rates of early recur-rence and varying rates and patterns of deterioration andprognosis; therefore accurate diagnosis is required forappropriate management.

A history and physical examination may assist in theclassificationof the stroke subtype and allow priorities tobe determinedfor additional investigationsand treatments.Subtypesinclude stroke due to arterial atherothrombosis,cardiac embolism, small-vessel occlusion andcrypotogenicand uncertain aetiologies. In a recent study,early categorization of the initial stroke type on clinical

and CT criteria proved to be correct in 62% of patientscompared with a final diagnosis 3 months later for allstroke types (Madden et al., 1995).Even then, 15%couldnot be categorized. In another study, lacunar stroke wascorrectly distinguished from non-lacunar stroke in 56%.of cases within 12h after onset in 517patients presentingwith first-ever stroke (Toni et al., 1995).The effect of thison prognosis was demonstrated by Libman et al. (1995)who showed that pure motor hemiparesis tended to im-prove rapidly over 10days. These studies show that even for expert neurologists, the early diagnosis of strokesubtype is difficulton clinical grounds alone but may be-come more reliable when the results of further examina-tions, in addition to the initial CT, are readily available.

NEUROLOGICALSTROKE UNITS ARE NOWWIDELY ACCEPTED

The use of neurological strokeunits within the first weekhas yet to be evaluated in formal trials. Most of the evi-dence for the effectiveness of organized stroke care hascome from stroke rehabilitation.

Level I evidenceRandomized studies have shown that stroke units are ef-fective in reducing mortality compared with treating pa-tients on general medical ward. A meta-analysisof all tri-als of strokeunits compared with care in a generalmedicalsetting showed a 21% reduction in mortality after 12months (Langhorneet al., 1993).Individualtrials includea prospective randomized study of acute stroke patientsin which there was an improvement in functionaloutcomeand a reduction in the need for long-term care in patients

compared with a general medical ward (Strand et al.,who randomly allocated to a non- intensive stroke unit

1985). In this study, 15% of those randomized to stroke unit care and 39% of those on a general ward remained hospitalized. Functional outcome was better, as measured by the Activities of Daily Living scale, including meas-urements in the domainsof walking, personal hygiene anddressing. The precise mechanism for this remains unclear, though the authors suggest that teamwork and early onset of rehabilitation may be important. Kaste et al. (1995)showed that patients randomly allocated to care in the neu-rology department left hospital earlier, went home directly more often, and were more commonly independent after1year than those treated on medical wards. While the fa-tality rate was no different, the authors suggested that bet-ter organizationof care played a part in the improved out-come.

Demographic variables are well matched in most stud-ies, but data about the time of admission and the onsetand intensity of rehabilitation measures are usually lack-ing in these studies, so that no general conclusions can bedrawn about the efficacy of acute strokeunits.

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Level II evidenceTwo studies have compared the efficacy of stroke reha-bilitation units with historical controls treated on general medical wards. Jørgenson et al. (1995) studied 936 acute stroke patients managed in a stroke unit of 61 beds and compared them with 305 patients managed in general wards at another hospital. Both groups were similar interms of age and time of admissionto the unit. Case fatal-ity rates, percentage discharged to a nursing home, lengthof stay for all patients and length of stay for those agedover70years were all lower among those treated in a strokeunit. The authors (Jørgenson et al., 1995) attributed their success to a standardevaluationprogramme, intensiveob-servation and goal-oriented treatment in the first few daysafter admission.

Bath et al. (1996) provided some evidence that imme-diate admission to a stroke unit might be efficacious.Pa-tients admitted immediately to an eight-bed stroke unitand transferred after an average of 7 days to postacute treatment facilitieswere compared with historical controls treated on a general medical or geriatric ward. The pa-tients treated in a special unit showed a reduced time to admission from the emergency unit, earlier CT, more ca-rotid sonography, a greater likelihood of being given as-pirin on discharge and a reduced in-patient hospital stay.Bath et al. (1996) suggest that a better outcome might berelated to an improved diagnosis, directed rehabilitation, fewer early complications and better early secondary pre-vention measures.

Level III evidenceIn a survey in 18 Spanishhospitals, the time from the on-set of a stroke or a transient ischaemic attack to contactwith a neurologistwas compared. Those admitted or evalu-ated early had an improved outcome as measured by animpairment scaleand a reduced length of stay (Davalosetal., 1995). Intensive management of hypertensionand hy-perglycaemia in the acute phase was thought to have con-tributed to this. Some evidence from North America sug-gests that neurologists who treat stroke are more likely to be knowledgeable about the causes of stroke that others, and their patients have a better outcome than those treated by internists or general practitioners. Medicare evaluated 20% of their stroke patients treated in 1991 and foundthat patients treated by neurologists had a significantly lower 90-day mortality (Mitchell et al., 1996); however these patients were not matched for stroke severity or comorbid disease. The same data showed that neurolo-gists used more imaging procedures, including CT, mag-netic resonance imaging (MRI), angiography and moreprothrombin tests for anticoagulant control. They alsomade more use of rehabilitation facilities and made lessuse of nursing facilitiesand nursing homes. However, the neurologistsincurred high hospitalization costs compared

with internists and general practitioners. This mirrorsMedicare costs for myocardial infarction as cardiologistshave gradually taken over the care of this group of pa-tients.

There are no evidence-based guidelines in the follow-ing areas, though clinical trials are under way in some:the management of swallowing disorders and the preven-tion of aspiration using either a nasogastric tube or viapercutaneous gastrostomy (Holas et al., 1994; Smithard et al., 1996), nutritional supplements after a stroke, theuse of intracranial monitoring and other aspects of inten-sive care, including optimal control of hyperpyrexia(Grotta et al., 1995; El-Ad et al., 1996;Reith et al., 1996;Schwabet al., 1996;EuropeanAd Hoc Consensus Group,1997).

Ethical issues alsoneed to be considered,and a rationalapproach to ‘do not resuscitate’ orders is required, espe-cially to assist in the management of patients who arelocked in or in vegetative states (Alecandrow et al., 1995,1996).

Further unanswered questions about acute stroke careincludequestions about appropriatediagnostic techniques (Mohr et al., 1995; Schneider et al., 1996), pharmaco-therapy for cerebral ischaemia (Marshall and Mohr, 1993)and effectivemeans of preventing complications (Daven-port et al., 1966).

None of the studies reported above give a detailed analy-sis of the elements of stroke care that might be essential ina neurological acute stroke unit and detailed descriptions of all the components remain to be undertaken.

RECOMMENDATIONS

Twomodels of care are proposed. One involves the use ofdedicated facilities for acute neurological care within ahospital, the other a mobile neurological acute stroke teamwhen dedicated facilities are not available.

The primary aim of either model is:accurate diagnosis to minimize complications and recurrence;initiation of acute stroke treatment.Acute care starts with the patient as soon as symptoms

are experienced. Patients require education about the sig-nificance of their symptoms, while paramedical staff and general practitioners need to know how to accessthe stroketeam or stroke unit. All admissions trails should thereforebe clearly visible and available to the community prehos-pita1 services. Within the hospital setting neurologistsshould have early access to patients with stroke and fullaccess to appropriate investigational facilities.

Neurological acute stroke unit It is important to have a stroke unit within a defined set-ting. These units mostly consist of a small number of bedswhich are exclusively and immediately available for all

438 European Journal of Neurology .Vo1 4 . 1997

NEUROLOGICAL ACUTE STROKE CARE

FIG. 1.Flow chart showing organization of an acute neurologicalstroke unit.

admissions with stroke-like symptoms. Many neurologi-cal departments treating acutepatients already have moni-toring devices available for their patients as well as neu-rologists with a specialized interest and training to treatacute strokes. With an increasing tendency to apply early and very early interventions, especially thrombolysis, itis also evident that neurological acute stroke units will bethe specialized setting for any kind of treatment which has to be performed within the first few hours after the onset of a stroke. Initial management on a general wardwill not be easily justified for treatments that have a haz-ardous potential.

A concept for neurological acute stroke care should follow an integrated concept for treatment and include theprehospital emergency setting, rapid transfer to centerswith a neurological stroke unit, emergency treatment fol-lowing admission, initial neurological and neuroradiolog-ical assessment, additional investigations, secondary andtertiary prophylaxis, continuous neuromonitoring and ther-apy during the acute phase, and consecutive transfer, pref-erably to a non-intensive-care stroke rehabilitation unit (Fig. 1).

This acute stroke unit has the primary task of perform-ing very early evaluation and management following the early days after a stroke. Other additional elements are optional and vary from country to country. In some coun-tries or regions, stroke units have been established to in-clude early rehabilitation as well. This is a compatible addition to an acute stroke unit. Stroke units that exclu-sively focus on rehabilitation in the postacute phase fol- low a different task and their efforts cannot easily be com-pared with a neurological acute stroke unit.

TABLE I. Investigative facilities required to be readily accessible (24 h) for acute neurologicalstroke units

Computed tomography Neurosonological investigations (extracranial and intracranial

vessels, colour-codedDuplexsonography, transcranial Doppler sonography)

ElectrocardiographyEchocardiography (transthoracic)Laboratory examinations (including coagulation parameters)Blood pressure,blood gases, blood glucose, body temperature

TABLE II. Additional investigatory facilities recommended to be available for patients in acute neurological stroke units

Magnetic resonance imaging/Magnetic resonance angiography Computed tomography angiography Echocardiography (transoesophageal) Cerebral arteriographyTranscranial Doppler sonography (embolus detection monitoring)Electroencephalography monitoringMonitoringof central breathing disturbances

Acute stroke units have the primary aim of initiatingstroke treatment on an emergency basis and of clarifyingthe causes of the stroke in order to prevent further relapses and complications. All other aspects are secondary.Prehospital structures must be adapted to this primary aim. Within the hospital their patients must have access to all investigations on an emergency basis. There should be aready availability of CT, arteriography, echocardiography, Dopplersonography including transcranial Doppler sonography and transcranial Doppler monitoring, as wellas CT angiography,MRI and MRA if situated within reach (Tables 1 and 2).

Neurological acute stroke team Many hospitals do not yet have acute stroke units. Theseare often large general hospitals with a neurological de-partment that consists of a small number of beds provid- ing a ward consultation service. In this type of traditionalsetting, neurologists are recommended to install mobile stroke teams that are rapidly available on an emergency basis throughout the hospital (Fig. 2). These neurologistsshould have the primary competence for all acute strokes as soon as they are admitted. If there is an emergency room or emergency department for all hospital admissions, aneurologist should be easily and rapidly available for thoseadmissions and have a chance to take a history from the paramedics and make a first assessment. They should fol- low the patients to intensive care, to coronary care, to gen- eral medical or geriatric wards. After initial management,neurologists should be able to start with neurorehabilita-tion as soon as possible. Physiotherapists, occupationaltherapists and speech therapists should therefore also be-

European Journal of Neurology .Vo14 .1997 439

Acute stroke

Regional Hospital

General Medical/Geriatic

Ward

Coronary Care Unit

Paramedics Emergency physicians

Emergeny Department

Intensive Care Unit

Stroke Rehabilitation Unit

Neurological Ward

Regional Hospital

Home

Acute Neurological

Stroke Unit

EFNS TASK FORCE

FIG. 2. Flow chart showing organizationof an acute neurologicalmobile stroke team.

long to the mobile stroke team. After some time, a suc-cessful mobile stroke team is often able to install an acutestrokeunit with beds and neuromonitoring equipment. Inorder tojustify this, the work of this team should be care-fully and separately documented from the beginning, to allow an evaluationof the clinical successes and the costs of the interventions. In addition, a checklist of interven-tions and investigations is helpful in recording the workon an individual patient. A written clinical pathway foracute strokes is even better than a mere checklist because it makes the process of clinical decision-making more transparent. Interdisciplinary cooperation with othermed-ical specialists is essential for the general management ofstroke.

Prehospital and acute inhospital managementA neurological acute stroke unit must startoutside the hos-pital: Emergency physicians, paramedics and referring doctors as well as the general population within the dis-trict should know that this acute stroke unit exists and isoperational at all hours. A neurologist should be available 24 h a day on an emergency basis in order to attend to all admissions with a stroke syndrome, to perform a rapidneurological investigation and to check vital and cardio-vascular parameters. He will take a short patient history and decide on the location and cause of the infarct. Inev-itably, a CT scan and a laboratory screening will be need-ed on an emergency basis as well as further investigations. Doppler investigationsof the extra- and intracranial ves-sels, echocardiographic investigations of the heart andaortic arch and the option to perform cerebral angiogra-

440 European Journal of Neurology . Vo1 4 . 1997

phy should be made available within an organizationalstructure which defines the accessibility to those teams according to the emergency status of the patient.

Within the first few hours and days the patient will bemonitored continuously. It is essential that a portablemonitor for electrocardiography (ECG) and pulse-oxymetry is available when the patient is moved to ex-aminations outside the acute stroke unit (Tables 1and 2).Blood pressure, ECG lood glucose, peripheral oxygen

monitored continuouslywhile the patient is in the unit. Ashort neurological stroke scale repeated at regular inter-vals in helpful to detect progression or deterioration. It is essential to observe changes in consciousness and to rec-ognize secondary or tertiary complication.

saturation,body temperature and fluid balance should be

GEOGRAPHICAL RECOMMENDATIONS

A neurological acute stroke unit should consist of four to eight beds (ideal size six beds) and aim at treating acutestrokes for 2-7 days (average 4-5 days) depending on theseverity, complicationsand case-mix.With a regional in-cidence of 200 first-ever strokes per 100000 inhabitantsper year and a hospitalization rate of 70-80%, one acute stroke unit may serve approximately 200,000-300,000inhabitants. This implies that 350-500 strokes are treatedper year, including recurrent strokes. If the average pa-tient stay can be reduced to 2-4 days, a stroke unit can serve a larger population of approximately 300,000-400,000 inhabitant, thus treating up to 800 strokes per year.

ORGANIZATIONAL RECOMMENDATIONS

Diagnosticand therapeutic measures are standardizedandareupdated at regularintervals. Strokeprotocols and pres-ent clinical pathways are important for a continuous as-sessment of the quality of performance of the strokeunit.The first assessment includes the decision on whether thepatient has to be intubated and ventilated and thereforetransferred to an intensive.care unit. If no intensive care unit is easily available some strokeunits might decide to start artificial or assisted ventilation before transferring the patient. The majority of patients, however, do not re-quire ventilation and can be referred on after stabilization, preferably to a non-intensive-care stroke rehabilitation unit. Physiotherapy, occupational therapy and speech therapy can be started in order to guarantee seamlesscare.

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Geriatic Ward

Emergency Ward

Intensive Care Ward

Coronary Care Unit

Stroke Rehabilitation Unit

Neurological Ward

Regional Hospital

Home

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Mobile Stroke Unit

Paramedics Emergency physicians

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