Cereda Carlo W, George Paul M, Pelloni Lorenzo S, Gandolfi-Decristophoris Paola, Mlynash Michael, Biancon Montaperto Lucia, Limoni Costanzo, Stojanova Vesna, Malacrida Roberto, Städler Claudio, Bassetti Claudio L
Neurocenter of Southern Switzerland, Neurology, Lugano, Switzerland.
Cerebrovasc Dis. 2015;39(2):102-9. doi: 10.1159/000369919. Epub 2015 Jan 23.
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.
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.
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).
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.
卒中单元（SU）有效性的确切机制尚未完全明确。目前缺乏比较监测性卒中单元（半强化型，SI-SU）与基于重症监护病房（ICU）的移动卒中团队（MST-ICU）的研究。尽管全球范围内获得卒中单元治疗的不平等现象正在改善，但急性卒中患者可能会被收治入重症监护病房进行监测，随后在缺乏具备持续心血管监测功能的卒中单元的医院由移动卒中团队进行后续治疗。我们旨在比较SI-SU和MST-ICU的卒中结局，并假设SI-SU的益处是由心血管监测以外的其他因素驱动的，而这两种护理系统都同样提供心血管监测。
在单中心环境中，我们比较了在具有半强化监测的卒中单元（SI-SU）收治的连续缺血性卒中或自发性脑出血患者与在ICU住院并在27个月的同等观察期内由移动卒中团队（MST-ICU）进行后续治疗的卒中患者队列在3个月时的不良结局（依赖和死亡率）。次要目标包括比较死亡率和预后良好（改良Rankin量表（mRS）0-1）患者的比例。SI-SU和MST-ICU收治的患者均接受同等的心血管监测。
458例患者在SI-SU接受治疗，并与MST-ICU队列（n = 370）进行比较。与MST-ICU相比，SI-SU患者在3个月后的死亡和依赖比例显著改善（p < 0.001；调整后比值比（aOR）= 0.45；95%置信区间（CI）：0.31-0.65）。mRS分布的转移分析显示，SI-SU组显著向较低的mRS转移，p < 0.001。MST-ICU和SI-SU患者在3个月后的死亡率比例也有所不同（p < 0.05），但在调整混杂因素后，这种关联不显著（aOR = 0.59；95% CI：0.31-1.13）。SI-SU中预后良好患者的比例更高（59.4%对44.9%，p < 0.001），但调整后这种关系不再显著（aOR = 1.17；95% CI：0.87-1.5）。
我们的研究表明，从监测环境（ICU）中的卒中团队转变为有组织的卒中单元可显著降低急性缺血性或出血性卒中患者3个月时的不良结局。心血管监测是必不可少的，但半强化卒中单元的益处是由强化心血管监测以外的其他因素驱动的。这一观察结果支持了正在进行的卒中中心高效卒中护理的发展。
