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Kate Tilling and Charles Wolfe Stroke Subtypes Re : Randomized Controlled Study of Stroke Unit Versus Stroke Team Care in Different

Re: Randomized Controlled Study of Stroke Unit Versus Stroke Team Care in Different Stroke Subtypes To the Editor: We have read with interest the article by Evans et al,1 which presents a post hoc analysis of a previously published randomized controlled trial comparing a stroke unit, a stroke team, and domiciliary care.2 The demonstration that the stroke team could not provide sufficient stroke management can be considered the most important conclusion of this trial. This finding confirms our previously reported study comparing a stroke unit with a stroke team within the same neurological department, demonstrating that a stroke unit is better than the stroke team in terms of reduction of mean hospital stay, systemic and neurological complications, and hospital costs, in addition to an improvement of functional state at discharge with an increase in the number of independent patients and a decrease in long-term hospitalization. Besides, we also demonstrated that cerebral hemorrhage and territorial infarction patients (both atherosclerotic and cardioembolic stroke subtypes) get more benefit from a neurological stroke unit care than lacunar or transient ischemic attack patients,3 a finding that could help us to optimize the stroke unit results, taking into account the limited stroke unit resources, and the preliminary data of this analysis were communicated in the 10th European Stroke Conference that took place in Lisbon, Portugal, in May 2001.4 In this report Evans et al, in a post hoc analysis of a randomized trial, found no differences in outcome in the stroke unit versus the stroke team in terms of mortality, mortality or institutionalization, level of neurological recovery, or dependence, confirming our observations about lacunar stroke. In our study, the data of 285 lacunar stroke patients admitted in a neurological department during 3 consecutive years, 78 attended by a stroke team (first year) and 206 in a stroke unit (second and third years), were analyzed. There were no differences in vascular risk factors or comorbidity between the 2 samples. Stroke unit care was associated with a decrease in both systemic and neurological complications, 54.7% and 84.4% reductions, respectively, as well as a decrease of 61.8% in the percentage of lacunar stroke patients with any complication. Only 1 patient in the stroke unit (0.49%) and no patients in the stroke team group died. No patient required institutionalization. There was a trend to an improvement in functional status (modified Rankin Scale). Moreover, we found that lacunar stroke patients in the stroke unit had a significantly lower length of stay than in the stroke team group (7.17 versus 12.83 days; P 0.000 Bonferroni post hoc test). However, in the report by Evans et al, lacunar stroke patients had a longer length of stay in the stroke unit (27.4 versus 18.5 days; P 0.01). The shorter length of stay in our study (whether stroke team or stroke unit) is easily explained by the different stroke unit design as compared with the design by Evans et al. Our stroke unit is an acute neurological stroke unit, attending patients within the first 48 hours from stroke onset, and does not include the rehabilitation ward stay. In addition, although early physiotherapy and rehabilitation are important features of our stroke unit, when a stroke patient has been clinically stabilized, the diagnostic procedures have been finalized, and the patient has a modified Rankin Scale 2, the rehabilitation treatment can continue in an appropriate poststroke rehabilitation ward. On the other hand, Evans et al’s stroke unit is a combined acute and rehabilitation stroke unit settled in a geriatric medicine ward, with no limit of time in unit, although with a program of discharge, usually to final placement (home or institution).5 It has been suggested that an early start of physical therapy and stabilization of blood pressure are probably the most significant aspects of care at the stroke units, in addition to a reduction in the number of patients with a temperature 38°C in the first 5 days, that contribute to the positive results of stroke units as compared with a general medicine ward.6 A possible explanation for the lesser benefit of a stroke unit in lacunar stroke is that in this stroke subtype, located in subcortical white matter, the prognosis is probably not as sensitive to changes in blood pressure, temperature, or glucose blood levels than in large vessel infarctions with cortical damage. In our opinion, all stroke patients should be admitted to an acute stroke unit. However, the data of Evans et al’s study as well as ours, showing that large vessels infarctions get more benefit from a stroke unit than lacunar strokes, are useful to improve stroke unit resources, taking into account that there are not always enough available beds. Finally, although we agree with Hacke7 that it is difficult to understand the design of this randomized study on stroke units, considering the amount of evidence about their benefit from previous randomized studies at the time of the beginning of this study when stroke unit care was a level of evidence I, grade A recommendation, it is true that an adequately powered prospective, randomized, controlled trial in patients with lacunar syndromes to compare the benefits and cost-effectiveness of stroke unit care with organized care in other settings could have no ethical problems, because of the lack of evidence in this stroke subtype both on outcome and in costs. Although this study observed a longer length of stay in the stroke unit group, in our study we found benefits in lacunar stroke in terms of reduction of length of stay and consequently a decrease in hospital costs, and better clinical outcome. However, a randomized trial would clarify the efficacy of the stroke unit in lacunar stroke patients.