Supply in Switzerland

Brain stroke is the leading cause of long-term disability. The population is still insufficiently educated. Specialized interdisciplinary stepwise care and assessment can significantly improve the prognosis of stroke patients. A stroke unit is a specialized treatment unit of a hospital for stroke patients of any age and for strokes of any severity. A stroke center includes a stroke unit and extends it to include specific structural neuroradiology and neurosurgical services. Patients treated in stroke centers and/or stroke units are significantly more likely to survive, regain independence, and have shorter hospitalizations. In most regions with certified stroke centers and/or stroke units, a significant improvement in the care structure has been observed so far.

According to the WHO, stroke is the second leading cause of death in the world from the age of 60 – and the third in industrialized countries – and the fifth leading cause of death between the ages of 15 and 59. Globally, around 15 million people currently suffer a stroke every year. Three million women and two and a half million men die from it. According to the Federal Statistical Office, 14,178 cerebral strokes occurred in Switzerland in 2014. Men were 51.6% affected. 2715 died as a result. Without optimal treatment, up to every second patient remains relevantly disabled. A cerebral stroke and its consequences represent a great burden for those affected and their relatives, but also for the healthcare system and the national economy. The acute treatment of a cerebral stroke patient costs tens of thousands of Swiss francs. If a patient remains disabled, the cost of care and loss of earnings can amount to hundreds of thousands of Swiss francs per patient.

85% of cerebral strokes are ischemic cerebral infarcts (occluded cerebral vessel), 10% are cerebral hemorrhages (ruptured cerebral vessel), and 5% are subarachnoid hemorrhages (caused by a ruptured aneurysm in two-thirds of cases) [1,2].

Education of the population

Of key importance is educating the public on how to recognize a stroke and that an alert should be made immediately by dialing 144. If a stroke is suspected, there is no time to lose. Depending on the collateral circulation, tens of thousands of neurons and many millions of synapses perish per second in ischemic stroke [3].

Approximately 40% of the Swiss population is unaware of stroke symptoms. 35% would wait if they had brain stroke symptoms, 64% would contact emergency 144, and 35% did not even know the number 144 [4].

Acute care of stroke patients

Acute stroke patients should be referred to a stroke center or stroke unit as soon as possible by ambulance or helicopter. Patients treated in specialized centers (stroke centers and/or stroke units) are significantly more likely to survive, regain independence, and have shorter hospitalization [5–7].

Acute treatment aims to support vital functions such as circulation and breathing and to avert the immediate life-threatening situation. Immediately following clinical evaluation, computer and/or magnetic resonance imaging of the brain and vasculature is performed. The treatment procedure is decided on an interdisciplinary basis on the basis of the patient’s medical history, clinical findings and additional diagnostics, but in particular on the basis of imaging (Fig. 1) [8].

Intravenous thrombolysis and endovascular methods.

An occluded cerebral vessel can be rapidly reopened and cerebral blood flow restored with intravenous thrombolysis and/or endovascular methods. We thus have very effective treatments for ischemic stroke at our disposal. Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA, 0.9 mg/kg body weight, 10% of total dose as an intravenous bolus) may be administered in the first four and a half hours after symptom onset. The Number Needed to Treat (NNT) for a functionally favorable treatment outcome increases from 4.5 to 14.1, depending on the latency of treatment onset from <90 minutes to four and a half hours after symptom onset. For occlusions of large vessels in the anterior circulation area, endovascular methods (time window: medicinal six hours, mechanical variable, sometimes up to twelve hours, rarely longer, depending on the tissue still to be saved in multimodal imaging and the clinical findings) are clearly superior to intravenous thrombolysis alone. This was clearly demonstrated by several randomized controlled trials as of spring 2015 [8].

Treatment in stroke centers and stroke units

A stroke unit is a specialized treatment unit of a hospital for stroke patients of any age and any severity. Neurovascular specialists lead a multidisciplinary team of specially trained nurses and therapists (physical therapists, occupational therapists, speech therapists) and social workers. A spatially organized stroke unit is superior to a functional one (i.e., treatment of stroke patients in different wards in the hospital by a team of stroke specialists) [9]. This has monitored and non-monitored treatment beds.

A stroke center includes a stroke unit and extends it to include specific structural neuroradiology and neurosurgical services. The focus is on acute endovascular treatment of cerebral stroke, recanalization of the carotid arteries, elimination of a bleeding aneurysm, and decompressive craniectomy.

The task of the stroke unit includes defined referral steps in the prehospital phase, immediate measures upon hospital admission, rapid and multi-hour/day monitoring of neurological deficits, respiration, cardiovascular function, electrolyte/fluid balance, metabolism, body temperature, and, if necessary, early detection and treatment of secondary clinical deterioration or stroke. Complications. Rapid clarification, therapy of the etiology and secondary prevention are performed. These measures are eminently important for the best possible prevention of the following vascular events. Stage-appropriate mobilization of the patient, detailed patient and family education, psychosocial care, and early initiation of rehabilitative measures by specialized therapists and nurses also play an important role. The average length of stay in the stroke unit is three to five days [5,10,11].

Certification of Stroke Centers and Stroke Units in Switzerland

In 2012, the Swiss Federation of Clinical Neuro-Sciences (SFCNS) received a mandate from the decision-making body of the Intercantonal Agreement on Highly Specialized Medicine (IVHSM) of the Swiss Conference of Cantonal Directors of Public Health (GDK) to certify stroke centers and stroke units with the main goal of creating conditions for comprehensive high-quality care for stroke patients.

In recent years, a working group of the Swiss Stroke Society (SHG) developed professional guidelines for stroke centers and stroke units. These were supported by the Swiss Neurological Society, Swiss Society of Neuroradiology, Swiss Society of Neurorehabilitation, Swiss Society of Neurosurgery, Swiss Society of Clinical Neurophysiology, SFCNS, and the Swiss Society of Intensive Care Medicine, and took into account suggestions from the Swiss Society of General Internal Medicine.

The SFCNS Brain Stroke Commission then developed the profile of requirements i.e. the certification guidelines for stroke centers and stroke units based on the guidelines developed by the SHG working group and based on the guidelines of the European Stroke Organization (ESO). The primary goal was defined as quality assurance in the care of stroke patients, based on professional competence, infrastructure, networking of care providers, organization of the rescue chain, and treatment procedures and monitoring. In addition, the establishment of the Swiss Stroke Registry was initiated, which serves to identify gaps in care as well as quality control. In addition, the SFCNS Brain Stroke Committee was charged with promoting coordination in the areas of continuing education, training, and research.

Currently, there are 10 established stroke centers and 14 certified stroke units in Switzerland. (Fig. 2). In most regions with certified stroke centers and/or stroke units, a significant improvement in the care structure has been observed so far. Detailed information can be found at www.sfcns.ch [5,10–12].

Networking

The SFCNS Brain Stroke Committee and SHG recommend that stroke centers and stroke units form regional networks of stroke care in consultation with each other. Primary care providers, emergency physicians, rescue services, regional hospitals and rehabilitation clinics are involved in this process. Teleradiology and teleradiology offer the possibility to closely network and optimally care for geographically more remote regions with a stroke center and/or stroke unit. This network formation is currently still at different stages of progress in different regions [5].

Conclusion

Brain stroke is one of the biggest health problems worldwide and in Switzerland. The population is still insufficiently educated about how to recognize brain stroke symptoms and how to act as an affected person or in the environment. Interdisciplinary stepwise care and assessment can significantly improve the prognosis of stroke patients. Patients treated in specialized centers (stroke centers and/or stroke units) are significantly more likely to survive, regain independence, and have shorter hospitalizations. Acute treatment, the care structure of patients with cerebral strokes has developed rapidly in recent years. Further optimizations will be sought in the coming years.

Disclosure: Since the authors have written various review articles on the topic of “Assessment and Therapy of Cerebral Stroke Patients” in recent years, certain overlaps of content and style cannot be avoided.

Literature:

1. World Health Organization: Global burden of stroke. Deaths from stroke. www.who.int/cardiovascular_diseases/resources/atlas/en/
2. Swiss Federal Statistical Office: Health. Pocket statistics 2016. www.bfs.admin.ch/bfs/de/home/statistiken/gesundheit.html
3. Saver JL: Time is brain – quantified. Stroke 2006; 37: 263-266.
4. LINK Institute Bern: Method: LINK Day To Day Omnibus (telephone survey). Survey phase: March 7-12, 2016. Target group: 1213 people aged 15 to 79 from German-speaking and French-speaking Switzerland and Ticino. 2016.
5. Arnold M, Sarikaya H, Mono ML: Brain stroke care in Switzerland: where do we stand today? Cardiovasc 2014; 13(5): 18-20.
6. Stroke Unit Trialists’ Collaboration: Organised inpatient (stroke unit) care for stroke (Cochrane Review). The Cochrane Library 2009; 1. Oxford: Update Software.
7. Sun Y, et al: A systematic review and meta-analysis of acute stroke unit care: What’s beyond the statistical significance? BMC Med Res Methodol 2013; 13: 132.
8. Heldner MR, Jung S, Fischer U: Assessment and treatment of cerebral stroke. Primary & Hospital Care 2016; 16: 214-217.
9. Fuentes B, Diez-Tejedor E: Stroke units: many questions, some answers. Int J Stroke 2009; 4: 28-37.
10. Swiss Stroke Society: Stroke Units and Stroke Centers in Switzerland: Guidelines and Requirements Profile. Switzerland Med Forum 2012; 12: 918-922.
11.  Bassetti C, Arnold M, von Below G: Certification of Stroke Centers and Stroke Units in Switzerland. Swiss Medical Journal 2012; 93: 19.
12. Bassetti C, et al: A strong alliance of clinical neurodisciplines. Swiss Medical Journal 2013; 94: 23.

CARDIOVASC 2017; 16(2): 15-19