title: Beneficial effects of a semi-intensive stroke unit are beyond the monitor.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors: Neurocenter of Southern Switzerland, Neurology, Lugano, Switzerland.
authors: Carlo W
authors: CW
authors: Cereda
authors: Paul M
authors: PM
authors: George
authors: Lorenzo S
authors: LS
authors: Pelloni
authors: Paola
authors: P
authors: Gandolfi-Decristophoris
authors: Michael
authors: M
authors: Mlynash
authors: Lucia
authors: L
authors: Biancon Montaperto
authors: Costanzo
authors: C
authors: Limoni
authors: Vesna
authors: V
authors: Stojanova
authors: Roberto
authors: R
authors: Malacrida
authors: Claudio
authors: C
authors: Städler
authors: Claudio L
authors: CL
authors: Bassetti
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000150:complications / Q000401:mortality*; D016022:Case-Control Studies; D002543:Cerebral Hemorrhage / Q000150:complications / Q000401:mortality*; D015331:Cohort Studies; D005260:Female; D006757:Hospital Units; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D020521:Stroke / Q000209:etiology / Q000401:mortality*; D055815:Young Adult