Stroke Care in EuropeStroke Care in Europe

L. Garcia-Castrillo, MD, SEMES

Department of Emergency Medicine

University Hospital Marques de Valdecilla

Cantabria, Spain

L. Garcia-Castrillo

Stroke Chain of recoveryStroke Chain of recovery

Pepe PE. Ensuring the chain of recovery for stroke in your community. Acad Emerg Med 1998;5(4):352-8

EMS EMS Response & Response & TransportTransport

AlertAlert

EDED

DiagnosisDiagnosis&&

TreatmentTreatmentIdentificatioIdentificationn

DispatchDispatch

L. Garcia-Castrillo

Teaching Points to be AddressedTeaching Points to be Addressed

• Stroke care in Europe

• The role of Emergency Medicine in Stroke care

SettingSetting

L. Garcia-Castrillo

L. Garcia-Castrillo

EuropaEuropa

• 45 Languages

• 43 Countries

• 727. Mill. 400 Mill. in EU

• 15% >65 years

L. Garcia-Castrillo

Stroke in EuropeStroke in Europe

• 3rd Cause of death

• 1 million of new cases, with 400.000 casualties per year

• First cause of disability

• Accounts 3-5% of total health cost

• Great differences in cost and results

L. Garcia-Castrillo

Cerebrovascular Disease: FemalesCerebrovascular Disease: Females

per 100,000           < 41.64

          < 62.64

          < 83.64

          < 104.6

          < 125.6

          125.6

AdjustedAdjusted

Death rateDeath rate

L. Garcia-Castrillo

Cerebrovascular Disease: MalesCerebrovascular Disease: Males

per 100,000           < 58.33

          < 86.33

          < 114.3

          < 142.3

          < 170.3

          ³ 170.3

AdjustedAdjusted

Death rateDeath rate

L. Garcia-Castrillo

Stroke Incidence in EuropeStroke Incidence in Europe

Rate per 100.000 Standardized EU

Erlagen London Dijon

Incidence rate males

154.4135-173 95%CI

147.2133-161 95%CI

131115-146 95%CI

Incidence rate females

123.4109-137 95%CI

103.593-113 95%CI

81.270-91 95%CI

Charles D.A. Variations in Stroke Incidence and Survival in 3 Areas of Europe. Stroke;31:2074-2079.

L. Garcia-Castrillo

Relevant ContributionsRelevant Contributions

• WHO Task Force on Stroke and other Cerebrovascular Disorders, 1989;

• European Federation of Neurological Societies Task Force, 1997;

• European Ad Hoc Consensus Group, 1996;• Pan European Consensus Meeting on Stroke

Management, 1995;• EUSI European Federation of Neurological

Societies (EFNS), European Neurological Society (ENS) and European Stroke Council (ESC). 2000;

L. Garcia-Castrillo

Recommendations Recommendations Emergency AreaEmergency Area

• Education • Stroke symptoms• EMS use

• Identify Stroke as an emergency medical problem• Use protocols to identify stroke symptoms in the Dispatch

Center• Reduce delays in the prehospital phase • Transport to a Hospital with an adequate Stroke Unit

• ED • Rapid evaluation• Treat Medical Problems

ResultsResults

L. Garcia-Castrillo

Variations in OutcomesVariations in OutcomesCases Coma % CT % Barthel=20 % Mortality 3 m %

UK1 214 12 73 30 29

UK2 160 20 81 20 36

UK3 220 19 71 15 38

UK4 172 20 80 45 40

UK5 256 28 30 31 56

France 213 16 97 63 17

Portugal 6657 24 87 48 31

Hungary 160 18 64 56 22

Spain 393 16 74 34 32

Germany 1 1152 7 92 59 18

Germany 2 302 15 89 43 25

Italy 635 19 88 44 27

Chales DA Wolfe. BIOMED Study of Stroke Care Group. Stroke 1999;30:350-356. L. Garcia-Castrillo

L. Garcia-Castrillo

European Stroke Care InventoryEuropean Stroke Care Inventory

• 30 EFNS member countries collect information on acute stroke care

• 22 countries were represented

• Information represents national data

M. Brainin. Acute neurological stroke care in Europe: Results of the European Stroke Care Inventory Eu J Neurol 2000;7:5-10

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Stroke Management in Europe IStroke Management in Europe I

WE(10) 238 M EE(12) 300 M

Incidence 2-2.5/1000/y 3-5/1000/y

Stroke non in Hospital

20% 25-60%

CT acute 50-95% 5-50%

Hemorrhagic S. 15-18% 19-35%

L. Garcia-Castrillo

Stroke Management in Europe IIStroke Management in Europe II

WE(10) 238 M EE(12) 300 M

In hospital <3h 5-40% 20-49%

Stroke Units 0.37/1 mill 1.1/ 1 mill

Mortality 30 days

12-20% 25-35%

L. Garcia-Castrillo

Time to CareTime to Care

40%

18%

29%

13%

0-3 h

3-6 h

6-26 h

>24 h

L. Serrano Latency time and thrombolitic treatment of ischemic ictus. Emergencias 1998; 10:236-238

L. Garcia-Castrillo

Stroke Emergency CareStroke Emergency Care

15.166 (IST) Systolic BP >160 mmHg % Alert %Italy 55 80

Netherlands 64 81

Norway 60 81

Poland 57 72

Sweden 65 84

Switzerland 60 69

UK 51 74

IST Collaborative Group. Variations Between Countries in Outcome After Stroke in International Stroke Trial (IST) Stroke 2001;32:1370-77

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Pre-hospital Stroke CarePre-hospital Stroke Care

• European European Emergency Emergency Data ProjectData Project

T.Krafft EED Group Comparing European EMS Systems GEOMED geomed@uni-bonn.de

L. Garcia-CastrilloL. Garcia-Castrillo

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EMS Stroke Care Two SystemEMS Stroke Care Two Systemss ComparisonComparison

CVA in two EMS

23,7

23,8

23,9

24

24,1

24,2

24,3

Birmingham Bonn

ME

ES

0

0,2

0,4

0,6

0,8

1

ME

ES

B-M

EE

S A

MEES A

Dif B-AP <0.05

EED Project

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Integrated Network Stroke CareIntegrated Network Stroke Care

• Period 1998-2000• Cases 2313• Arrive with ALS unit

doctor 27%• At hospital < 3h 57%• CT < 30 min 54%• Thrombolysis 4.1%• 3 months mortality 12.9%

Steiner MM. The quality of acute stroke units on nation-wide level: the Austrian Stroke Registry for acute stroke units. Eur J Neurol 2003;4:353-60

AustrianAustrian

L. Garcia-Castrillo

Teaching Points to be AddressedTeaching Points to be Addressed

• Stroke care in Europe

• There are important geographical differences between areas; in incidence, process of care and outcomes

• Different outcomes can be explained, in part, due to the level of resources available

L. Garcia-Castrillo

Teaching Points to be AddressedTeaching Points to be Addressed

• The role of Emergency Medicine in Stroke care• EMS is a fundamental part of Stroke care

facilitating; access, high level pre-hospital care and integration with in hospital systems

• EMS-ED must be part of the concept of Integral Stroke care

L. Garcia-Castrillo

SummarySummary

• The role of Emergency Medicine in the pre-hospital and in the ED is clearly defined in guidelines and consensus documents

• More high quality research is needed to clarify the best model of care

Questions?Questions?