Acute Stroke Management: Brain Protection and Reperfusion
Cerebrovasc Dis 2009;27(suppl 1):140147
DOI: 10.1159/000200452
Relevance of Stroke Code, Stroke Unit and Stroke
Networks in Organization of Acute Stroke Care
The Madrid Acute Stroke Care Program
Mara Alonso de Leciana-Cases a Antonio Gil-Nez b Exuperio Dez-Tejedor c
Stroke Unit, Department of Neurology, a Ramn y Cajal University Hospital, b Gregorio Maran University Hospital,
and c La Paz University Hospital, Madrid, Spain
Key Words
Acute stroke Stroke network Medical care Attention
chain Stroke code Care resources Stroke management
Abstract
Stroke is a neurological emergency. The early administration
of specific treatment improves the prognosis of the patients.
Emergency care systems with early warning for the hospital
regarding patients who are candidates for this treatment
(stroke code) increases the number of patients treated. Cur-
rently, reperfusion via thrombolysis for ischemic stroke and
attention in stroke units are the bases of treatment. Health-
care professionals and health provision authorities need to
work together to organize systems that ensure continuous
quality care for the patients during the whole process of
their disease. To implement this, there needs to be an appro-
priate analysis of the requirements and resources with the
objective of their adjustment for efficient use. It is necessary
to provide adequate information and continuous training
for all professionals who are involved in stroke care, includ-
ing primary care physicians, extrahospital emergency teams
and all physicians involved in the care of stroke patients
within the hospital. The neurologist has the function of co-
ordinating the protocols of intrahospital care. These organi-
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Published online: April 3, 2009
zational plans should also take into account the process be-
yond the acute phase, to ensure the appropriate application
of measures of secondary prevention, rehabilitation, and
chronic care of the patients that remain in a dependent state.
We describe here the stroke care program in the Community
of Madrid (Spain). Copyright 2009 S. Karger AG, Basel
Care for the acute stroke patient has changed radical-
ly in the past few years. It continues to evolve to include
improvements not only in the scientific-technical re-
sources for diagnosis and treatment, but also in working
towards improving the systems of organization of care
with the objective of ensuring equitable access to these
resources by all who need them. There are essentially two
reasons underlying this evolution. Firstly, stroke is a dis-
ease with a high incidence and prevalence and is the main
cause of incapacity in the adult. Secondly, it is well docu-
mented that it is a neurological condition that is amena-
ble to effective treatment; the earlier the patient is evalu-
ated by a specialist and the earlier the specific treatments
are applied, the better the outcome. As such, stroke con-
stitutes an important problem of public health, with ter-
rible consequences that can be palliated, at least in part,
Maria Alonso de Leciana, MD, PhD
Unidad de Ictus, Servicio Neurologa, Hospital Universitario Ramn y Cajal
Ctra de Colmenar Km 9,100
ES28034 Madrid (Spain)
E-Mail mariaalonsoleci@telefonica.net
if the appropriate treatments are administered in time.
This makes it necessary that the healthcare resources are
organized efficiently, the objective being to ensure access
to the treatments and their correct application.
Stroke as a Public Health Problem
Throughout the world, but especially in the industrial-
ized countries, stroke is a very frequent disease. The rates
of incidence vary between 200 and 600 cases/100,000 cit-
izens/year, depending on the epidemiological studies in
different geographical areas. This implies that the disease
is the second, or even the first, most common cause of
death in many of these countries [14]. In Spain, the cur-
rent data show rates of incidence of stroke between 140
and 169 cases/100,000/year in the case of women and be-
tween 170 and 364 cases/100,000/year in men [5, 6]. The
incidence increases with age, such that in women 165
years of age the incidence is 510/100,000/year and in men
it is 704/100,000/year [6]. These rates increase up to 1,493
and 2,371 in females and males, respectively, above 70
years of age [5]. In Spain, the prevalence of stroke in indi-
viduals 165 years of age is approximately 6% in females
and 7% in males. Given the progressively aging Spanish
population, it is forecast that, at the current rhythm, there
will be 742,500 individuals affected by stroke by the year
2030 and, by the year 2050, the level will reach 1,129,000;
a highly significant number, especially when taking into
account that half of them will have a certain grade of re-
sidual incapacity. Hence, with the increase in life expec-
tancy and an aging population, a progressive increase in
hospitalization will occur as a consequence of stroke [7].
In Spain, stroke is the most common cause of death in
women and the first or second most common cause of
death in men, depending on the different Autonomous
Communities [7]. The mortality rates from stroke in the
year 2006 were 74,657/100,000 (63,675 in males and 85,248
in females) compared to 84,169/100,000 from acute myo-
cardial infarct and other ischemic heart diseases (97,615
in males and 71,096 in females) [7]. Further, it is the high-
est cause of incapacity in the adult (up to 53% of patients
are left with a grade of dependence) and the second high-
est cause of dementia (between 30 and 50% of patients
have cognitive deterioration after stroke) [8]. This implies
an important consumption of resources during the acute
phase (approximately 4% of the healthcare budget) and
subsequently, as well, in secondary prevention measures
or rehabilitation. This does not include the long-term in-
direct costs derived from the necessary measures to pro-
Organization of Acute Stroke Care
vide care for these dependent patients (cessation of pro-
ductive labor not only of the patient but of the family
member providing care, or contracting a nonfamily carer
if necessary, adapting the home to the patients incapacity,
etc.) [911].
Hence, it would seem logical to invest in resources and
in organization to improve the healthcare provision for
these patients in all possible phases of the disease. It is
important to implement measures of prevention and, as
well, to ensure adequate emergency access to the treat-
ment available in the acute phase. The objective is that all
the patients who suffer a stroke have a better opportunity
of reducing the cerebral damage that they suffer and, as
such, the probability of suffering subsequent invalidity.
Stroke as a Treatable Neurological Emergency
Awareness of stroke as a neurological emergency is
based on the demonstration that the application of ap-
propriate therapeutic measures improves the clinical
evolution of the patients, and that these treatments are
more efficacious the earlier they are administered [12,
13]. The majority of advances have been developed in the
field of cerebral ischemia, but hemorrhages, as well, can
benefit from appropriate management during the acute
phase. Contrary to what has been thought for some con-
siderable time, cerebral damage after stroke is not instan-
taneous, but rather develops progressively over a pro-
tracted period. This offers the possibility of applying
treatments directed towards inhibiting the different
mechanisms underlying the lesions in order to reduce the
gravity of the consequences [1417]. These mechanisms
are becoming better known not only with respect to the
action but also to the time at which the damaging effects
are produced [18]. The inhibition of these mechanisms
using different therapeutic strategies is described as neu-
roprotection [19]. This is a wide concept that brings to-
gether different therapeutic aspects, from reperfusion of
the ischemic tissue to maintenance of tissue homeostasis
and to the application of drugs with inhibitory action on
the different steps in the cascade of cell death that is set
in motion after stroke. Of the treatments applied in the
acute phase of stroke, two have been demonstrated to be
beneficial with a class I evidence [20]: stroke units (SUs)
and intravenous thrombolysis with rtPA within the first
3 h from the onset of symptoms [12, 21, 22]. Recently it
has been shown that reperfusion therapy with iv rtPA is
also beneficial when administered up to 4.5 h from onset
of symptoms [23, 24]. Both of these treatments have been
Cerebrovasc Dis 2009;27(suppl 1):140147 141
well documented as being efficacious in improving the
clinical evolution of patients who suffered an ischemic
stroke.
Thrombolysis is a cost-effective treatment. There is no
significant increase in the costs of managing the acute
process and the probability of becoming incapacitated is
reduced. The patient has a better quality of life and there
is a reduction in the long-term healthcare costs [25]. How-
ever, thrombolytic treatment is restricted to patients with
ischemic stroke, and of these, only a small percentage of
around 1015% [12, 26, 27] can benefit from the treatment.
This is due, in part, to the contraindications and risks, but
also because the therapeutic window is very narrow and
there are often delays in the patients transfer to, and treat-
ment at, centers capable of administering this treatment.
The SU offers a benefit to the majority of patients as
the treatment offered in this type of specialized care unit
improves morbido-mortality and reduces the probability
of suffering complications and dependency, together
with a favorable cost-efficacy balance. This benefit is de-
rived from noninvasive neurological monitoring and
from the application of protocols of general care directed
towards maintaining homeostasis, and the essential ob-
jective is to ensure a nonpharmacological neuroprotec-
tion as well as the correct application of specific treat-
ments [2831].
However, it is clear that these efficacious treatments
are not available for the whole patient population. A vari-
able percentage of the patients who suffer a stroke do not
have access to these facilities and are dependent on the
geographic zones in which they reside. This phenomenon
has been described as a postcode lottery. Some hospitals
that deal with stroke patients do not fulfill the minimum
requirements to conduct thrombolytic treatment. These
include the lack of specialists trained in the management
and treatment of stroke, and/or the technical resources
for an appropriate diagnosis and care of the possible com-
plications that could arise. Many have neither dedicated
SUs nor a minimum level of the necessary healthcare re-
sources such as cranial computed tomography during the
first 24 h, or an on-call neurologist [32, 33].
The Importance of Urgent Transport to the Hospital:
The Stroke Code
It is important to attend to stroke patients early be-
cause the appropriate treatment needs to be applied as
early as possible if a good outcome is to be achieved.
Hence, it is important to urgently transfer the patient to
142 Cerebrovasc Dis 2009;27(suppl 1):140147
the center capable of administering these treatments.
One of the main reasons for excluding the thrombolytic
treatment option is the delay in transferring the patient
to the specialist care unit (the therapeutic window has
lapsed by the time the patient is seen by the neurologist).
This is also related to the patient not seeking emergency
attention as a consequence of not knowing and not rec-
ognizing the symptoms of stroke and not being aware of
the seriousness of the disease [34, 35]. Lack of awareness
is very easily resolved via information campaigns for the
general population. A good example is the celebration of
a National Stroke Awareness Day an initiative pio-
neered in Spain where this day is celebrated annually
since the year 1999 with several activities organized that
raise awareness in the communication media.
Once the clinical assistance is solicited, it is necessary
that the extrahospital emergency services react quickly
in coordination with the assigned hospital centers that
have all the resources necessary to attend to patients with
stroke in the acute phase. The acute-phase stroke needs
to be recognized as urgent so as to identify those patients
who may be candidates for specific treatments, and to
assign consensus protocols that place the patient in the
best situation for the latest treatment. The prehospital-
ization procedure is based on the knowledge of the emer-
gency, the objective being to organize transport of the
patient to the center with the appropriate capability (neu-
rologist on call, SU and the competence to apply specific
treatments such as thrombolysis) which, together with
alerting the emergency services and on-call neurologist
to facilitate rapid attention for these patients, is termed
the extrahospital stroke code. This code reduces the time
to patient care and the delay in administering specific
treatment [3639]. Also, the hospital emergency service
needs to be organized to attend to this type of patient to
reduce the delay as much as possible. The protocols di-
rected towards this objective are termed intrahospital
stroke code and have also been shown to be very effica-
cious [27].
SU, Stroke Team and Stroke Comprehensive Centers
Once the patient is in the hospital, it is necessary to
rapidly evaluate his/her neurological status with the ob-
jective of applying the appropriate diagnostic-therapeu-
tic protocols in the hyperacute phase, which would max-
imally reduce the cerebral damage produced after stroke,
as well as clarifying the etiology so that the strategy of
secondary prevention and rehabilitation may be imple-
Alonso de Leciana-Cases /Gil-Nez /
Dez-Tejedor
mented. Specialist attention is required during the entire
disease process. The SU has been demonstrated to be the
organizational model for most of the efficacious stroke
care provision [2831].
SUs are geographically restricted structures. They de-
pend on the neurology service and are dedicated to the
specific care of patients with stroke. They need to be co-
ordinated and staffed by neurologists who are experts in
cerebrovascular disease and who rely on the collaboration
with other related clinical specialties (cardiology, vascu-
lar surgery, neuroradiology, neurosurgery, rehabilitation,
emergency medicine, etc.). Also, there needs to be a col-
laborating physiotherapist and social worker so that early
physiotherapy/rehabilitation can be initiated. There needs
to be continuous noninvasive monitoring by a trained
nurse. The recommended nurse-to-patient ratio is 1: 6.
Personnel and diagnostic services need to be available
24 h a day, together with protocols and clinical routes for
the evidence-based management of the patients. The num-
ber of beds in the SU should be sufficient to accommodate
the needs of the hospitals catchment population [40].
The best results of the SU in relation to the attention
provided in conventional clinics are due to better adher-
ence right from the start to the protocols of care, and to
continuous monitoring. The consequences are early de-
tection of complications and rapid therapeutic interven-
tion, resulting in more efficacious neuroprotection. The
admission of the patient to the SU decreases mortality
and morbidity, and/or functional dependence. The ben-
efit persists after adjustment for age, gender, severity of
neurological deficit at admission, and differences in etio-
logical subtypes of stroke [41]. Apart from the clinical
advantages related to improvement in the clinical evolu-
tion of the patients, the care provided in the SU improves
the indicators of care quality (mean hospital stay, hospital
readmission, mortality, and the need for institutionaliza-
tion) and significantly reduces the economic costs of
stroke care provision [4244].
In relation to the SU, the stroke team (ST) is the basic
model of specialist neurological care oriented towards as-
sessment and specific treatment of the patients with
stroke who, because of their clinical characteristics, do
not necessarily depend on complex technologies, but
nevertheless benefit from evidence-based protocols and
continuous follow-up. The ST is defined as a multidisci-
plinary group of specialists with a specific organization-
al function, which collaborates in the diagnosis and treat-
ment of stroke patients coordinated by a neurologist with
expertise in the field of cerebrovascular disease, and uses
systematized stroke care protocols outside of a geograph-
Organization of Acute Stroke Care
ically delineated SU structure and without continuous
monitoring. The ST is an alternative for centers that do
not have their own SU due, mainly, to the low require-
ment and low volume of patients which does not justify
the costs of setting up a dedicated SU in an economic en-
vironment in which resources are limited. Nevertheless,
these hospitals do receive stroke patients, and therefore
quality care needs to be provided [45, 46].
Finally, some techniques for diagnosis and/or treat-
ment are particularly complex and costly and, as such,
cannot be made available in all hospitals/centers, but all
patients should have access to the facilities in the better
equipped Stroke Comprehensive Centers via protocols
established in their own hospitals [46].
Strategies of Health Provision Organization to
Improve Stroke Care
The Declaration of Helsingborg of 1995 and its 2006
update [47, 48] are consensus documents developed by
experts of different scientific societies which established
the recommendations for Europe. The recommenda-
tions state that all patients with stroke should have easy
access to treatments in the acute phase that have been
demonstrated to be efficacious and, specifically, to the
care available in the SU, and to subsequent rehabilita-
tion and secondary prevention strategies. Also, the con-
sensus established specific objectives to be achieved in
relation to the improvement in the clinical evolution of
the patients, and the measures necessary to achieve
them. This document has a great potential to influence
the politics of healthcare provision of the different coun-
tries, given the trustworthiness of the different scien-
tific societies that were signatories to the document and
the level of evidence that backs the recommendations.
Hence, many countries and/or communities have al-
ready commenced the planning of healthcare networks
with the objective of ensuring appropriate and equitable
health care for all patients, adapted to the strategies,
characteristics and necessities specific to each popula-
tion [46, 4952].
One of the reasons why scientific-technical advances
in the field of medicine are not sufficiently well imple-
mented and effective in populations is the lack of organi-
zational structures to facilitate their application and
equal access for all those needing the treatment, indepen-
dent of socioeconomic level or place of residence. It is
necessary to have these advances brought to the attention
of those responsible for healthcare administration. This
Cerebrovasc Dis 2009;27(suppl 1):140147 143
could be in the form of evidence-based guidelines of clin-
ical practice, and by ensuring a coordinated working re-
lationship between administration and healthcare pro-
fessionals. The objective would be to assess the require-
ments resulting from putting the recommendations into
clinical practice and to ensure assignment of resources
and budget of the hospitals that provide attention for
these patients according to those requirements.
As commented earlier, stroke is a frequent and devas-
tating neurological disease and thus generates high social
and healthcare costs. However, the severe consequences
of this disease could be reduced if the available appropri-
ate treatments were applied. As such, it is a good example
of the need to establish efficacious systems of healthcare
provision that ensures emergency attention for all pa-
tients in centers with the specialist facilities for appropri-
ate care over the whole process of the disease.
Acute Stroke Care Program in the Community of
Madrid
An analysis of the resources available for stroke care
in the Community of Madrid (CM) showed that in the
year 2004, there were only 4 SUs, which implies that
3,391,932 citizens did not have an SU available (58.43% of
the total population), i.e. only a minority of the Madrid
population (41.57%) had access to this highly efficacious
healthcare resource. An on-call neurologist was only
available in 50% of the 14 public hospitals providing care
for acute stroke patients. This implies that 1,465,924 citi-
zens, i.e. 25% of the CM population, received attention in
hospitals in which there was no on-call neurologist and
did not have access to emergency specialist attention
[53].
When a cost-effectiveness analysis compared the situ-
ation of the 4 existing SUs with that of an alternative or-
ganizational strategy that contemplates the setting-up of
10 SUs in specific hospitals in the CM, the results showed
that the alternative strategy would cost EUR 28,789,170,
while the existing setup costs EUR 33,994,169, i.e. a sav-
ing of EUR 5,204,999 would be produced each year. The
alternative model would avoid 103 deaths and 277 depen-
dencies a year while gaining 380 independencies. The
cost of avoiding one death is EUR 50,432, that of avoiding
one dependency is EUR 18,788, and the gain of one inde-
pendency is EUR 13,689, i.e. the model indicates that the
new proposal is cost-effective; these outcomes were main-
tained throughout the sensitivity analyses conducted
[53].
144 Cerebrovasc Dis 2009;27(suppl 1):140147
Table 1. Stroke code protocol
Objectives
Time from the start of the symptoms to the hospital no
longer than 2 h
Time from notification to the hospital less than 1 h
Greatest alacrity possible under all circumstances
Criteria for inclusion
Time from the start of the symptoms to the hospital <6 h
Baseline status of the patient: modified Rankin Scale score 2
Neurological focal deficit present at the time of diagnosis:
presence of any symptom suspicious of stroke
1 Numbness, weakness or marked one-sided paralysis of the
face, arm or leg
2 Difficulty in speaking or understanding
3 Sudden loss of vision in one or both eyes
4 Intense headache, marked and without apparent cause,
associated with nausea and vomiting (not attributable
to other causes)
5 Difficulty in walking, loss of equilibrium or coordination
Criteria for exclusion from the stroke code
1 The diagnostic criteria of ictus not fulfilled
2 More than 6 h of symptom evolution
3 Coma <9 on the Glasgow Scale
4 Poor general clinical status with hemodynamic instability
refractory to basic support measures
5 Terminal disease and/or dementia
The extrahospital stroke code was established in the
year 2006 by the Healthcare Council of the CM under the
central coordination of the Emergency Medical Service
of Madrid (SUMMA-112). The established structure was
rationalized with respect to the existing resources so as
to enable patients with stroke to receive attention in the
healthcare centers that had SU available (table 1) [54].
The Healthcare Council, following the recommenda-
tions of the General Directorate of the Madrid Health
Service and the Sub-Directorate of Specialist Care, and in
collaboration with a panel of expert neurologists of the
Stroke Forum of the Madrid Association of Neurology,
developed a Plan for Stroke Care. This integrated plan
incorporates all the aspects necessary to ensure correct
care for all patients who suffer a stroke, and to make
available all the healthcare resources and measures nec-
essary in an equitable manner. The plan begins with in-
formation provided to the patients, doctors and health-
care professionals of the primary care service, extrahos-
pital emergency services, hospital emergency service, and
neurology departments of the hospitals that are respon-
sible for the care of the stroke patient. Included in the plan
Alonso de Leciana-Cases /Gil-Nez /
Dez-Tejedor
are the emergency transport systems to the hospital and
the management of the emergency service (Extra- and
Intrahospital Stroke Code). Different levels of healthcare
provision are established (hospital with STs, hospital
with SUs, and referral hospital) with a plan for inter-
change or sharing of resources, i.e. a network of stroke
care provision. The plan also incorporates patient man-
agement after the acute phase and includes measures of
prevention, rehabilitation and social reintegration [52
55].
The plan is already in the developmental stage. In
2007, the 4 existing SUs were updated and a new SU was
created. It is envisaged that in the year 2008, 3 more SUs
will be created, bringing the total to 8. Under consider-
ation is the establishment of STs in the rest of the Madrid
hospitals that are not equipped with SU so as to establish
a good network of healthcare cover for acute stroke in the
whole of the CM.
Implementing an overall strategic plan in a specific
healthcare area, the function of which is to coordinate
each section of the health provision network, ensures pa-
tient access to specific care according to the specific clin-
ical requirements in each stage of the disease. Patients
with !6 h since the stroke event, and particularly those
within 3 h of the event who would especially benefit from
reperfusion techniques, should, by activating the stroke
code, be transferred to a hospital with an SU in which the
necessary facilities are available. Those patients with a
longer time since the stroke event, or those who are not
amenable to the complex therapies but nevertheless re-
quire specific care, will be transferred to hospitals with
ST, i.e. the strategic plan puts in place interhospital pro-
tocols for those patients who would benefit from them.
After the acute phase, the resources necessary for the sub-
sequent care of the patient need to be organized to ensure
that appropriate measures of secondary prevention are
implemented and that there is outpatient follow-up by the
specialist as well as by the primary care physician. There
needs to be access to rehabilitation centers for those pa-
tients who need this assistance, and centers for chronic
care or home help for those patients who are in a state of
dependence. The implementation of these coordinated
systems of health care requires that all the healthcare pro-
fessionals involved are properly informed and trained in
order to achieve a correctly functioning network that
continues to provide care for the stroke patient in all stag-
es of the disease.
Disclosure Statement
None of the authors has any conflict of interest in relation to
the subject of this publication.

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