Acute stroke care pathway in Hong Kong West Cluster

Abstract

Stroke is not an accident but a brain attack. It ranks second among the world’s leading causes of death. Among all adult neurological diseases, stroke ranks number one in frequency and importance. Ischaemic stroke accounts for about 80% of all strokes and haemorrhagic strokes for about 20%. Annually more than six million people die of stroke in the world. In addition, stroke survivors outnumber stroke deaths by three folds, and persistent neurological disability of varying degrees is common among stroke survivors. An unstable ischaemic penumbra allows acute therapy for ischaemic stroke and thus stroke is a true neurological emergency. Time window for intravenous thrombolysis has recently been extended to 4.5 hours after onset, and endovascular thrombolysis or thrombectomy has a time window of 6 hours. Managing stroke patients in a stroke unit will improve outcome and reduce mortality. The ‘time is brain’ concept demands acute stroke care and avoidance of delays. Pre-hospital delay should be tackled via public education on recognising stroke symptoms and appropriate attitudes to acute stroke as well as use of emergency ambulance service. In-hospital delay is due to a failure to identify stroke as an emergency, inefficient in-hospital transport, delayed medical assessment, delay in imaging and uncertainty in administering thrombolysis. There is much room for improvement of acute stroke care in Hong Kong. In the Hong Kong West Cluster, neurologists, neurosurgeons, radiologists, emergency physicians, rehabilitation specialists, nurses and administrators have worked together to organise an acute stroke care pathway. The pathway will run 24 hours a day and for 7 days a week and involve rapid triage of patients presenting with stroke or transient ischaemic attack at the Emergency Department, immediate neuroimaging, direct admission to a comprehensive acute stroke centre with intensive monitoring, joint management by neurologists and neurosurgeons, protocol-driven administration of thrombolysis, consideration of endovascular or neurosurgical interventions, subsequent management in designated stroke beds and early commencement of rehabilitation.