1. Stroke Care in Europe L. Garcia-Castrillo, MD, SEMES Department of Emergency Medicine University Hospital Marques de Valdecilla Cantabria, Spain

2. L. Garcia-Castrillo Stroke Chain of recovery Pepe PE. Ensuring the chain of recovery for stroke in your community. Acad Emerg Med 1998;5(4):352-8 EMS Response & Transport AlertED Diagnosis&Treatment Identification Dispatch

3. L. Garcia-Castrillo Teaching Points to be Addressed Stroke care in Europe The role of Emergency Medicine in Stroke care

4. Setting L. Garcia-Castrillo

5. Europa 45 Languages 43 Countries 727. Mill. 400 Mill. in EU 15% >65 years

6. L. Garcia-Castrillo Stroke 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

7. L. Garcia-Castrillo Cerebrovascular Disease: Females per 100,000 < 41.64 < 62.64 < 83.64 < 104.6 < 125.6  125.6 Adjusted Death rate

8. L. Garcia-Castrillo Cerebrovascular Disease: Males per 100,000 <58.33 <86.33 <114.3 <142.3 <170.3 ³170.3 Adjusted Death rate

9. L. Garcia-Castrillo Stroke Incidence in Europe Rate per 100.000 Standardized EU ErlagenLondonDijon Incidence rate males 154.4 135-173 95%CI 147.2 133-161 95%CI 131 115-146 95%CI Incidence rate females 123.4 109-137 95%CI 103.5 93-113 95%CI 81.2 70-91 95%CI Charles D.A. Variations in Stroke Incidence and Survival in 3 Areas of Europe. Stroke;31:2074-2079.

10. L. Garcia-Castrillo Relevant 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;

11. L. Garcia-Castrillo Recommendations Emergency 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

12. Results L. Garcia-Castrillo

13. Variations in Outcomes CasesComa %CT %Barthel=20 %Mortality 3 m % UK121412733029 UK216020812036 UK322019711538 UK417220804540 UK525628303156 France21316976317 Portugal665724874831 Hungary16018645622 Spain39316743432 Germany 111527925918 Germany 230215894325 Italy63519884427 Chales DA Wolfe. BIOMED Study of Stroke Care Group. Stroke 1999;30:350-356. L. Garcia-Castrillo

14. European 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

15. L. Garcia-Castrillo Stroke Management in Europe I WE(10) 238 MEE(12) 300 M Incidence2-2.5/1000/y3-5/1000/y Stroke non in Hospital 20%25-60% CT acute50-95%5-50% Hemorrhagic S.15-18%19-35%

16. L. Garcia-Castrillo Stroke Management in Europe II WE(10) 238 MEE(12) 300 M In hospital <3h5-40%20-49% Stroke Units0.37/1 mill1.1/ 1 mill Mortality 30 days 12-20%25-35%

17. L. Garcia-Castrillo Time to Care L. Serrano Latency time and thrombolitic treatment of ischemic ictus. Emergencias 1998; 10:236-238

18. L. Garcia-Castrillo Stroke Emergency Care 15.166 (IST)Systolic BP >160 mmHg %Alert % Italy5580 Netherlands6481 Norway6081 Poland5772 Sweden6584 Switzerland6069 UK5174 IST Collaborative Group. Variations Between Countries in Outcome After Stroke in International Stroke Trial (IST) Stroke 2001;32:1370-77

19. L. Garcia-Castrillo Pre-hospital Stroke Care European Emergency Data ProjectEuropean Emergency Data Project T.Krafft EED Group Comparing European EMS Systems GEOMED geomed@uni- bonn.de

20. L. Garcia-Castrillo

21. EMS Stroke Care Two Systems Comparison P <0.05 EED Project

22. L. Garcia-Castrillo Integrated 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 Austrian

23. L. Garcia-Castrillo Teaching 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

24. L. Garcia-Castrillo Teaching 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

25. L. Garcia-Castrillo Summary 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

26. Questions?