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Stroke Unit- / Stroke Center Care Abstract. About 16'000 people in Switzerland suffer from stroke, each year. In Switzerland, 23 Stroke units and Stroke centers are available to provide individual care for the vast majority of stroke patients. Comprehensive, interdisciplinary therapeutic strategies are standardized and include prevention and therapy of acute complications, expedited diagnostic workup, and early rehabilitation. Stroke units not only reduce mortality and permanent disability in stroke patients, but-alongside advanced recanalization therapies-represent the cornerstone of modern stroke care. The following article gives a detailed overview of core tasks and the current standards of treatment in stroke unit care.

Intracerebral haemorrhage - acute event and chronic disease Abstract. Intracerebral hemorrhage accounts for 10-15% of all strokes and approximately 1'500-2'000 patients per year in Switzerland. Acute treatment by multi-disciplinary experts at certified stroke units and stroke centers is important to provide optimal care. A simple ABC-care bundle (revert anticoagulation, control blood pressure, inform neurosurgeon) decreases poor outcome. Despite a high mortality, one third of patients are functionally independent after intracerebral hemorrhage contradicting widespread pessimism. About 80% of all intracerebral hemorrhage are attributable to different types of cerebral small vessel disease. Relative and absolute risks of recurrent hemorrhage and ischemic stroke differ significantly. Patients with intracerebral hemorrhage are vascular high-risk patients with chronic cerebrovascular disease. Long-term outpatient management should include neurovascular specialists to deal with important decisions (blood pressure management, antithrombotic therapy including anticoagulation, specialized neurorehabilitation to improve neurocognitive deficits, therapy of possible complications such as epilepsy) to provide optimal and individual care to patients. Currently ongoing randomized controlled trials will provide important results in the next years further improving treatment of intracerebral hemorrhage.

Alone a carotid bruit by itself may have limited clinical value. If a physician hears a carotid bruit by auscultation, it may lead to further exams, such as neurovascular ultrasound, what will eventually disclose an asymptomatic stenosis of the carotid artery. For this purpose the auscultation may reach specificity values up to approx. 80 %, indeed with a low sensitivity of about 50 %. In comparison to modern non-invasive diagnostic methods, such Duplex-ultrasound or MR-angiography, the diagnostic performance of the carotid auscultation is low and many authors have suggested not using it any more. However it may be considered, that screening of an otherwise asymptomatic population, that is at low risk of stroke, by technical methods may gender costs, while carotid auscultation is easy to perform and cheap.

Organised care of stroke patients is based on scientific evidence from randomized controlled trials,clinical practice guidelines, and expert consensus. Important features include emergency room facility, the presence of a dedicated stroke unit ward, and a multi-professional team approach. In adherence to diagnostic and therapeutic time-windows, intravenous thrombolytic therapy, periods of automated monitoring, access to decompressive craniectomy and intraarterial thrombolysis or clot removal, early swallowing diagnostics and therapy, early mobilization and rehabilitation are warranted. Further supported discharge and basic aftercare with treatment of risk factors and post-stroke prevention are consequently applied. The main components of the necessary infrastructure, technical equipment, diagnostic pathways, therapeutic interventions, nursing care and multi-professional rehabilitation are to be organised and planned for each institution, who aims to treat stroke patients. This also covers the hospital environment and interactions between the stroke unit and other departments. Quality indicators are also required.

For many decades Vitamin K antagonists were the standard orally given medication for primary and secondary prevention of thromboembolism in patients with atrial fibrillation and stroke. Three compounds, dabigatran, rivaroxaban, and apixaban, are now challenging this well established prescription, as they showed similar effect in preventing thromboembolism with a lower bleeding rate in recently published well designed, controlled randomised, non-inferiority trials. Their advantages of each are to have a fixed dosage, no need to monitor coagulation factors, and fewer interactions with food and other drug intake. The therapeutic effect is estimated overall similar between the three compounds. Who is a candidate for one of the new drugs: Patients with atrial fibrillation and the clear indication to get a future oral anticoagulation are potential candidates to receive one of the new drugs. Further this may be patients where the treatment with Vit K antagonists was difficult to optimise, patients who are not willing to have blood controls done regularly or where blood controls are difficult to obtain. This will also be an option in patients who had a stroke due to atrial fibrillation and had no history of cerebral bleeding. Who should not receive the new anticoagulants: patients who present stable blood coagulation values in the treatment range and no complications should not be merged to the new drugs. Patients with severe renal insufficiency or receiving a medication that interacts with the new drugs (e. g. ketoconazole) or with synthetic heart valves will not be candidates to receive the new drugs.

Life style modification has been shown to reduce stroke risk. In patients with risk factors several drugs have proven their efficacy. The most effective medications are antihypertensives, antidiabetics, statins and antithrombotics. In the prevention of recurrent stroke in patients with a noncardioembolic ischemic stroke antiplatelet agents are used. Aspirin or a combination aspirin/dipyridamol are the first-line agents. Clopidogrel is recommended for patients with aspirin intolerance, several risk factors or recurrent cerebrovascular events. Warfarin has demonstrated efficacy in stroke prevention in patients with cardioembolic stroke, cerebral venous thrombosis and antiphospholipid antibody syndrome. Other, less well established indications for warfarin in the secondary prevention of stroke are: symptomatic intracranial artery stenosis; large aortic atheroma and extracranial carotid or vertebral artery dissection.

We report on a 77-year-old man who was suffering from pain in the chest, which was initially circumferential, along with paresthesia in his left leg, a fluctuating spastic paraparesis and dissociated sensory disturbances caudal to segment T8. In his history, he had received an aortoiliac Y-prothesis for a ruptured retroperitoneal intrarenal aortic aneurysm 39 months previously. Diagnostically, magnetic resonance imaging of the spine revealed advanced degenerative changes with osseous stenoses in segments C5-6 and less pronounced on C6-7. There were no signs of myelopathy. The results of the computerized tomogram of the neurocranium were consistent with the patient's age. The computerized tomogram of the chest and abdomen revealed a left outward bulge in the descending branch of the thoracic artery that was almost 20 mm in length. Based on the differential diagnosis, this was interpreted as an aneurysmatic sacculation with wall thrombosis or a locally circumscribed intramural hematoma upon dissection. Electrophysiologic testing by conduction of magnet-evoked potentials showed no lesions of the pyramidal tract to the extremities above the lumbosacral level. Lumbosacral stimulation evoked potentials on both sides whereas cortical stimulation did not. Based on the patient's history, the clinical findings and additional tests, the diagnosis of anterior spinal artery syndrome was rendered although its cause could not be determined with certainty. The previous transitory ischemic attack and the varying course of the disease is very exceptional in the presented case.