Stroke is a heterogeneous cerebrovascular disorder that is a major cause of death and disability in the industrialised world. Anecdotal clinical evidence and expert opinion has suggested that organised stroke care results in better patient outcomes compared with care provided in general medical units, although results from randomised control trials (RTC) have been inconclusive. However in 1993, a meta-analysis of 10 RTCs of patients assigned to acute care stroke units (ACSUs) versus routine ward care reported a reduction of early mortality rate of 28% for those assigned to ACSUs. In 1997, the Stroke Unit Trialist Collaboration conducted a meta-analysis of 18 RTCs and concluded that organised inpatient care is effective in reducing death, dependency and institutionalisation after stroke. The analysis also found that age, gender and stroke severity should not be restricting factors to stroke unit care because all categories benefit from organised stroke care. These important studies establish the efficacy of organised stroke care. A variety of stroke care models are used throughout the world. The distinguishing characteristic, regardless of model, is the organisation of a specialised, coordinated, multidisciplinary team of professionals who are interested and knowledgeable about stroke, and who provide comprehensive assessment, management and rehabilitation services for stroke patients. This article discusses a model of a dedicated ACSU used in some centres in the US. Dedicated ACSUs are gaining prominence because of the emergence of time-sensitive therapeutic strategies such as thrombolytics. The major organisational components of the ACSU include: policies and procedures; protocols, guidelines, and pathways; discharge planning; patient/family education; staff education; research; and outcomes management. Leadership in stroke care includes creating a comprehensive programme of primary and secondary prevention and a comprehensive stroke recovery programme. Primary prevention strategies are supported through education of the public and health professionals about stroke risk factor identification and modification, and information about `brain attacks'. A comprehensive stroke recovery programme creates a seamless continuum of care of timely emergency medical transport to an appropriate healthcare facility at the time of stroke, comprehensive acute, subacute and long term care, and secondary prevention strategies. In the future, the challenge for practitioners will be to combine contemporary models of acute stroke care and the characteristics of care that have been shown to be effective in randomised trials.
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