Stroke Unit (Neurovascular Unit)
What is a Stroke Unit (Neurovascular Unit)?
The Stroke Unit (or Neurovascular Unit) is a specialized hospital facility dedicated exclusively to the acute phase management of patients who have suffered a stroke. It is a neurovascular intensive care unit that reduces mortality and neurological sequelae through:
- Close clinical and neurological monitoring (24/7).
- Stroke treatment via intravenous thrombolysis (clot dissolution) within 4.5 hours of symptom onset.
- Treatment via mechanical thrombectomy (clot removal by catheterization) up to 6 hours, or even 24 hours for selected patients.
- A multidisciplinary team: vascular neurologists, interventional neuroradiologists, intensivists, physiotherapists, speech therapists, occupational therapists, psychologists, and social workers.
- Immediate rehabilitation and secondary prevention (antihypertensive, antiplatelet or anticoagulant, statin therapy).
In Tunisia, several Stroke Units are accredited and operate 24/7, with standards close to European recommendations (ESO – European Stroke Organisation).
Why is Stroke Unit Management a Life-Threatening Emergency?
Stroke is an absolute medical emergency because the human brain loses approximately 1.9 million neurons per minute without treatment. Stroke Unit management allows:
- Reducing 1-month mortality by 20 to 30% compared to conventional hospitalization.
- Decreasing the risk of severe dependency (mRankin 4-5) by 30%.
- Increasing the number of patients able to return home independently.
- Reducing hospital length of stay and overall care costs.
Every minute counts: time to Stroke Unit arrival is the main modifiable prognostic factor.
What are the Signs of a Stroke and How to React?
It is essential to quickly recognize the signs of a stroke. The mnemonic FAST (Face – Arm – Speech – Time) is universal:
- F (Face): Facial drooping, mouth deviated to one side, inability to smile symmetrically.
- A (Arm): Weakness or paralysis of one arm, leg, or half of the body.
- S (Speech): Speech difficulties (aphasia: difficulty speaking or understanding), slurred speech (dysarthria).
- T (Time): Call emergency services immediately (197 in Tunisia) and note the exact time of symptom onset. Do not give any medication, do not let the patient sleep, do not give anything to eat or drink.
Other signs may also be alarming:
- Sudden loss of vision in one eye or on one side (monocular blindness or homonymous lateral hemianopia).
- Severe dizziness, imbalance, fall without cause (cerebellar syndrome).
- Sudden, intense "thunderclap" headache (subarachnoid hemorrhage).
How is Stroke Unit Management in Tunisia?
Management follows a rigorous chronological protocol.
Admission and Emergency Workup (Time is Brain)
- Direct admission to the Stroke Unit or dedicated emergency department (or "code stroke" triggered by emergency services).
- Neurological clinical examination (NIHSS score – National Institutes of Health Stroke Scale).
- Immediate laboratory tests: blood glucose (hypoglycemia mimics stroke), CBC, platelets, PT, PTT, creatinine, lipid profile.
- Non-contrast brain CT scan (in less than 20 minutes): rules out cerebral hemorrhage (absolute contraindication to thrombolysis) and looks for early signs of ischemia (hyperdense middle cerebral artery sign, sulcal effacement).
- CT angiography of the supra-aortic trunks and brain: looks for arterial occlusion (thrombus), assesses the ischemic territory and penumbra volume (perfusion CT).
- Brain MRI (if rapidly available): diffusion sequences (hyperintense in acute ischemia) and MR angiography. More sensitive than CT, especially for brainstem or small strokes.
Treatment of Ischemic Stroke (80% of strokes)
Intravenous Thrombolysis (IV t-PA: recombinant tissue plasminogen activator, Alteplase)
Indicated in patients with acute ischemic stroke, with known exact onset time, managed within 4.5 hours (or up to 6 hours in some protocols with advanced imaging). The medication (0.9 mg/kg, 10% as bolus then 90% as infusion over 1 hour) dissolves the clot and restores blood flow. Thrombolysis reduces the risk of severe sequelae by 30% but carries a bleeding risk (symptomatic cerebral hemorrhage in 5-6% of cases).
Mechanical Thrombectomy (MT)
Indicated in patients with large artery occlusion (internal carotid artery, middle cerebral artery M1, M2, basilar artery). It involves inserting a catheter via the femoral artery to the occluded cerebral artery, then aspirating or capturing the clot with a stent retriever. The therapeutic window is 6 hours (or up to 24 hours for certain patients with favorable perfusion imaging). Mechanical thrombectomy doubles the rate of good functional outcome (mRankin 0-2) compared to thrombolysis alone. Our interventional neuroradiologists are trained in this advanced technique.
Medical Treatment in the Absence of Thrombolysis/Thrombectomy
Aspirin (160-300 mg/day) urgently, then antiplatelet therapy (aspirin + clopidogrel, or alone).
Treatment of Hemorrhagic Stroke (20% of strokes)
Hemorrhagic stroke (intracerebral or subarachnoid hemorrhage) is treated in a neurovascular intensive care unit: blood pressure control (target < 140 mmHg), correction of coagulation disorders (vitamin K, fresh frozen plasma, PPSB), neuroprotection, sometimes surgical drainage or decompression.
Intensive Monitoring in the Stroke Unit (24-72 hours)
Patients are continuously monitored:
- Neurological monitoring (repeated NIHSS score, vigilance, speech, motor strength).
- Cardiovascular monitoring: non-invasive or invasive blood pressure, continuous ECG (atrial fibrillation screening), pulse oximetry.
- Laboratory monitoring: capillary blood glucose, electrolytes, renal function, liver function.
- Complication prevention: deep vein thrombosis prevention (compression stockings, LMWH), pressure ulcer prevention (position changes every 2 hours), urinary and pulmonary infection prevention, swallowing disorder screening (aspiration risk).
Early Rehabilitation (from the first 24 hours)
Rehabilitation begins immediately in the acute phase: motor physiotherapy (passive then active mobilization), speech therapy (language disorders, swallowing disorders), occupational therapy (assistance with activities of daily living).
Etiological Workup and Secondary Prevention
After the acute phase, an etiological workup is systematic:
- Ultrasound of the supra-aortic trunks: search for carotid stenosis (treated by endarterectomy or stenting).
- Holter ECG (24-72h, or up to 7-14 days): search for paroxysmal atrial fibrillation.
- Transesophageal echocardiography: search for patent foramen ovale (PFO), intracavitary thrombus, vegetations.
- In-depth laboratory tests: lipid profile, HbA1c, hemostasis workup, immunological workup.
Depending on the mechanism, preventive treatment is initiated: antiplatelet (aspirin, clopidogrel, ticagrelor), anticoagulant (DOAC), statin, antihypertensive, salt-free and sugar-free diet, smoking cessation, physical activity.
What are the Risks and Complications in the Stroke Unit?
Possible complications in the acute phase are:
- Hemorrhagic transformation (hemorrhagic cerebral infarction, particularly after thrombolysis or thrombectomy).
- Cardiovascular complications: malignant hypertension, hypotension, arrhythmias, heart failure.
- Respiratory complications: aspiration pneumonia, inhalation, atelectasis.
- Deep vein thrombosis / pulmonary embolism.
- Post-stroke epilepsy (partial or generalized seizures).
- Post-stroke depression (30-50% of patients).
- Hemorrhage under antithrombotic therapy (intracranial, digestive, urinary).
Close monitoring in the Stroke Unit allows early detection and treatment of these complications, reducing their impact on prognosis.
What to Do After a Stroke? Rehabilitation and Long-Term Follow-up
Discharge from the Stroke Unit (average duration 5 to 10 days) does not mark the end of management. An intensive neurological rehabilitation program is essential:
- Physiotherapy: gait restoration, balance, muscle strength, contracture prevention.
- Speech therapy: language rehabilitation (aphasia), swallowing rehabilitation, cognitive function rehabilitation (memory, attention).
- Occupational therapy: home adaptation, assistive devices (wheelchair, cane, ramp).
- Psychologist / neuropsychologist: management of depression, anxiety, behavioral disorders.
- Social worker: financial aid, home adaptation, return to work.
- Regular neurological follow-up: consultations at 1, 3, 6, 12 months, monitoring of treatment adherence, recurrence screening (10-15% at 1 year without treatment).
In Tunisia, post-stroke neurological rehabilitation centers offer stays of 4 to 8 weeks at very competitive rates, with personalized support.
Why Choose Tunisia for Stroke Unit Management?
Tunisia has high-level vascular neurologists, interventional neuroradiologists, and rehabilitation specialists, trained in the best European and Canadian centers (Paris, Lille, Marseille, Lyon, Geneva, Montreal). Several public and private Stroke Units are accredited by the Ministry of Health and operate according to international guidelines (ESO, AHA/ASA). Imaging equipment is modern: 128 and 256-slice CT scanners, 3 Tesla MRI, interventional neuroradiology suites (biplane angiographs for thrombectomy).
- Extremely short access times: Stroke Unit admission within 1 hour of emergency department arrival, thrombolysis administered within 45-60 minutes (door-to-needle), mechanical thrombectomy performed within 90 minutes of CT angiography.
- All-inclusive packages: our packages include Stroke Unit hospitalization, imaging tests (CT scan, CT angiography, MRI), thrombolysis and/or mechanical thrombectomy, intensive care, early rehabilitation, and 3-month follow-up.