General information about stroke care
In this chapter, we wish to delve deeper into one specific condition within the group of cardiovascular disorders: stroke. Every year in Belgium, an average of 29,000 patients are admitted to a hospital with a principal diagnosis of stroke.[1]. A stroke, also known as a stroke or cerebrovascular accident (CVA) – is a disease event in which certain parts of the brain suffer damage due to a lack of oxygen.
A CVA can be caused by two different incidents:
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“In 2022, 28,810 people were hospitalised with a principal diagnosis of stroke.”
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In 2022, 28,810 people were hospitalised with a principal diagnosis of stroke. From the age of 40 onwards, we see a marked increase in the incidence of hospital stays with this problem. The difference between men and women is minimal, with 51% men and 49% women. However, it can be said that in the 40-79 age range, more men than women are hospitalised with stroke.
Number of stays with a principal diagnosis of stroke by gender and age group
The symptoms of a stroke manifest very quickly and include loss of strength or paralysis in the face, arm and/or leg, speech difficulties, vision loss, dizziness or balance disorders and severe headaches. The severity of a CVA depends on the extent of the damage caused to brain tissue and the length of time between the accident and treatment. If the CVA was caused by a thrombosis, it is crucial to start treatment to remove a blood clot (thrombectomy) or to dissolve the clot by intravenous administration of blood-thinning medication (thrombolysis) within 6 hours. The sooner this treatment can be started, the greater the chance of recovery. In this regard, the principle “Time is brain” is applied.
A full recovery from this serious condition is not guaranteed. For example, in Belgian hospitals, 2,934 (or 10.2%) patients died in 2022 as a result of a CVA. Unfortunately, a large number of patients also continue to suffer a permanent disability from the accident.
To learn more, visit
https://www.belgianstrokecouncil.be/
Care programmes for stroke care
Scientific research[2] has shown that the establishment of specialist stroke treatment units – known as stroke units – significantly improves patient recovery. This reduces the risk of death, the risk of admission for rehabilitation in a healthcare facility, and the length of stay in hospital.
Since 2014, there has been a legal framework regarding the establishment of stroke care programmes. This defines a tiered organisation of care according to the complexity and severity of the stroke. This is linked to a number of quality frameworks that must be fulfilled.
The module ‘Acute care in the hospital’ distinguishes between 3 types of care:
- S0 – Hospital without accreditation for S1 or S2, but with a stroke care protocol;
- CVA_S1 – Basic care programme in ‘Acute stroke care’
- CVA_S2 – Specialist care programme in ‘Acute stroke care with invasive procedures’. Each accrediting authority may not accredit more than 8 centres, and a maximum total of 15 CVA_S2 centers may be accredited in Belgium.
The concentration of invasive stroke care is an important objective in the context of Public Health to ensure sufficient quality for the patient. The Royal Decree of September 20, 2022, introduced several changes to this regulation with the aim of implementing volume standards, geographic distribution, and an allocation of the maximum number of invasive stroke care centers across the various accrediting authorities. However, these changes were annulled following an appeal lodged with the Council of State. [3]
In order to operate an CVA_S1 or CVA_S2 care programme, a hospital must receive accreditation from the competent authority. In anticipation of accreditation, hospitals have already put in place extensive collaboration within and outside their networks. Indeed, close cooperation with both urgent care and accredited rehabilitation centres is of great importance.
The course of a patient’s care pathway
Hyperacute
Whenever a stroke is suspected, it is very important to notify the emergency services as soon as possible. They will take the patient to hospital as quickly as possible to receive the correct treatment. They will always choose the most suitable hospital, taking into account the time needed to drive to that hospital.
In 2022, 92% of stroke patients were admitted to hospital after passing through the emergency department. In 46% of the stays, the patient came to the hospital without an ambulance and 41% of the stays involved an ambulance. A Mobile Emergency Group (MUG/SMUR) function was called in only 14% of cases.
When the patient arrives at the emergency department, the first step in all cases will be to carry out a diagnostic examination and initial drug treatment will be started as quickly as possible.
Acute
Depending on the severity of the stroke and the degree of specialisation of the hospital, a multidisciplinary consultation will determine whether on the one hand, the patient can continue to be treated within the current hospital, or on the other hand should be transferred to a more specialised centre to perform thrombolysis or a thrombectomy.
Depending on the patient’s condition, he or she will be admitted to the specialised unit for the treatment of stroke – the stroke unit - for more intensive follow-up and monitoring. If the patient’s condition is fairly reassuring, immediate admission to the neurology service may follow for further recovery.
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Thrombolysis To prevent permanent brain tissue damage, it is important in a group of patients to start treatment with blood-thinning medication as soon as possible and certainly within 30 minutes of arrival at the hospital[4]. About 20% of stroke patients need this treatment.[5]. A 2017 studyconducted in 44 European countries found that only 7% of stroke patients received thrombolysis. In 2022, 2,323 stroke patients in Belgium received treatment with blood-thinning medication (thrombolysis). This represents 10% of the total number of stroke patients, which is well below the recommended 20%[6]. |
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Number of thrombolyses by age group in 2022
Thrombectomy
Whenever, due to the size of the blockage, treatment by thrombolysis is insufficient, it may be decided to remove the thrombus by catheterisation or thrombectomy. Some 5-10% of patients with cerebral infarctions are eligible for this. In 2022, 1,749 thrombectomies were performed in Belgian hospitals. This amounts to 7% of the total number of stroke patients in 2022.
In 2022, a total of 139 patients were transferred to a more specialised hospital for further treatment.
Number of thrombectomies by age group in 2022
Recovery and rehabilitation
The nature and intensity of aftercare depend on the patient’s condition. For example, after hospital treatment, it may be decided to refer the patient to a rehabilitation centre for aftercare. This may be a centre affiliated to the hospital where the patient is staying, or another rehabilitation centre closer to home or a rehabilitation centre specialising in the patient’s specific needs.
In 2022, 1,465 patients were referred to an accredited service for the treatment and rehabilitation of neurological disorders: 3,348 patients were referred to another accredited service for treatment and rehabilitation.
[1] Source: FPS Public Health (undated). Technical unit. [Dataset].
[2] Michiels Dominik, Sun Ying, Thys Vincent, Saka Rasit Omer, Hemelsoet Dimitri, Eyssen Marijke, Paulus Dominique. Stroke units: Doeltreffendheid en kwaliteitsindicatoren (Stroke units: effectiveness and quality indicators). Health Services Research (HSR). Brussels. Brussels: Belgian Health Care Knowledge Centre (KCE). 2012. KCE Reports 181A. DOI: 10.57598/R181A.
[3] Cf. Notices prescribed under Article 3quater of the Regent’s Decree of 23 August 1948 regulating the procedure before the Administrative Litigation Division of the Council of State, published in the Belgian Official Journal on 10 January 2023, 14 February 2023, and 12 April 2023. These are respectively available at the following links:
www.ejustice.just.fgov.be/cgi/article.pl?language=nl&sum_date=2023-01-10&lg_txt=N&numac_search=2022043265;
www.ejustice.just.fgov.be/cgi/article.pl?language=nl&sum_date=2023-02-14&lg_txt=N&numac_search=2023040505;
www.ejustice.just.fgov.be/cgi/article.pl?language=nl&sum_date=2023-04-12&lg_txt=N&numac_search=2023040509
[4] Source: Federation of Medical Specialists. (2019). Brain infarction and cerebral haemorrhage. Consulted at https://richtlijnendatabase.nl/
[5] Source: Vlaams Instituut voor Kwaliteit van Zorg vzw (Flemish Institute for Care Quality) (2024). Topic: Stroke care. Consulted at https://www.zorgkwaliteit.be/beroertezorg.
[6] These figures may represent an underestimate of actual situation due to an under-recording of treatments.