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Heilaslagdeild : mikilvæg nýjung í meðferð heilaslags

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Authors
Albert Páll Sigurðsson
Issue Date
1999-06-01

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Other Titles
Stroke unit. An important addition to stroke treatment
Citation
Læknablaðið 1999, 85(6):528-41
Abstract
In Iceland, about 770 strokes can be estimated to occur annually. Until recently no treatment had been shown to be effective for acute and subacute strokes. This may have led to therapeutical nihilism and inconsistency in treatment. In 1995, however, t-PA was shown to improve functional outcome when given within three hours of stroke onset. The effectiveness of organized stroke care (stroke unit) has been controversial for 30 years. It is only in 1992 that its effects has become apparent with improved research design and systemic evaluation of the available data. Stroke unit treatment reduces mortality and improves functional outcome with more patients being discharged to home. All groups of patients benefit from this form of treatment, and there is no ground for excluding patients because of gender, age or stroke severity. Good results are obtained both in dedicated as well as mixed assessment/rehabilitation stroke units. Acute (<7 days) or delayed (>7 days) admission to a stroke unit does not affect outcome, however, the duration of treatment must exceed several weeks. The effectiveness of the stroke unit appears to be due to the novel approach of treatment (multi-disciplinary team approach). The departmental setting in which it takes place (within the department of neurology, medicine, geriatric medicine or rehabilitation) has no influence on outcome. Stroke unit treatment is most reliable when delivered in a dedicated geographic location rather than as a consultative service. The cost of acute hospitalization/rehabilitation on such unit is probably not increased, since hospital/ rehabilitation stay seems to be the same or slightly less than with conventional care. Long term cost after such treatment is reduced, since fewer patients need long term placement.
Á Íslandi má búast við að um 770 einstaklingar fái heilaslag árlega. Þar til nýlega hefur ekki verið sýnt fram á árangursríka bráða- og síðbúna meðferð heilaslaga. Þetta hefur sennilega leitt til tregðu og stefnuleysis í meðferð. Árið 1995 var hins vegar sýnt fram á að t-PA (tissue plasminogen activator) meðferð bætir starfsgetu ef hún hefst innan þriggja tíma frá upphafi einkenna. Deilt hefur verið um það í nálega 30 ár hvort skipuleg meðferð heilaslaga á sérhæfðum deildum (heilaslagdeildum) sé gagnleg. Það var ekki fyrr en árið 1992 að ljóst var að svo er, eftir að rannsóknaraðferðir urðu betri og skipulagt mat á niðurstöðum rannsókna lá fyrir. Meðferð á heilaslagdeild fækkar dauðsföllum og dregur úr varanlegri fötlun þannig að fleiri sjúklingar lifa af slagið og fleiri útskrifast heim. Allir heilaslagsjúklingar hafa gagn af slíkri meðferð og ekki er ástæða að hafna þess háttar meðferð á grundvelli kyns, aldurs eða upphafsfötlunar. Góður árangur fæst bæði á „hreinni" endurhæfingarheilaslagdeild og á blandaðri uppvinnslu- og endurhæfingarheilaslagdeild. Bráða- (innan við átta daga) og síðbúin (eftir sjö daga) innlögn á heilaslagdeild hefur ekki áhrif á árangur meðferðar, en hins vegar þarf meðferð að standa yfir í nokkrar vikur. Árangur heilaslagdeilda stafar sennilega af góðu meðferðarformi (teymisvinnu). Staðsetning deildar sem veitir meðferð (taugalækninga-, lyflækninga-, öldrunarlækninga- eða endurhæfingardeilda) hefur ekki áhrif á árangur meðferðar. Árangur heilaslagdeilda er bestur þegar meðferð er veitt á staðbundinni deild og betri en þegar nýtt er hreyfanlegt teymi sérfræðinga. Kostnaður vegna bráðasjúkrahúslegu/-endurhæfingar á heilaslagdeild eykst sennilega ekki þar sem sjúkrahús-/endurhæfingardvöl hefur reynst sú sama eða örlítið styttri en við hefðbundna meðferð. Langtímakostnaður er minni þar sem færri sjúklingar þurfa á langtímavistun að halda.
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