Acute neurological diseases (AND) are among the major contributors to the problem of illness worldwide. In recent years, the global burden of AND, in particular cerebrovascular diseases and ischemic or hemorrhagic strokes, has increased (Prust et al., 2022). Stroke is the second leading cause of death worldwide (World Health Organization, 2018a). According to the Global Burden of Disease study, neurological diseases are the greatest driver of worldwide disability, with stroke accounting for nearly half of this disease burden (Prust et al., 2022). This is mainly due to the increase in the average age of the population, the greater presence of vascular risk factors, and the improvement in the treatment of diseases (World Health Organization, 2018a). AND [e.g., traumatic brain injury (TBI), epilepsy, and other pathologies in their acute phases], as cerebrovascular diseases, have important repercussions on social and economic costs (Prust et al., 2022). Acute neurological survivors experience a significantly greater affliction of long-term disability (Langhorne et al., 2018).

At the same time, the need for specialist neurocritical care skills aimed at managing neurological emergencies has increased, as well as the need for resources such as intensive monitoring beds, advanced neuroimaging, sophisticated neurointerventional skills, and drugs (Prust et al., 2022). Specialized neurocritical care is predominantly in high-income countries (Mateen, 2011; Prust, 2020) because of costly public health resources and investments (Prust et al., 2022). A recent paper reported more than 70 countries with less than five intensive care unit beds per 100,000 inhabitants (Ma and Vervoort, 2020); the number decreases in low-income countries (Phua et al., 2020). Often, medical doctors and health professionals specialized in the management of neurological diseases in the acute phase are missing (0.13–4.75 neurologists per 100,000 inhabitants) (Prust et al., 2022).

Therefore, it is necessary provide the best possible critical clinical care for patients with AND. For example, for patients with stroke, the concept of stroke unit care was conceived (Prust et al., 2022).

The model of stroke unit care was born about 50 years ago, but its effectiveness has only been demonstrated in the last 20 years (Garraway et al., 1980; Ebrahim, 1990; Indredavik et al., 1991; Stroke Unit Trialists' Collaboration, 1997a,b; Langhorne, 2021). In fact, until recently, it was thought that the natural history of the stroke could not be changed (Weatherall et al., 1983; Langhorne, 2021).

The first description of a stroke unit setting was reported in the 1950s and 1960s (Langhorne, 2021). The concept was to focus stroke care around a multidisciplinary team of stroke specialists who operated out of a single specialized unit (the “stroke unit”), defined as incorporating a “multidisciplinary team of specialists in the care of stroke patients” (Langhorne et al., 1993; Langhorne, 2021). In 2020, the Cochrane Collaboration has demonstrated that stroke patients admitted to stroke units are more likely to survive and have less residual functional disability; the benefits remain independent of patient age, sex, initial stroke severity, or stroke type (Langhorne and Ramachandra, 2020). This evidence has resulted in recommendations reported in many national and regional guidelines (Stroke Foundation, 2002; Norrving et al., 2018; Langhorne and Ramachandra, 2020) that all stroke patients should be treated in a specific dedicated setting, such as stroke units. Some articles have highlighted the negative aspect of stroke units in terms of costs, thus questioning their effectiveness in terms of cost benefits (Mateen, 2011). For this and other reasons, the actual geographical distribution of stroke units, including in Italy, is patchy (Langhorne, 2021). More recent studies (Urimubenshi et al., 2017; Norrving et al., 2018) have shown an association between hospitalization in stroke units and better patients outcomes (Langhorne, 2021).

In the last 10–20 years, similar concepts were introduced for neurocritical care (Suarez, 2006). The birth of the concept of Neurocritical Care Unit was even more complicated than that of the Stroke Unit concept (Shrestha and Lamsal, 2020; Prust et al., 2022). Generally, neurocritical care was mainly for management of TBI, central nervous system infectious, and surgery patients, especially if in a serious clinical condition and with imminent risk to life. The establishment of neurocritical care units with acute phase neurointerventional treatments was associated with improved clinical outcomes compared with more traditional management (Varelas et al., 2004; Suarez, 2006; Kramer and Zygun, 2014; Shrestha and Lamsal, 2020). The possible reasons for better outcomes included: dedicated physicians and nurses, protocolized management, and stricter adherence to neurocritical care protocols (Shrestha and Lamsal, 2020). Nevertheless, neurocritical care is often not recognized as a separate specialty and is restricted to a few large academic institutions with a shortage of neurocritical care beds and common neurocritical care modalities (Shrestha and Lamsal, 2020).

Intracerebral hemorrhage (ICH), the second most common and more deadly cause of stroke (15–30% of strokes), with a one-year mortality around 50% and 5-year survival <30% (Sporns et al., 2021; Prust et al., 2022), has resulted in the urgent need to develop new strategies to treat and try to stop ICH in its hyperacute phases (World Health Organization, 2018b; Sporns et al., 2021). Although there is no specialized medication for ICH, there are some innovative approaches for the acute management and recovery. The main therapeutic strategies, according to guidelines, are strict blood pressure control (in ICH due to small vessel disease), and endovascular treatment with embolization (in ICH due to arteriovenous malformations or aneurysm). The implementation of multimodal imaging allows timely etiological diagnosis and the assessment of early hematoma expansion, also with a view to therapeutic intervention and evacuation surgery (Sporns et al., 2021). ICH patients are generally hospitalized in intensive care units (not always with neurological care settings) or in neurosurgery.

In modern times, there has been a sharp increase in TBI due to the increase of motor vehicles (Bannick et al., 2019). Road accidents cause ~1.3 million deaths each year and are among the leading causes of death worldwide, particularly in young people (Bannick et al., 2019). In addition, in patients over the age of 70, the trauma related to falls is very frequent with consequent post-traumatic (subdural and/or epidural) hematoma (Dewan et al., 2018). As the global population ages, the incidence of fall-related TBI continues to increase, especially with substantial gains in life expectancy in recent decades (Dewan et al., 2018; Bannick et al., 2019). Some studies have demonstrated the advantages of neurocritical care units and effect of a specialized neurocritical care team in monitoring and treating TBI patients (Varelas et al., 2004; Suarez, 2006; Kramer and Zygun, 2014; Shrestha and Lamsal, 2020).

Other AND to be taken into account for the severe impact on the neurocritical care include: polyradiculoneuritis (infectious, inflammatory, or autoimmune), encephalitis, epileptic seizures, acute phases of myasthenia gravis, and myelitis (Prust et al., 2022).

The global burden of epilepsy and epileptic status is mainly secondary to dystocic delivery at birth, central nervous system infections, and structural causes, such as traumatic and non-traumatic brain injuries (vascular, neoplastic, etc.). In case of epileptic seizures (especially of first epileptic seizures), access to electroencephalogram (EEG) and neuroimaging for early diagnosis is very important. Rapid access to neurophysiological investigation, as continuous EEG, is required to detect, monitor, and treat critical non-convulsive epileptic status (Prust et al., 2022). Treatment of convulsive and non-convulsive epileptic status includes both management and prompt cessation of seizure activity and the earliest possible detection of an underlying etiology for specific acute treatment (Trinka and Leitinger, 2022). In the real life continuous EEG monitoring is often missing, also because there are no dedicated beds.

Furthermore, beyond acute phase management, neurological expertise, coupled with neurophysiological expertise, also allows early patient prognostication with stratification of patients both for the purposes of more or less aggressive treatment and for the definition of an appropriate rehabilitation pathway (e.g., acquired brain injured patients, epilepsy, etc.).

In addition to AND, there are systemic complications of acute phases of neurological patients: fever, glycemic and blood pressure decompensations, infectious and sepsis, pneumonia, dysphagia, systemic thromboembolism, respiratory failure, and shock (Prust et al., 2022). For a better outcome, patients should undergo regular monitoring of vital signs and correction of hypertension and diabetes, as well as the treatment of fever, correction of electrolyte imbalances and hypoxemia, early mobilization, and prevention of thromboembolism and dysphagia while avoiding complications (Prust et al., 2022).

In this paper, we report the pilot experience of Stroke Unit/Neurocritical Care (2A) of the Santo Stefano Hospital (Prato, USL Toscana Centro).

The neurology department in the Santo Stefano Hospital consists of 30 beds. The 2A setting of Stroke Unit/Neurocritical Care includes 15 beds; 8 ± 2 beds are monitored by portable multi-parameter monitoring devices. In the Stroke Unit/Neurocritical Care (2A), patients undergo acute phase treatment and subsequently diagnostic and etiopathogenetic exams with continuous monitoring of vital functions, as well as secondary prevention therapy. Moreover, patients undergo early rehabilitation and prevention of complications beyond anti-immobilization strategies.

We retrospectively assessed the diagnoses in the hospital discharge forms (HDF) of Stroke Unit/Neurocritical Care (2A) of 249 patients consecutively analyzed between 1st January 2022 and 30th June 2022.

From a methodological point of view, we considered diagnoses of the main AND, considering in particular: ischemic stroke, hemorrhagic stroke, transient ischemic attack (TIA), cerebral vein thrombosis, epilepsy (first epileptic seizures), epileptic status, TBI (post-traumatic subdural hematoma, epidural hematoma, and subarachnoid hemorrhage), acute inflammatory polyradiculoneuritis, acute encephalitis, acute myelitis, acute myasthenia gravis, and others.

To be included in this report, patients had to be diagnosed as affected by the pathologies listed above according to the standard neurological definition, and confirmed on neuroimaging (CT scan or cerebral MRI) or neurophysiological standard criteria. Regarding ischemic strokes, we considered intravenous fibrinolytic and intra-arterial treatment; our patients are treated with endovascular treatment at the AOU Careggi Hospital, as the hub-center of USL Toscana Centro. Regarding hemorrhagic stroke, we considered typical and atypical intraparenchymal cerebral hemorrhage (according to ICH criteria, and on the basis of CT/MRI injury site) and spontaneous non-traumatic subarachnoid hemorrhage.

The assessment was retrospective and consecutive.

To illustrate the baseline total sampled descriptive analyses were used. Univariate statistical analyses (independent samples t-test for continuous variables) were used to compare the groups of TBI patients.

We screened 378 patients hospitalized in the 6-month period between 1st January 2022 and 30th June 2022 and consecutively selected among diagnoses of HDF of Stroke Unit/Neurocritical Care (2A).

We excluded 129 patients (34%) because they did not fit the criteria for “acute” neurological syndromes: dizziness (n = 11, 9%), headache (n = 16, 13%), transient loss of consciousness (n = 16, 13%), multiple sclerosis (n = 5, 0.4%), chronic subdural hematoma (n = 31, 24%), and others (n = 50, 38%). Figure 1 shows the main exclusion criteria.

According to the international standard diagnostic criteria, out of the 249 patients affected by AND, 155 had cerebrovascular diseases (62.2%). In particular, 100 (64.5%) were diagnosed as ischemic stroke, nine (5.8%) as TIA, 44 (28.4%) as hemorrhagic stroke, and two (1.2%) as affected by central venous thrombosis (Figure 1).

Out of the 100 patients with diagnosis of acute ischemic stroke, 36 (36%) were treated with r-TPA, seven (7%) patients with endovascular treatment, and 12 (12%) underwent r-TPA combined with intararterious thrombectomy; 45 (45%) patients were outside the therapeutic window for thrombolytic treatment and treated with antiaggregation therapy (Figure 1). One stroke patient (1%) was intrahospital stroke. The setting discharge of the cerebrovascular patients were: rehabilitation (28%), intermediate care hospitals (31%), long-term care (6%), and home (35%).

Among the main classical ethiopathogenic causes of stoke, 30% were cardioembolic, 24% atherosclerotic, 38% lacunar, and 8% were embolic stroke of undetermined source (ESUS); one patient had diagnosis of Mitochondrial myopathy, Encephalopathy, Lactic Acidosis and Stroke-like episodes Syndrom (MELAS), and two patients of venous thrombosis of the central nervous system.

Out of the 44 patients with hemorrhagic stroke, 23 (52.3%) had a hemorrhage in a typical area of hypertensive microangiopathy, while 16 (36.4%) hemorrhages were atypical. Five (11.3%) patients had primarily spontaneous subarachnoid hemorrhages (Figure 1).

Regarding some outcome data, analyzing the residual disability of the cerebrovascular events in out cohort, the 3-month modified Rankin Scale (mRS) in 36 stroke patients treated with r-TPA was 0–2 (low disability) in 60% of cases, 3–4 (moderate-severe disability) in 35%, and 5–6 (severe disability/death) in 5% of patients. In 64 non-treated patients, the mRS was 0–2 in 21%, 3–4 in 53%, and 5–6 in 26% of patients.

Out of the 44 ICH patients, 31% reported severe disability or death, 47% moderate-severe degree of disability (3–4), and 22% 0–2 mRS.

Thirty-two patients (32/249, 12.8%) were hospitalized following a TBI; 25 (78%) for post-traumatic subdural hematoma, two (6.25%) for acute post-traumatic epidural hematoma, and five (15.6%) for post-traumatic subarachnoid hemorrhage (Figure 1) (underlying causes are available upon request).

Taking into account the 30 TBI patients hospitalized in different departments (geriatric, medicines, and intensive therapy) for comparison, the mRS range was from 1 to 5 for all TBI patients, with differences between the patients in Stroke Unit/Neurocritical Care (2A) and those in other departments (mRS 1–3 vs. mRS 3–4, respectively).

Sixteen patients (6.4% of all AND) were hospitalized for a new diagnosis of epilepsy and three (1.2%) for epileptic status (Figure 1) (underlying causes are available on request).

Out of the other AND, acute inflammatory polyradiculoneuritis was found in five patients; of these, one had a Miller Fisher syndrome, three had Guillain–Barré syndrome, and one had Bickerstaff brainstem encephalitis (Figure 1). One patient had acute crisis of myasthenia gravis, and one had acute myelitis (Figure 1). The remain patients (n = 26) were hospitalized for: syncope (7), altered consciousness and coma (7), non-bacterial/infectious encephalitis and meningitis (4), delirium (2), transient global amnesia (TGA) (2), and others (4) (Figure 1).

The detailed distributions of patients are shown in Figure 1.

Globally, the setting discharge of all AND patients were: rehabilitation (26%), intermediate care hospitals (44%), long-term care (5%), and home (25%).

Regarding other summary outcome data, the one-month mortality rate in Stroke Unit/Neurocritical Care (2A) patients was 1.8%.

Moreover, the percentages of re-entry to hospital of patients admitted to our setting was around 17% (generally due to infectious causes and not recurrences of the primary cause of hospitalization).