Benefits of ESO stroke unit certification: A report from a Tertiary Stroke Center in Bucharest, Romania

Introduction: Stroke is a leading cause of death and disability. The European Stroke Organization (ESO) developed Stroke Unit certification criteria to standardize and improve stroke care quality. This study evaluates the impact of implementing these criteria on outcomes for acute ischemic stroke patients treated with intravenous thrombolysis (IV alteplase) in an Emergency Hospital in Bucharest, Romania. Methods: Our retrospective observational study compared outcomes before (2017-2020) and after (2021-2024) implementation of ESO Stroke Unit certification protocols. Data from 568 patients receiving IV alteplase were analyzed. Our analysis included in-hospital mortality, modified Rankin Scale (mRS) and NIH Stroke Scale (NIHSS) at discharge, NIHSS shift, and key time metrics (door-to-CT, neuro-to-needle, door-to-needle). Results: Post-intervention, the annual IV alteplase rate increased significantly (15.47% vs 4.51%, p < 0.001). Time metrics improved, with reductions in door-to-CT (20.41 min vs 49.45 min, p < 0.001), neuro-to-needle (36.43 min vs 63.28 min, p < 0.001) and door-to-needle times (44.64 min vs 73.07 min, p < 0.001). Favorable outcome (mRS 0-1) improved (44.8% vs 33.2%, aOR = 2.33, p < 0.001), and in-hospital mortality decreased (7.3% vs 12.5%, aOR = 0.48, p = 0.02). Symptomatic hemorrhagic transformation also decreased (3.1% vs 7.6%, aOR = 0.31, p = 0.02). Discussion: Implementing ESO Stroke Unit certification criteria was associated with significant improvements in thrombolysis rates, key time metrics, and patient outcomes. Conclusions: ESO Stroke Unit certification may lead to improved stroke care and patient outcomes, particularly in emerging healthcare systems.