<b>Background</b> Tremendous progress in acute stroke therapy has improved short-term outcome but part of this achievement may be lost in the long run. Concepts for a better long-term management of stroke survivors are needed to address their unmet needs and to reduce the burden of post-stroke complications, residual deficits and recurrent vascular events.

<b>Aims</b> This review summarizes current knowledge on post-hospital care and the scientific evidence supporting individual programs.

<b>Summary of review</b> A systematic search of electronic databases according to PRISMA guidelines identified 10,374 articles, 77 of which met the inclusion criteria. One large randomised controlled trial on a multifaceted care program delivered by the multidisciplinary stroke team reduced recurrent vascular events and improved quality of life and functional outcome one year after the event while a number of studies offer solutions for individual components of post-hospital disease management like patient education, counselling, and self-management or the management of post-stroke complications and residual deficits. A majority of studies, however, was small in size and limited by a short follow-up. Most initiatives with a narrow focus on risk factor control failed to lower the risk of recurrent events. The caregivers’ central role in post-stroke patient management is broadly neglected in research.

<b>Conclusions</b> Over the past years, first knowledge on how to best organize post-hospital care of stroke patients has emerged. Comprehensive and pragmatic programs operated by the multidisciplinary stroke team hold promise to reduce the long-term health burden of stroke. There is a clear need for further high-quality studies with both clinical endpoints and patient-reported outcomes to establish sustainable solutions in different settings and regions to improve life after stroke, a key priority of the Stroke Action Plan for Europe 2018-2030.

<b>背景</b> 急性卒中治疗的巨大进步改善了短期结果，但从长远来看可能会失去部分成就。需要更好地长期管理中风幸存者的概念来解决他们未满足的需求并减少中风后并发症、残留缺陷和复发性血管事件的负担。

<b>目标</b> 本综述总结了目前关于出院后护理的知识以及支持各个项目的科学证据。

<b>综述总结</b> 根据 PRISMA 指南对电子数据库进行系统搜索，确定了 10,374 篇文章，其中 77 篇符合纳入标准。一项由多学科卒中团队提供的多方面护理计划的大型随机对照试验减少了复发性血管事件并改善了事件一年后的生活质量和功能结果，而许多研究为院后疾病管理的各个组成部分提供了解决方案，例如患者教育、咨询和自我管理或中风后并发症和残留缺陷的管理。然而，大多数研究规模较小，并且受到短期随访的限制。大多数只关注风险因素控制的举措未能降低复发事件的风险。看护人？？？？中风后患者管理中的核心作用在研究中被广泛忽视。

<b>结论</b> 在过去的几年里，关于如何最好地组织中风患者的出院后护理的初步知识已经出现。由多学科卒中团队运营的全面而务实的项目有望减轻卒中的长期健康负担。显然需要进一步开展具有临床终点和患者报告结果的高质量研究，以在不同环境和地区建立可持续的解决方案，以改善中风后的生活，这是 2018-2030 年欧洲中风行动计划的关键优先事项。