Stroke care has witnessed significant advances over the past few decades, fundamentally changing how Emergency Medical Services (EMS) respond to and manage stroke patients. As EMS professionals, you are not just a part of the process but a vital component in the continuum of stroke management. Staying informed about these advancements is crucial to ensure our patients' highest quality of care. This article aims to provide both seasoned professionals and newcomers with a comprehensive overview of the latest developments in stroke care, emphasizing your integral role.

Understanding Stroke

A stroke occurs when the blood supply to a part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients. This can result in significant neurological damage if not promptly treated. There are two main types of stroke:

1. Ischemic Stroke: Caused by a blockage in an artery supplying blood to the brain. This is the most common type, accounting for about 87% of all strokes.

2. Hemorrhagic Stroke: This occurs when a blood vessel in the brain bursts, leading to bleeding within or around the brain.

Rapid identification and treatment are essential in minimizing the damage caused by a stroke. The phrase "time is brain" underscores the importance of immediate medical intervention.

Advances in Stroke Identification and Assessment

Pre-Hospital Stroke Scales

Several pre-hospital stroke assessment scales have been developed to help EMS providers quickly identify potential stroke patients:

• Cincinnati Prehospital Stroke Scale (CPSS) assesses facial droop, arm drift, and speech. It is simple and quick, making it ideal for use in the field.

• Los Angeles Prehospital Stroke Screen (LAPSS): Besides CPSS criteria, LAPSS includes assessing patient history and blood glucose levels.

• Rapid Arterial oCclusion Evaluation (RACE): This scale helps identify large vessel occlusions (LVOs), often suitable for endovascular therapy.

These tools are invaluable in improving stroke identification accuracy and ensuring patients receive appropriate care promptly.

Mobile Stroke Units (MSUs)

One of the most significant advancements in pre-hospital stroke care is the development of Mobile Stroke Units (MSUs). These specialized ambulances have a CT scanner, point-of-care laboratory testing, and telemedicine capabilities. MSUs enable the administration of thrombolytics (clot-busting drugs) in the pre-hospital setting, significantly reducing the time to treatment.

Studies have shown that MSUs can improve outcomes by providing earlier diagnosis and treatment. However, the implementation of MSUs is still limited to certain regions due to the high costs associated with their operation.

Advances in Stroke Treatment

Thrombolytic Therapy

Introducing tissue plasminogen activator (tPA) revolutionized the treatment of ischemic stroke. Administered intravenously, tPA dissolves the clot, obstructing blood flow to the brain. The effectiveness of tPA is highly time-dependent, with the best outcomes achieved when administered within 4.5 hours of symptom onset.

Endovascular Therapy

Endovascular therapy (EVT) has emerged as a game-changer for patients with large vessel occlusions. EVT involves the mechanical removal of the clot using a stent retriever or aspiration device. Recent trials, such as the MR CLEAN, ESCAPE, and REVASCAT trials, have demonstrated the efficacy of EVT in improving functional outcomes in stroke patients when performed within 6 to 24 hours of symptom onset, depending on individual patient factors.

Neuroprotective Agents

Research into neuroprotective agents aims to find drugs that can protect brain tissue during a stroke. While several agents have shown promise in preclinical studies, none have yet become standard practice. However, ongoing trials continue to explore potential neuroprotective therapies.

Advances in Post-Stroke Care

Stroke Centers and Networks

The establishment of stroke centers and stroke networks has been a critical advancement in post-stroke care. Stroke centers are designated as primary or comprehensive based on their capabilities to provide specialized stroke care. Comprehensive stroke centers can offer advanced interventions like EVT and have specialized neurocritical care units.

Telestroke Programs

Telestroke programs use telemedicine to provide remote neurological assessment and consultation, which is particularly beneficial for rural or underserved areas. These programs allow EMS providers and community hospitals to connect with stroke specialists, facilitating timely and accurate decision-making regarding patient management.

Rehabilitation and Recovery

Advancements in post-stroke rehabilitation focus on early and intensive therapy to promote recovery. Techniques such as constraint-induced movement therapy, robotic-assisted therapy, and virtual reality have shown promise in improving functional outcomes. Additionally, research into neuroplasticity—the brain's ability to reorganize itself—continues to inform rehabilitation strategies.

The Role of EMS in Stroke Care

Early Recognition and Rapid Response

The role of EMS in stroke care begins with early recognition and rapid response. EMS providers are often the first point of medical contact for stroke patients. Utilizing pre-hospital stroke scales and maintaining a high index of suspicion for stroke are critical steps in the early identification process.

Pre-Notification to Stroke Centers

Pre-notification to stroke centers is a crucial step that EMS providers can take to expedite care. By alerting the receiving hospital of an incoming stroke patient, the hospital can prepare its stroke team and resources, reducing door-to-needle and door-to-groin times for thrombolytic and endovascular treatments.

Comprehensive Stroke Protocols

EMS agencies should implement and regularly update comprehensive stroke protocols. These protocols should include guidelines for stroke assessment, pre-notification procedures, and transport destinations. Collaboration with local stroke centers and participation in stroke networks can enhance the effectiveness of these protocols.

Continuing Education and Training

Ongoing education and training are essential for EMS providers to stay current with the latest advancements in stroke care. Participation in stroke simulation exercises, attending educational conferences, and completing continuing education courses can help providers maintain their skills and knowledge.

Challenges and Future Directions

Access to Advanced Stroke Care

Despite significant advances, access to advanced stroke care remains a challenge, particularly in rural and underserved areas. Efforts to expand telemedicine capabilities, increase the availability of MSUs, and enhance regional stroke networks are essential to address these disparities.

Public Education and Awareness

Public education and awareness campaigns are vital in improving stroke outcomes. Educating the public about stroke symptoms and the importance of calling 911 immediately can reduce pre-hospital delays. EMS providers can participate in these efforts through community outreach and education programs.

Research and Innovation

Ongoing research and innovation are crucial to further advancing stroke care. Areas of focus include the development of new thrombolytic agents, exploring neuroprotective therapies, and improving rehabilitation techniques. EMS providers can contribute to research by participating in clinical trials and data collection initiatives.

Conclusion

Advances in stroke care have significantly improved outcomes for stroke patients. As EMS professionals, staying informed about these developments is essential to provide the highest quality of care. From early recognition and rapid response to collaboration with stroke centers and ongoing education, EMS providers play a critical role in the continuum of stroke care. By embracing these advancements and addressing ongoing challenges, we can continue to improve the lives of stroke patients and their families.

References

1. Saver, J. L. (2006). Time is brain—Quantified. Stroke, 37(1), 263-266.

2. Prabhakaran, S., Ruff, I., & Bernstein, R. A. (2015). Acute stroke intervention: A systematic review. JAMA, 313(14), 1451-1462.

3. Campbell, B. C. V., Mitchell, P. J., Yan, B., Parsons, M. W., Davis, S. M., & Donnan, G. A. (2019). Endovascular thrombectomy for acute ischemic stroke: A meta-analysis of randomized trials. International Journal of Stroke, 14(3), 249-255.

4. Hsiao, J., & Sayre, J. (2020). Mobile stroke units: Bringing emergency stroke care to the patient. Emergency Medicine Clinics of North America, 38(4), 819-831.

5. Powers, W. J., Rabinstein, A. A., Ackerson, T., et al. (2019). 2018 Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50(12), e344-e418.