Getting the Right Stroke Treatment
Strokes remains one of the major causes of death and creates more disability than any other medical condition. Fortunately, great advances in treatment have been made, especially for more severe strokes.
For strokes caused by blockage of a major brain artery (known as emergent large vessel occlusion, or ELVO), a procedure called thrombectomy can be performed. This can substantially reduce disability and even reverse the effects of a stroke. In this procedure, a small catheter is maneuvered through the blood vessels to the site of the blockage, where tiny devices are then used to remove the clot by retrieving it from out of the blocked artery.
For thrombectomy to be successful, it needs to be performed in well-equipped, higher-level hospitals that have special imaging suites for taking angiographic X-rays, as well as doctors trained to perform these specialized procedures. With these prerequisites, thrombectomy is now proven to be one of the most effective treatments in all of medicine.
The challenge now is to make sure the first hospital a stroke patient is taken to is the one that’s best matched to his or her specific needs. Time is of the essence in stroke treatment. It’s estimated that patients lose 2 million brain cells each minute during a stroke. The loss may be even higher in major ELVO strokes. Every additional minute lost in treating stroke patients can increase their disability. Delays can mean the difference between life and death, or between living independently and needing long-term assistance due to substantial disability.
Our emergency medical services colleagues work hard to identify stroke in the field, and most protocols in the country direct stroke patients to the closest hospital. However, for severe ELVO strokes, the closest hospital is often not equipped with the equipment and personnel needed to perform thrombectomy. That means transfer to a second hospital is required, which delays treatment. While EMS is generally excellent at bringing the patient to the first hospital, secondary transfers can sometimes take up to three hours, which can be devastating to a patient’s outcome. This has led to calls to change how we triage stroke in the field, with EMS bypassing closer, smaller hospitals to get to an appropriate higher-level facility that can perform thrombectomy.
Protocols for other critical conditions provide helpful precedents. The best model to follow in stroke is that of trauma. In situations of severe trauma, such as a major motor vehicle accident, EMS providers are trained to take patients to a Level 1 Trauma Center, which meet specifications to prove it can handle the most severely injured patients. Evidence has shown that this in-the-field triage to higher-level trauma centers has improved survival for trauma patients. Triaging patients to the appropriate center has become the standard for trauma system design. Similar data on stroke treatment is accumulating, and it suggests that bypassing a closer hospital without thrombectomy capability may be acceptable if a thrombectomy-capable hospital can be reached within 15 to 30 minutes.
Tools and scales now exist to aid EMS providers in identifying severe strokes in the field. Hospitals in specific regions can be sorted according to their capabilities in stroke care, and EMS can use this information to direct patients to the hospital best matched to caring for their patient’s condition. While some regions of the country have been successful in implementing these enhanced stroke systems of care with field bypass, more widespread efforts are required to ensure patients do in fact arrive at the right hospital the first time. Efforts such as Get Ahead of Stroke aim to raise awareness about improving systems of care for stroke patients. We all want to ensure the best outcomes for patients dealing with this life-threatening event.
The system can be highly effective, but it needs to be activated quickly. We must also educate everyone on stroke signs and symptoms so they can call EMS and get medical attention as quickly as possible. It’s good to memorize the acronym BE FAST:
B – Balance
E – Eyes
F – Face droopiness or weakness
A – Arm (or leg) weakness
S – Speaking difficulty
T – TIME TO CALL emergency care unit!
It’s essential to call your emergency care unit and get medical attention right away, as this can mean the difference between life and death, and between disability and no disability.