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When Time Is of the Essence: Developing Recommendations for Prehospital Care of Stroke Patients

image of hour glass stroke treatment timingWhen going on a business trip or vacation, it’s great when you get a direct flight. Even better when the check-in, baggage handling and boarding processes are smooth.

When traveling, time efficiency is desirable, but it can be critical when treating medical conditions like stroke. That is why stroke specialists (probably more than the airline industry) make timing and efficiency their main priority.

This priority and how to implement it was discussed in a recent article co-authored by Columbia University Medical Center/NewYork-Presbyterian Hospital neurointerventionalist Dr. Philip Meyers.

A neurointerventionalist is a physician with special training in radiology and knowledge of diseases of the brain. These specialists are experts in the use of sophisticated nonsurgical techniques to treat many conditions affecting the brain and nerves.

The field in which a neurointerventionalist practices is called endovascular neuroradiology. It is a relatively new specialty, and Dr. Meyers trained just as it was being created. His expertise and experience have been welcome in the Society of NeuroInterventional Surgery, where he has long been a member and also served a term as president.

Dr. Meyers has also served on the Society’s Standards and Guidelines Committee—a group of experienced neurointerventionalists who most recently have come up with guidelines for rapid treatment of a type of stroke called emergent large vessel occlusion. This group gave their recommendations in an article recently published in the Journal of NeuroInterventional Surgery.*

When treating stroke, a neurointerventionalist such as Dr. Meyers can perform a procedure known as a mechanical embolectomy. Here, a long thin and flexible tube, called a catheter, is threaded from a blood vessel in the leg all the way to the artery in the brain that contains the blood clot that is blocking blood flow and causing the stroke. The clot can then be removed using a device at the end of the catheter.

In many cases, mechanical embolectomy has replaced older treatments for many types of stroke, including emergent large vessel occlusion. In addition, specialists have been able to perform the procedure with increased speed and efficiency, thanks to improved equipment and techniques.

Because the neurointerventionalists, staff and equipment are available at a comprehensive stroke center (CSC) like the one at Columbia, the authors recommend that stroke patients be transferred to such a facility. Issues arise, however, when arrival at such a center is delayed.

The committee reviewed multiple studies that examined stroke-to-treatment timing. These showed that delays of even minutes can decrease chances of a good outcome. How can a stroke victim get what’s needed more quickly?

First, the authors note that in order to have access to early treatment, it’s important to recognize when a stroke may be happening. To accomplish this goal of “stroke awareness,” many medical facilities are rolling out educational campaigns and beginning to devise easily scored stroke “scales” for use by the public.

Second, they point out the importance of a stroke victim or witness dialing 911 and accessing Emergency Medical Services (EMS), rather than attempting self-transport. There are many good reasons for this. Emergency personnel are trained in the rapid assessment of stroke patients.

In addition, through the EMS system there is an increasingly available transport option known as a mobile stroke unit. In addition to transporting a stroke victim, this unit may have the capability to help diagnose and treat the condition and communicate more easily with stroke specialists.

Finally, EMS personnel have unsurpassed knowledge of the location of comprehensive stroke centers and the best ways to quickly deliver patients to those facilities. The authors make the point that ideally, a stroke patient should be transferred from the scene of the stroke directly to the CSC. Due to distance or other factors, however, there may be a delay in reaching this facility. What then?

When a comprehensive stroke center really is too far away to provide quick treatment, the best alternative is a primary stroke center, or PSC. There are many more PSCs than CSCs across the United States.

Though patients can’t receive an embolectomy there, there is an alternative treatment known as tissue plasminogen activator that can be given. This is a medication given intravenously that can help to dissolve a clot. Primary stroke centers also have diagnostic equipment and can help stabilize patients until they can be transported for more definitive treatment.

Whether the patient reaches the CSC by a direct route or via a “connecting” facility, such as a primary stroke center or other hospital, the ultimate goal is to perform embolectomy within six hours of onset of a stroke. The authors note that treatment within this time frame offers the best chance for recovery.

Learn more about Dr. Meyers on his bio page here.

*Full list of authors: G. Lee Pride, Justin F. Fraser, Rishi Gupta, Mark J. Alberts, J. Neal Rutledge, Ray Fowler, Sameer A. Ansari, Todd Abruzzo, Barb Albani, Adam Arthur, Blaise Baxter, Ketan R. Bulsara, Michael Chen, Josser E. Delgado Almandoz, Chirag D. Gandhi, Don Heck, Seven W. Hetts, Joshua A. Hirsch, M. Shazam Hussain, Richard Klucznik, Seon-Kyu Lee, William J. Mack, Thabele Leslie-Mazwi, Ryan A. McTaggart, Philip M. Meyers, J. Mocco, Charles Prestigiacomo, Athos Patsalides, Peter Rasmussen, Robert M. Starke, Peter Sunenshine, Donald Frei, Mahesh V. Jayaraman, on behalf of the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery (SNIS

patient journey

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