Prehospital stroke care: new prospects for treatment and clinical research

Abstract

Brain cells die rapidly after stroke and any effective treatment must start as early as possible. In clinical routine, the tight time-outcome relationship continues to be the major limitation of therapeutic approaches: thrombolysis rates remain low across many countries, with most patients being treated at the late end of the therapeutic window. In addition, there is no neuroprotective therapy available, but some maintain that this concept may be valid if administered very early after stroke. Recent innovations have opened new perspectives for stroke diagnosis and treatment before the patient arrives at the hospital. These include stroke recognition by dispatchers and paramedics, mobile telemedicine for remote clinical examination and imaging, and integration of CT scanners and point-of-care laboratories in ambulances. Several clinical trials are now being performed in the prehospital setting testing prehospital delivery of neuroprotective, antihypertensive, and thrombolytic therapy. We hypothesize that these new approaches in prehospital stroke care will not only shorten time to treatment and improve outcome but will also facilitate hyperacute stroke research by increasing the number of study participants within an ultra-early time window. The potentials, pitfalls, and promises of advanced prehospital stroke care and research are discussed in this review.

Figure 1. Stroke emergency mobile unit

CT scanner on the left side; a separated shielded working station is placed on the right side including a point-of-care laboratory. The ambulance is used for immediate diagnostic workup and transportation of patients under intensive care conditions.

Figure 2. Different approaches of pre- and in-hospital stroke management

The first row represents standard care with hospital-based diagnostic workup and treatment. The second row illustrates the “freezing” concept like Field Administration of Stroke Therapy–Magnesium (FAST-MAG) with application of a neuroprotective agent by paramedics and delivery of patients after prenotification of hospital-based stroke teams. The third row exemplifies the “ambulysis” approach with prehospital brain imaging and point-of-care laboratory, starting IV thrombolysis in the field, and transport of patients to specialized facilities for interventional treatment (if indicated). tPA = tissue plasminogen activator.