We identified references for this Review by searching PubMed for articles published between Jan 1, 1980, and Dec 31, 2012, that contained the terms “prehospital” and “stroke”; “stroke management”; “emergency medical service” and “stroke”; or “thrombolysis” and “stroke”. We also identified articles through searches of reference lists and our own files. We reviewed only articles published in English, focusing on originality and relevance to the broad scope of this Review.
ReviewStreamlining of prehospital stroke management: the golden hour
Introduction
Stroke is the most frequent cause of permanent disability in adults and one of the most frequent causes of death.1, 2 In addition to substantial individual suffering, stroke results in enormous costs to society.3, 4 Intravenous thrombolysis with alteplase is an effective treatment for acute ischaemic stroke, as shown in several randomised and placebo-controlled multicentre studies.5, 6, 7, 8, 9 The approved time window for stroke treatment after the onset of symptoms ranges from 3·0 h to 4·5 h in various countries. However, even within this time window, the benefit of treatment strongly decreases as time passes (the so-called time-is-brain concept).10, 11 The same time-sensitivity can be expected with novel endovascular treatment options.12
The number needed to treat with intravenous alteplase for a good outcome, defined as a modified Rankin score of 0–1, has been calculated at 4·5 if treatment is initiated within 1·5 h after the onset of symptoms.7, 13 This number doubles to 9 if treatment is initiated between 1·5 h and 3·0 h after symptom onset, and reaches 14·1 if treatment is delivered between 3·0 h and 4·5 h after onset7 (smaller numbers needed to treat might have been achieved if the modified Rankin scale had been used in its original full seven-level version). For every minute a large-vessel stroke goes untreated, an estimated maximum of 1·9 million neurons and 14 billion synapses are potentially lost, suggesting that even small differences in time to reperfusion could produce clinically relevant differences.14
In this Review of prehospital stroke management we emphasise that all links in the prehospital stroke rescue chain must be optimised so that in the future more than a small minority of patients can profit from time-sensitive acute stroke therapy.
Section snippets
Prehospital stroke management to reduce treatment delay
Before alteplase can be delivered, a complex diagnostic work-up (including neurological examination, imaging, and laboratory analysis) is necessary for exclusion of haemorrhage, diseases mimicking stroke, and other contraindications. This work-up consumes crucial time, often precluding treatment within the approved therapeutic window. Although in some experienced specialised centres administration of intravenous altepase to 20–30% of patients with ischaemic stroke within 3 h is possible,15, 16
Delay in seeking medical attention
Delay in seeking medical attention after the onset of stroke symptoms is an important reason for the underuse of thrombolytic therapies.36, 37, 38, 39, 40 Reported delays in seeking treatment range from 38 min to 4 h.41, 42, 43, 44, 45 Between 24% and 54% of patients with stroke do not call for help within 1 h,41, 45, 46 and many do not seek medical care at all. Reports suggest that only 38–65% of patients use EMS.23, 27
Much evidence suggests, however, that the use of EMS is a crucial variable
Educational programmes for EMS personnel
A great potential for optimisation of stroke management lies with the EMS. The structures of EMS are highly variable between countries and even between states or areas of individual countries.90, 91 Therefore, generalisation of the results of studies in one setting to other settings is difficult. Fairly good evidence already exists for several factors, such as the effectiveness of educational programmes for EMS personnel, the use of instruments for symptom recognition, priority transport to
Use of ambulances as clinical laboratories for research on stroke treatments
Interest is increasing in diagnostic and therapeutic approaches for use in the prehospital phase of stroke management; such approaches might allow responders to reach the patient at a time when the chance of rescuing ischaemic brain tissue is highest. Several ambulance-based studies have been done or are underway on topics including diagnostic measures such as ultrasound140 or electrical impedance tomography for detection of haemorrhage141, 142 and therapeutic approaches such as neuroprotection
Conclusion
This Review clearly shows that every link in the prehospital stroke rescue chain matters and must be further studied for potential improvements. Further research is needed to establish the most effective public awareness programmes that can affect behaviour in an actual emergency situation. Guideline-recommended measures, such as ongoing EMS education, use of stroke recognition scales, triage to hospitals with stroke expertise, and advance notification to the receiving hospitals, should be
Search strategy and selection criteria
References (172)
- et al.
Population-based study of event-rate, incidence, case fatality, and mortality for all acute vascular events in all arterial territories (Oxford Vascular Study)
Lancet
(2005) - et al.
Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modelling
Lancet Neurol
(2009) - et al.
Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials
Lancet
(2010) - et al.
Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis
Lancet
(2012) - et al.
Alteplase for ischaemic stroke—much sooner is much better
Lancet
(2010) - et al.
Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study
Lancet
(2007) - et al.
Intravenous desmoteplase in patients with acute ischaemic stroke selected by MRI perfusion-diffusion weighted imaging or perfusion CT (DIAS-2): a prospective, randomised, double-blind, placebo-controlled study
Lancet Neurol
(2009) - et al.
Implementation and outcome of thrombolysis with alteplase 3–4·5 h after an acute stroke: an updated analysis from SITS-ISTR
Lancet Neurol
(2010) - et al.
Clinical characteristics of patients with early hospital arrival after stroke symptom onset
J Stroke Cerebrovasc Dis
(2005) - et al.
Awareness of stroke symptomatology and cardiovascular risk factors amongst stroke survivors
J Stroke Cerebrovasc Dis
(2012)
Understanding diversity among prehospital care delivery systems around the world
Emerg Med Clin North Am
Heart disease and stroke statistics—2012 update: a report from the American Heart Association
Circulation
The economic cost of brain disorders in Europe
Eur J Neurol
Tissue plasminogen activator for acute ischemic stroke
N Engl J Med
Thrombolysis with alteplase 3 to 4·5 hours after acute ischemic stroke
N Engl J Med
The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial
Lancet
Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study
Neurology
Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes
Circulation
Good clinical outcome after ischemic stroke with successful revascularization is time-dependent
Neurology
Time is brain—quantified
Stroke
Intravenous tissue-type plasminogen activator therapy for ischemic stroke: Houston experience 1996 to 2000
Arch Neurol
Reducing in-hospital delay to 20 minutes in stroke thrombolysis
Neurology
Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility
Neurology
Utilization of intravenous tissue plasminogen activator for acute ischemic stroke
Arch Neurol
Thrombolysis for acute ischemic stroke: results of the Canadian Alteplase for Stroke Effectiveness Study
CMAJ
Acute stroke care in the US: results from 4 pilot prototypes of the Paul Coverdell National Acute Stroke Registry
Stroke
Times from symptom onset to hospital arrival in the Get with the Guidelines–Stroke program 2002 to 2009: temporal trends and implications
Stroke
A systematic review of barriers to delivery of thrombolysis for acute stroke
Age Ageing
A comprehensive review of prehospital and in-hospital delay times in acute stroke care
Int J Stroke
Critical factors determining access to acute stroke care
Neurology
Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.)
Stroke
A multicentre observational study of presentation and early assessment of acute stroke
BMJ
Time to admission in acute ischemic stroke and transient ischemic attack
Stroke
Prehospital and hospital delays after stroke onset–United States, 2005–2006
MMWR Morb Mortal Wkly Rep
Hospital arrival time and intravenous t-PA use in US academic medical centers, 2001–2004
Stroke
Factors associated with prehospital delays in the presentation of acute stroke in urban China
Stroke
Will delays in treatment jeopardize the population benefit from extending the time window for stroke thrombolysis?
Stroke
Reducing prehospital delay in acute stroke
Nat Rev Neurol
Public perception of stroke warning signs and knowledge of potential risk factors
JAMA
Knowledge of stroke risk factors and warning signs among Michigan adults
Neurology
Care seeking after stroke symptoms
Ann Neurol
Temporal trends in public awareness of stroke: warning signs, risk factors, and treatment
Stroke
Knowledge of tissue plasminogen activator for acute stroke among Michigan adults
Stroke
Rapid response to stroke symptoms: the Delay in Accessing Stroke Healthcare (DASH) study
Acad Emerg Med
Emergency calls in acute stroke
Stroke
Prehospital delay after acute stroke in Kaohsiung, Taiwan
Stroke
Perceptual, social, and behavioral factors associated with delays in seeking medical care in patients with symptoms of acute stroke
Stroke
Stroke symptoms and the decision to call for an ambulance
Stroke
Factors associated with delayed admission to hospital and in-hospital delays in acute stroke and TIA: a prospective, multicenter study. Seek-Medical-Attention-in-Time Study Group
Stroke
Prehospital and emergency department delays after acute stroke: the Genentech Stroke Presentation Survey
Stroke
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