Suspected Large Vessel Occlusion
Should Emergency Medical Services Transport to the Nearest Primary Stroke Center or Bypass to a Comprehensive Stroke Center With Endovascular Capabilities?
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A patient calls 911 for acute onset of stroke-like symptoms. Emergency medical services (EMS) arrives within 2 hours of stroke symptoms onset; National Institutes of Health Stroke Scale score=14.
Should the emergency medical technician (EMT) take the patient to the nearest primary stroke center or should they bypass the primary stroke center to take the patient directly to a comprehensive stroke center with endovascular capabilities?
Yes. EMT Should Take Patients to the Nearest Primary Stroke Center
Andrew M. Southerland and Karen C. Johnston
There is no debate that new data demonstrating significant efficacy of endovascular therapy (EVT) in acute ischemic stroke (AIS) is a paradigm shift. For select patients with anterior circulation stroke, proximal large vessel occlusion (LVO), and supportive brain imaging, timely reperfusion using stent retriever thrombectomy substantially increases the odds of a favorable outcome.1 However, the suggestion that EMS should bypass primary stroke centers (PSC) to proceed to comprehensive stroke centers (CSC) for patients with suspected moderate/severe AIS is premature.
If you don’t know where you're going, you might wind up someplace else.
– Yogi Berra
This case highlights the challenge of accurate prehospital diagnosis. In the scenario, an EMT arrives to find the patient with a National Institutes of Health Stroke Scale score=14, but this is misleading. Numerous prehospital stroke scales have been validated for EMS use, but are not measures of stroke severity and lack the requisite sensitivity/specificity for diagnosing anterior circulation LVO.2–4 Even more compelling is the discrepancy in number of stroke patients screened compared with the small fraction who are ultimately eligible for EVT (Extend-IA [Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-Arterial] trial reported <1%).5 Using our current tools, selective bypass to a CSC would result in many endovascular …