Acute ischemic stroke is a severe and life-threatening disease, particularly when caused by a large-vessel occlusion. The only available 2 treatment options are intravenous alteplase and endovascular ...therapy (mechanical clot removal), both of which are highly time-dependent. Thus, rapid patient transfer, diagnosis, and treatment are crucial, and time-consuming imaging methods and overly selective treatment selection criteria should be avoided. A combined endovascular therapy approach using stent-retrievers and aspiration is the most effective way to achieve fast first-pass complete reperfusion and should thus be used. To diagnose and treat patients as fast as possible, the organization of existing systems of care, and particularly pre-hospital transfer systems, have to be changed. Several different transport models are currently in use because the optimal patient transfer paradigm is highly dependent on local geography and hospital efficiency.
Prehospital stroke triage is especially complicated because the optimal balance between triage sensitivity (ie, triaging as many patients as possible who can benefit from treatment at a ...treatment-capable centre) and specificity (ie, avoiding triaging patients with stroke mimics to a stroke centre) depends on local circumstances such as geography, available staff resources, and financial constraints at the prehospital and hospital level.1 As such, there is no one-size-fits-all solution when it comes to prehospital stroke triage, and the triage strategy needs to be tailored towards the individual circumstances. The trial compared Norway's standard prehospital stroke triage approach—which consists of a face, arm, speech, time test followed by discussion with an in-hospital stroke physician and a subsequent triage decision—with a standardised National Institutes of Health Stroke Scale (NIHSS) prehospital assessment that was performed by paramedics. Furthermore, stroke is seen relatively rarely in the paramedic daily routine; in some studies, acute stroke accounts for less than 2% of all emergency medical service dispatches,5 and it is very difficult to achieve high proficiency in assessing such a rare event. ...in ParaNASPP, due to the COVID-19 pandemic, the investigators had to temporarily halt enrolment, and in-person NIHSS training had to be switched to a virtual format.
Endovascular treatment is a highly effective therapy for acute ischemic stroke due to large vessel occlusion and has recently revolutionized stroke care. Oftentimes, ischemic core extent on baseline ...imaging is used to determine endovascular treatment-eligibility. There are, however, 3 fundamental issues with the core concept: First, computed tomography and magnetic resonance imaging, which are mostly used in the acute stroke setting, are not able to precisely determine whether and to what extent brain tissue is infarcted (core) or still viable, due to variability in tissue vulnerability, the phenomenon of selective neuronal loss and lack of a reliable gold standard. Second, treatment decision-making in acute stroke is multifactorial, and as such, the relative importance of single variables, including imaging factors, is reduced. Third, there are often discrepancies between core volume and clinical outcome. This review will address the uncertainty in terminology and proposes a direction towards more clarity. This theoretical exercise needs empirical data that clarify the definitions further and prove its value.
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