The chances of returning to a normal life after a stroke can depend on prompt clot-busting medication.
Among the many urgent things paramedics have to deal with when attending a seriously ill casualty are two pressing priorities:
- Trying to work out what is wrong with the patient
- Getting them to hospital as quickly as possible.
And like many other conditions, it is also very important to get the diagnosis of stroke right - not only to decide whether it is indeed a stroke that has struck the casualty, but also what kind of stroke.
There are two kinds of stroke - one caused by bleeding in or around the brain (hemorrhagic stroke), and the other caused by a blocked blood vessel in the brain (ischemic stroke).
Stroke patients have to wait until they are at the hospital to get treatment
Currently, ischemic stroke patients have to wait until they get to the hospital before they can receive clot-busting drugs. But now a new study published in the New England Journal of Medicine concludes it is feasible for paramedics to deliver the drugs on the way to the hospital.
The study was funded by the National Institutes of Health (NIH) National Institute of Neurological Disorders and Stroke (NINDS), whose acting director Dr. Walter Koroshetz says:
"Because a blocked blood vessel causes brain damage over minutes to hours this pre-hospital approach to treatment is sure to be adopted and refined in future clinical research studies. Ultra-early brain salvage in stroke patients will someday surely reduce the tremendous burden of disability and death due to stroke."
In most stroke trials, the effectiveness of treatment is tested by giving patients drugs once they get to the hospital, after they have undergone diagnostic tests. But this could be hours after the stroke event itself.
For the new study, Dr. Jeffrey Saver, director of the University of California, Los Angeles (UCLA) Comprehensive Stroke Center, and colleagues developed a new way of conducting a stroke clinical trial.
They asked themselves: is it possible to reduce the time between stroke event and treatment by having paramedics give the patient the correct drug once stroke is suspected - before the patient reaches the hospital?
Stroke patients received drugs faster when paramedics are able to give them
The researchers set up a clinical trial called the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) Phase 3 Trial. In this multi-center study, 1,700 patients suspected of having had a stroke were randomly assigned to magnesium sulfate or a placebo by paramedics within 2 hours of their stroke.
- Stroke is the leading cause of adult disability and the third leading cause of death in the US where it claims nearly 130,000 lives a year
- Nearly 9 out of 10 strokes are ischemic strokes, when blood flow to the brain is blocked
- The chances of surviving a stroke are greater when emergency treatment begins promptly.
To help paramedics rapidly assess whether their patients had suffered a stroke, the researchers showed them how to use a version of the Los Angeles Prehospital Stroke Screen that they had adapted.
After assessing the patient with the screen, the paramedics then consulted neurologists via cellphone to decide if the patient should be included in the study. If the neurologist said yes, then permission was sought from the patient or their representatives for inclusion in the trial.
The results showed that patients were able to receive a study drug faster on this trial - using paramedics to administer the medication - than on other stroke trials.
The study showed that 74.3% of patients received a study drug within 60 minutes of stroke onset.
The particular drug used in the trial - magnesium sulfate - did not improve patient outcomes 90 days after stroke compared with placebo. In animal studies, the drug has been shown to protect the brain from stroke damage.
However, the researchers point out that there are many promising drugs and devices in the pipeline that can now be tested with this new protocol - which opens a window of opportunity for improving their effectiveness.
Dr. Saver says there are several trials in progress that are using elements of the FASTMAG approach and applying them to test promising agents for neuroprotection, and notes:
"The most important finding of this study was that medication could be delivered within the 'golden hour' of first onset of stroke symptoms when there is the greatest amount of brain to save."
The team believes the study is a step-change in the treatment of stroke, and perhaps even other neurological conditions. And they say paramedics are not only eager to give their patients the best possible care, but are also capable of being highly invaluable partners in clinical trials where timing of treatment is critical.
In December 2014, Medical News Today learned of another NEJM study that showed prompt stent action helps severe stroke patients recover better and faster. That study investigated a procedure where the offending blood clot is removed via a stent. It concluded that when performed within the first 6 hours of a stroke, it is effective and safe.