Abstract
In this issue of the journal, there are several papers that deal with one of the recurring themes in stroke care: that of recognition and first reaction to stroke symptoms.
Stroke clinicians may not be the first port of call after sudden visual loss but recognise, of course, that the mechanism may be ischaemic. Bustamente and colleagues demonstrate that implementation of a retinal stroke-code protocol assists visual recovery through facilitating early thrombolysis among patients with central retinal artery occlusion. The results of ongoing randomised controlled clinical trials will likely provide an answer to whether we should treat CRAO patients with intravenous thrombolysis.
Wenstrup et al. have undertaken a systematic review of emergency medical dispatcher recognition of stroke. As first contacts, dispatchers need to be alert to many emergency scenarios but stroke is certainly among the most urgent, treatable and otherwise devastating conditions. Sadly, the authors find that across many reports, the dispatchers’ sensitivity to recognise stroke could be as low as 18% and that the positive predictive value of their assessments ranged from 88% in some settings down to just 24% in others. Should we all know how our local dispatchers would perform?
In some regions, an option open to dispatchers may be to send a mobile stroke unit (MSU). MSU have been demonstrated to shorten time to treatment and improve outcomes for patients with acute ischaemic stroke. However, the impact of MSU dispatch on care for patients with intracerebral haemorrhage is unknown. Schwabauer and colleagues examined the incidental subgroup of patients from the Berlin trial of MSU, B-PROUD. They found that systolic blood pressures were lower on hospital arrival in patients collected by MSU, but saw no difference in early survival or outcome. However, their sample was certainly underpowered for formal analysis.
Thus, it is relevant that a review and expert consensus statement also published in this issue by Parry-Jones and colleagues urges implementation of acute care bundles for patients with ICH, because they improve functional outcomes. Among the proposed bundle would be steps such as stabilisation, rapid imaging, coagulation tests, reversal of anticoagulation and commencement of blood pressure lowering: all steps that may be considered within an MSU.
Alongside these papers, colleagues will find several further publications on outcomes in ICH. This wealth of excellent work in ICH is a welcome sign that a group of hitherto rather underserved patients are now receiving close attention.