Comprehensive stroke care: faster, closer, better

There are two key causes of stroke: Something causes bleeding in the brain (hemorrhagic stroke), or a blocked artery obstructs the flow of blood in the brain (ischemic stroke). Ischemic strokes account for 80 percent of all strokes.

Regardless of what causes the stroke, a speedy, accurate diagnosis and subsequent treatment are paramount as brain cells begin to die after just a few minutes without blood. "Time is brain" means preventing brain tissue loss as much as possible, because undersupply can cause restricted or lasting physical and cognitive impairments based on the type, severity, location and time frame of the stroke injury.

In-ambulance care for stroke patients during their transport may save valuable time. According to a recent study by the Charité – Universitätsmedizin Berlin, mobile stroke units (STEMOs) play a key role in this setting: "Mobile stroke units are specialized ambulances equipped with a built-in CT scanner to obtain on-the-spot imaging to check for cerebral hemorrhage and diagnose stroke. Patients can then be immediately started on thrombolytic therapy long before they arrive at the hospital," explains Prof. Heinrich Audebert in a MEDICA-tradefair.com interview.

"Door-to-needle time" during which the patient receives thrombolytic therapy - the infusion of drugs to dissolve dangerous clots in blood vessels - is crucial. The treatment must be administered within 4.5 hours of stroke symptom onset. According to Audebert, the findings of the study show that the sooner you can start thrombolysis, the more effective the outcome will be for stroke patients as it may prevent permanent disabilities for many patients. If necessary, the hospital can also perform a thrombectomy, a catheter-based procedure to remove the artery occlusion. Unlike thrombolytic therapy, patients who undergo this procedure can expect a better outcome, though only about15 percent of all patients with stroke qualify for thrombectomy.

Imaging procedures are a key component to clinically diagnose and determine the cause of stroke and start the proper treatment. Hemorrhagic strokes require neurosurgery. Intravenous thrombolytic therapy would be fatal in this case as it prevents blood from clotting.

While multidisciplinary stroke care units are commonplace in large hospitals and university hospitals, specialized ambulances are still not as widespread. That's because these units require specialized staff and equipment. Says Audebert: "Besides the computer tomograph and a CT scan to reveal the structure of the vascular system, called CT angiogram, the STEMO units are also equipped with a mini-laboratory and the typical equipment found in an ambulance vehicle. In addition to a neurologist trained in emergency medicine, the unit is always accompanied by a specially trained medical care assistant. A neuroradiologist is included via teleradiology to assist with stroke patients." The continued development of equipment and telemedicine technology and infrastructure will increase the prevalence of these units, especially as a resource to rural and remote settings where a hospital with a stroke unit is not easily accessible.

After a stroke, a patient's life depends on getting acute care at a hospital. Continued monitoring of the patient’s vital signs and brain function are crucial. More imaging and scans are required if the specialists suspect more brain damage due to another stroke. However, "right now, acute stroke units do not feature an imaging system. Having a system right at a patient's bedside would be a notable benefit for physicians," says Dr. Matthias Gräser in a MEDICA-tradefair.com interview.

He is developing a compact system that is designed to close this gap since transporting the patient from the intensive care unit to radiology can be a complex endeavor and is not without risk. Gräser and his team at the University Medical Center Hamburg-Eppendorf and the Technical University of Hamburg focus on a Magnetic Particle Imaging (MPI) solution, which does not expose the patient to ionizing radiation and requires only small amounts of contrast medium. The MPI method also has low magnetic fields compared to the strength of an MRI machine. The system is designed to enable bedside monitoring.

Patients should ideally already embark on rehabilitation during their inpatient hospital stay. This is yet another great way to make better use of valuable time by utilizing the brain's plasticity. It can compensate for the post-stroke loss of function through the limited creation of new nerve cells or by prompting surviving nerve cells to take on other functions. Movement and speech difficulties can be improved with the help of physiotherapists, occupational therapists, and speech-language pathologists.

Having said that, the success of post-stroke rehabilitation is often impeded since there are not enough therapists that support the patient in performing the exercises. If patients are asked to exercise on their own, they tend to quickly lose interest due to monotony. Sometimes patients also perform the exercises incorrectly and make mistakes. Robots can assist patients by guiding their limbs. Gamification, an approach that uses computer games to train motor sequences and cognitive skills on a PC, tablet or via AR and VR devices, ensures that rehabilitation is more fun and motivating. Robots and games never get tired or inattentive and patiently assist in correcting exercise mistakes.

"Comprehensive stroke care" – this patient care approach includes emergency medical services, rehabilitation and beyond. Not only does this involve interdisciplinary interaction, but it also means patients depend on a multitude of devices. The human-technology interface always bears the risk that the overall patient care situation gets confusing and that key information is lost. Added to this is the pervasive shortage of healthcare professionals who are challenged with providing care to an increasing number of patients as a result of an aging population and lifestyle factors such as obesity and diabetes that increase the risk of stroke.

Time is our most important resource, which is why using it effectively and wisely is the key to successful patient care. Time is brain – indeed, time is of the essence for stroke patients as preserving cognitive function means a higher quality of life.