Advancement In Stroke Response And Recovery

When it comes to the world of medical emergencies, there are few events that get a team in action like the report of a patient exhibiting symptoms of a stroke. Each member plays a vital role in an ongoing effort to expedite treatment, valuing the reality that time is brain.

The American Stroke Association (ASA), a division of the American Heart Association (AHA), estimates that about 795,000 Americans have a new or recurrent stroke each year. Of these, 142,000 cases are fatal, comprising the fifth cause of death and the leading cause of disability in the United States. Though these statistics emphasize the commonality and severity of stroke events, the ASA also indicates that “opportunities for stroke recovery have never been greater.”¹

Such optimism is undoubtedly attributed in part to the commitment, innovation, and persistence of the emergency dispatchers who collaborate with specialized teams both on the road and at the hospital to ensure efficient care for stroke patients. The impactful hours after symptoms begin can define the patient’s long-term outcome, determining whether the patient may return home to recuperate or face an arduous, limited rehabilitation, if lucky enough to survive.

Stroke: the inside story

Every moment matters for the destructive battle occurring within the patient’s brain during a stroke or cerebrovascular accident (CVA), which can be simplified into two main origins:

An ischemic stroke (which comprises 87% of strokes) occurs when a vessel supplying blood to the brain is obstructed, mainly caused by blood clots that have broken loose and traveled from the heart, upper chest, or neck (cerebral embolism) or that have developed at the site of fatty deposits that line the vessel walls (cerebral thrombosis). The blood clot cuts off the blood supply, which damages or kills the affected downstream brain cells—32,000 neurons per second.²

Less common, but generally more severe, is hemorrhagic stroke (which comprises 13% of strokes). These cases occur when a weakened vessel ruptures and bleeds into the brain. Blood accumulates and compresses the surrounding brain tissue, debilitating its functionality. Hemorrhaging in the brain can cause increased pressure within the skull or spasms in the blood vessels, which may lead to decreased level of consciousness, unconsciousness, or death.

FAST symptoms

Observable stroke symptoms depend on the location of the brain that is deprived (or compressed), which is why stroke patients can be affected differently. The standard stroke symptom checklist is best represented with the appropriate acronym “F.A.S.T.” This list of symptoms and associated observational questions is closely related to the Medical Priority Dispatch System^™(MPDS^®) Stroke Diagnostic Tool used to determine evidence of stroke in the prehospital environment.

• F = Face Drooping: Does one side of the face droop or is it numb? Ask the person to smile. Is the person's smile uneven?
• A = Arm Weakness: Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?
• S = Speech Difficulty: Is speech slurred? (The MPDS Stroke Diagnostic Tool asks the patient to repeat the phrase “The early bird catches the worm.”)
• T = Time to call 911: Stroke is an emergency. Every minute counts. Call 911 immediately. Note the time when any of the symptoms first appeared.³

Beyond impairments discovered during this questioning, less obvious stroke symptoms include sudden numbness or weakness of face, arm, or leg, especially on one side of the body; confusion, trouble speaking or understanding speech; trouble seeing in one or both eyes; trouble walking, dizziness, loss of balance or coordination; and severe headache with no known cause.⁴

Charles Gipson, Quality/Compliance Manager at MEDIC EMS of Scott County (Davenport, Iowa, USA), emphasizes the importance to push through hesitations in this critical point of stroke discovery. “Time is neurons,” he said. “Every minute we fiddle around … tick tock … it’s more brain.”

But that efficiency doesn’t always begin with early symptom recognition and an immediate call to 911. “Elderly people having stroke symptoms won’t call 911 for anything,” Gipson said. “They’re part of a generation that doesn’t want to bother anybody. If they feel they might be in some trouble, they try to call the neighbor who is a nurse instead. But even if you have a trained medical professional at your door, they’re just a highly educated bystander without the team, equipment, or means to help.”

While ensuring that stroke symptoms are appropriately recognized and immediately sent efficient aid, it’s also important for EMDs to offer reassurance. A stroke patient, even with a decreased level of consciousness or responsiveness, may be completely aware of his or her surroundings, though with limited ability to communicate. Exercising compassion while outlining the next steps for the patient and the treatment they will receive can help alleviate some of the patient’s disorienting position.⁵

Critical assessment

Beyond early recognition, the immediate medical treatment of stroke patients provides an essential lifeline to prevent extensive brain damage.

Over the last 30 years, advancements in thrombolytic therapy have proven to be widely successful in dissolving blood clot obstructions for patients suffering from an ischemic stroke, mainly due to the use of tissue plasminogen activator (tPA). This medication is administered through an IV in the arm, aiming to dissolve the clot and improve blood flow to the part of the brain that’s deprived.

However, this same treatment would further complicate the situation for a patient suffering from a hemorrhagic stroke. TPA treatment could cause the stroke patient to bleed out at an increased pace, which could quickly become fatal. Thus, a CT scan is essential for a radiologist to review imaging of what is occurring in the brain before choosing the appropriate plan for stroke treatment.

Conversely, hemorrhagic stroke requires controlling the bleeding and reducing pressure in the brain caused by excess fluid. Medications may be administered to counteract regularly used blood thinners (if applicable) or to lower blood pressure, avoid blood vessel spasms, and prevent seizures. A large bleed may require surgery to remove blood and relieve built-up pressure or to repair blood vessel damage.⁶

Time and treatment

Another limitation of the tPA treatment is that it must be administered early in the “stroke treatment time window” to be effective, which is why the MPDS prompts the EMD to collect symptom onset information. This time frame is a research topic debated by different organizations, but it is most often referred to as a preferred 3- (to 4.5-) hour window (determined locally in the MPDS), often aiming for the “golden hour” after symptoms arise.

Research shows that administering tPA within the early stages of ischemic stroke results in nearly twice as favorable an outcome for the patient.⁷ Unfortunately, many people don’t arrive at the hospital in time to receive treatment that could potentially save lives and reduce long-term effects for stroke patients.

In recent years, another treatment for ischemic stroke has been developed that has the potential to be more effective than tPA (thrombolysis) alone. Mechanical thrombectomy (MT) involves making a small incision—typically in the wrist or groin—and inserting a catheter into an artery. The catheter is threaded through the artery into the brain vessel where the blood clot exists, then a wire-net device called a stent retriever is used to mechanically remove the clot, thus restoring blood flow and oxygen to the affected area of the brain.⁸

Mechanical thrombectomy has several advantages over thrombolysis. These include extending the therapeutic window beyond the 4.5-hour guideline for thrombolytics, up to 8 hours, treating patients that may have clots resistant to thrombolysis, and treating patients with certain contraindications to thrombolysis.^{9, 10}

Though it may be surprising that evidence of stroke does not currently elicit a lights-and-siren response while utilizing the MPDS (due to careful analysis of introducing greater risk to save negligible time for a stable patient),¹¹ the protocol serves as an important tool to expedite the process of identifying symptoms, diagnosing evidence of stroke, sending the appropriate response, and notifying the hospital’s stroke team for advance preparation before patient arrival.

Of course, not every patient with reported symptoms has truly experienced a stroke; in fact, the statistics may be as low as about 50%, according to Gipson (though overresponse is preferred to avoid missing true events). Patients report concerns over pupils not matching, Bell’s palsy (facial droop), elbow pain from a fall (numbness), hypoglycemia or diabetic issues (weakness and confusion), pregnancy (fainting or decreased consciousness), previous stroke (prior deficits), trauma, and even THC gummy intoxication (disorientation).

Often, stroke patients complain of general weakness actually caused by sepsis. “A lot of these patients still need to go to the hospital,” Gipson said. “Usually, their blood sugar is out of whack, they look like garbage, they are weak, and their speech is slurred. You have to check the patient’s vital signs to look for indicators. But we can’t know the whole story without imaging inside the brain. The CT is pivotal to that.”

Hospital preparation

Emergency Medical Dispatchers may choose to send stroke alerts with the Stroke Diagnostic Tool results, the symptom onset time, and the name and phone number of anyone who witnessed the onset of stroke symptoms (the alert is usually a 15-minute warning, depending on ambulance response, assessment at the scene, and transportation). These notifications prepare the hospital’s emergency department, neurologist, laboratory, and radiology/CT imaging staff of a pending stroke patient arrival. The ambulance crew then cancels or confirms the notification based off physical findings.

MEDIC EMS of Scott County operated this way until their alerts were frequent enough that the hospital chose to add additional CT scanners to avoid clearing imaging machinery and delaying routine patients during emergency intakes. To prevent alert fatigue, the hospital found a solution that no longer required advance warning. “They said, ‘You can stop calling us. We’ve added CTs, we have point of care. We’re always ready,’” Gipson said.

Mobile Stroke Unit: a gold standard in stroke care

Thirty years ago, the IAED^™ released an official statement predicting that “stroke could become one of the defining elements of the driving force behind prioritized EMD.”¹² Today, there is a literal “drive” to bring the hospital to the patient, which is the aim of a mobile stroke unit.

The Northwestern Medicine Central DuPage Hospital (Winfield, Illinois, USA) has successfully deployed their Mobile Stroke Unit (MSU) over the last eight years and is recognized as a trailblazer in the industry, though they were technically the seventh unit of its type in the nation (of roughly 25 now in use).

Northwestern Medicine’s MSU team collaborates with DuPage Public Safety Communications (DU-COMM), a large, consolidated dispatch center located in the Chicago suburbs that dispatches for 23 police and 22 fire agencies. When evidence of a stroke is indicated, DU-COMM sends a standard EMS and fire response and auto-launches the 33-foot, $1 million MSU rig, which more closely resembles a fire truck.

Weighing in at 33,000 pounds, the MSU is equipped with a full-size CT scanner, ventilator, cardiac monitors, medication pumps, remote access capabilities, specialized stroke medications, and room for a stretcher. On board is a driver and a specially trained three-person crew with a critical care neuro nurse, a critical care paramedic, and a CT technologist. This specialized team aims to treat stroke patients an average of 30 minutes earlier than the standard ambulance transportation treatment window by revolutionizing emergency response.

Wheels to patient: origins and growth

Northwestern Medicine’s MSU concept began when Hospital Medical Director (Stroke and Neurointerventional Programs) Dr. Harish Shownkeen was fascinated by a mobile stroke unit he’d seen while visiting a colleague in Germany. He collaborated with EMS Medical Director Dr. Steve Graham to tap into the potential value of offering definitive stroke treatment out in the field, referring to the initiative as a “quantum leap” in stroke response.

“We are the first [Illinois Department of Public Health] IDPH-approved mobile stroke unit in the state of Illinois,” Shownkeen said. “That tells you there was commitment, [there] was passion, and everybody was geared to the same thing: trying to save as many stroke patients as they can, as quickly as possible.”¹³

The initial idea took research and persuasion to invest in this new, costly endeavor, earning buy-in from those who didn’t fully understand the concept. As the MSU team grew, they understood they were delving into a unique situation, though they could rely on some networking with a few established mobile stroke teams, including UCLA in California (USA).

“We knew there was no playbook for this one, which was exciting but scary,” said EMS system coordinator Justin Williams, CCEMT-P. “We did a ride-along with a mobile stroke unit in Memphis, Tennessee (USA). Though their resources were different, we got a feel for how things work. To create our own unit, we built on good theories and good intentions—a complete exercise in blind trust.”

The time came to present the plan to Northwest Medicine leadership and the EMS system, projecting the outcomes they hoped to see. The DU-COMM center had never dispatched for a hospital entity before, but they were receptive, figuring out the evolution of the program together.

“It was an entire community of people fighting for one [the stroke victim] in that moment,” Williams said. “The outcomes are from several pieces that came together with effort and the same vision. We had a large group of fire chiefs saying, ‘We trust you because you’ve never lied to us yet.’”

Establishing a positive foundation in communication was central to making this innovation run smoothly. “I can’t say enough good about the MSU crew,” said DU-COMM Training Manager Amanda Schretter. “Their passion is pouring through them. They came out with the mobile stroke unit so we could tour it, sharing their knowledge and experience with our team of dispatchers so we could understand what we’re sending out. There’s no replacing that relationship.”

Patient processes

The Illinois MSU went live on Jan. 18, 2017. Since that time, they’ve doubled their service area from six towns to 12, with increased trust in what they do. The unit responds to each stroke case dispatched between 8 a.m. and 8 p.m., resulting in an average of two to three times per day within a service population of 870,000 people. The MSU also coordinates to meet ambulance transportations from 30 or 40 minutes away at one of their five predetermined meeting points to expedite the patient’s thrombolytic therapy before hospital arrival.

After making contact at the scene, the driver and CT tech immediately level and turn on the CT scanner for calibration (which takes 8–10 minutes) while the paramedic and neuro nurse assess the patient.

“It’s a very efficient process,” said Keely Buffo, manager of the MSU. “We each have our jobs. We have to be stopped to complete imaging, but otherwise we can get rolling.”

Using telemedicine, a radiologist can read the scan and a neurologist can determine care (whether the patient is a candidate for tPA medication). They can see what the MSU team is seeing in the field and explain treatment to the patient to get consent.

“We can mix the medication while en route to the hospital; in case the patient deteriorates rapidly, we are outfitted with additional equipment in case we need to intubate,” Buffo said.

Unlike many emergency services, Northwestern Medicine’s MSU team has a connection with the hospital to check on patients during their care. “It’s interesting what they remember when you visit them,” Buffo said. “It’s such a wild experience for them. They’ll remember it was bumpy, or they might remember your faces.”

One notable patient memory for the MSU team occurred in January 2023 when they helped one of their own. Jim Curtin, a retired Chicago firefighter had helped transport stroke patients for 30 years but didn’t recognize himself exhibiting symptoms of stroke until a friend called 911.

“Next thing I remember, I turned and the Elburn paramedics were standing there. I’m like, ‘what are they doing here?’” Curtin said. The MSU performed a CT scan, revealing three blood clots in his brain. After receiving clot-busting medications, one clot dissolved right away, and Curtin made a full recovery.¹⁴

“Time is of the essence in something like this,” Curtin said. “It’s just, I think it's so incredible. I just can't believe there's only one in the state.”¹⁵

Collaborative outcomes

The MSU team has noticed a heightened awareness of stroke throughout the community with patients and family members who are knowledgeable about stroke medications acting and asking for help sooner. That cooperation leads to amazing results, sometimes assessing, scanning, and providing treatment all within 45 minutes of symptom onset.

Studies examining patient data over several years show that Northwestern Medicine’s MSU patients receive treatment earlier (often within the first hour of stroke onset) and their return to functional baseline is higher compared to those transported via traditional EMS.¹⁶

The development of the Northwestern Medicine’s Mobile Stroke Unit showcases an inspiring display of innovation and collaborative efforts among the 911 center, local hospital, fire departments, and the specialized team that make this lifesaving initiative possible.

It’s understandable that mobile stroke units may not be a justifiable resource for some areas depending on traffic patterns, population distribution, patient data, hospital locations, cooperation, and funding. Still, the out-of-hospital treatment is an innovative way of applying standard care with an exceptional approach, saving lives by saving time.

“That time frame can make the difference between someone who can talk and not talk, whether someone can understand what you're saying or not,” Shownkeen said.¹⁷

Ultimately, the impact on the individual is what justifies the MSU resource. When considering the rehabilitation efforts and quality of life regained after stroke, stopping the brain’s destruction in the early moments matters.

“That's massive,” Graham said. “Who doesn't want to walk out of the hospital on their own accord? That's why we do this.”¹⁸

Sources

1. “Acute Ischemic Stroke Infographic.” American Heart Association. 2020. https://www.stroke.org/en/about-stroke/types-of-stroke/ischemic-stroke-clots/ais-infographic (accessed Jan. 30, 2025). 

2. “Ischemic Stroke (Clots).” American Heart Association. 2025. https://www.stroke.org/en/about-stroke/types-of-stroke/ischemic-stroke-clots (accessed Jan. 30, 2025). 

3. “Stroke Symptoms.” American Heart Association. 2025. https://www.stroke.org/en/about-stroke/stroke-symptoms (accessed Jan. 30, 2025).

4. See note 3.

5. Clawson JJ, Dernocoeur KB, Murray C. Principles of Emergency Medical Dispatch. Fifth Edition. Salt Lake City: International Academies of Emergency Dispatch. 2014.

6. “Stroke.” Mayo Foundation for Medical Education and Research. 2025. https://www.mayoclinic.org/diseases-conditions/stroke/diagnosis-treatment/drc-20350119 (accessed Jan. 30, 2025).

7. “Acute Ischemic Stroke: Current Treatment Approaches for Acute Ischemic Stroke.” American Heart Association. https://www.stroke.org/-/media/Stroke-Files/Ischemic-Stroke-Professional-Materials/AIS-Toolkit/AIS-Professional-Education-Presentation-ucm_485538.pdf (accessed Jan. 30, 2025).

8. “Mechanical Thrombectomy: A New, Minimally Invasive Treatment for Blood Clots.” Inside View. UVA Health. https://blog.radiology.virginia.edu/thrombectomy/ (accessed Feb. 3, 2025).

9. Samaniego EA, Roa JA, Limaye K, Adams HP Jr. “Mechanical Thrombectomy: Emerging Technologies and Techniques.” Journal of Stroke and Cerebrovascular Diseases. 2018; 27 (10): 2555-2571.

10. Kameda-Smith MM, Pai AM, Jung Y, Duda T, van Adel B. “Advances in Mechanical Thrombectomy for Acute Ischemic Stroke Due to Large Vessel Occlusion.” Critical Reviews in Biomedical Engineering. 2022; 49(5):13-70.

11. Patterson, B. Clawson, J. “Lights-and-Siren Response.” Journal of Emergency Dispatch. 2022; Aug 14. https://www.iaedjournal.org/lights-and-siren-response (accessed Jan. 30, 2025).

12. Sinclair, R. Marler, J. “ Using EMD for Acute Stroke Identification.” International Academies of Emergency Dispatch. 1998. https://www.emergencydispatch.org/the-science/diagnostic-assessment-tools/39a95a68-6787-4f56-b1b8-385dd140ceec (accessed Jan. 30, 2025).

13. “Mobile Stroke Unit | Northwestern Medicine Central DuPage Hospital.” Northwestern Medicine. 2017; Jan 30. https://www.youtube.com/watch?v=X1DwBNq-9Eg (accessed Jan. 30, 2025).

14. Petty, L. “Mobile Stroke Unit Assists in Getting Critical Care to West Suburban Patients.” NBCUniversal Media, LLC. 2023; May 4. https://www.nbcchicago.com/news/local/mobile-stroke-unit-critical-care-west-suburban-patients/3134292/ (accessed Jan. 20, 2025).

15. See note 11.

16. Shownkeen, H., Richards, CT., Buffo, K., Graham, S., Iacob, T., Mohajer-Esfahani, M., Lindstrom, A., Garg, A., Gutti, P., Sachdeva, K., Shrivastava, A., Williams, J., Crumlett, H., and Huml, J. “Outcomes of Patients Receiving Thrombolysis in a Mobile Stroke Unit: A 4-Year Retrospective, Observational, Single Center Study.” Prehospital Emergency Care 2022; 27(5): 652-658.

17. See note 10.

18. See note 10.