Stroke in 2021 Clinical presentation, review of stroke pathophysiology, and the evidence-based updates on prehospital care from the American Stroke Association® Educational Objectives • Examine the history and evolution of stroke diagnosis and treatment. • Discuss the pathophysiology behind stroke and compare with other medical conditions that mimic it. • Examine the latest evidence-based guideline updates from the American Stroke Association 2019 update as it applies to the prehospital setting. • Describe clinical features associated with stroke affecting either the left or right hemisphere. • Consider prehospital assessment and communication techniques to optimize care of the post-stroke patient. • Explore modifiable factors to reduce the risk of stroke. Introduction to Stroke A cerebral vascular accident (CVA, or stroke) is the leading cause of serious, permanent disability in the United States. In the US, someone is diagnosed with a stroke every 40 seconds, and sadly, a person dies from one every 4 minutes.1 EMS can decrease disability and death by recognizing stroke signs and symptoms, notifying the hospital with early activation, and providing appropriate treatment and care. Page | 1 Table of Contents Educational Objectives ......................................................................................................................................... 1 Introduction to Stroke .......................................................................................................................................... 1 Stroke: Just another modern-day disease? .......................................................................................................... 3 Jumping to the 17th century............................................................................................................................. 3 19th century...................................................................................................................................................... 4 20th century...................................................................................................................................................... 4 21st century ...................................................................................................................................................... 4 The impact of stroke in the United States ............................................................................................................ 5 Pathophysiology of stroke .................................................................................................................................... 6 Ischemic stroke ................................................................................................................................................. 6 Hemorrhagic stroke .......................................................................................................................................... 7 The great imitators ............................................................................................................................................... 9 A few of the stroke mimics ............................................................................................................................... 9 Updated EMS guidelines for the acute stroke victim ......................................................................................... 12 Living a changed life after stroke ........................................................................................................................ 17 Reviewing brain anatomy. .............................................................................................................................. 17 Examples of hemisphere-affected stroke survivors ....................................................................................... 19 Avoiding another stroke ..................................................................................................................................... 21 References .......................................................................................................................................................... 23 Image credits ...................................................................................................................................................... 24 Page | 2 Stroke: Just another modern-day disease? troke is often thought as a modern-day disease caused by S obesity, genetic disposition, and stress, but it really has a long history dating before Cheetos™ and desk jobs. Stepping back thousands of years, strokes not only existed but were even recognized as a serious impairment of the vascular system by ancient healers. During the neo-Sumerian period (2112 to 2004 BCE) in the Mesopotamia area of modern-day Iran, various healers documented the assessment, diagnosis, and their treatment recommendations for suspected stroke on clay tablets.2 They even differentiated stroke from temporary facial paralysis (Bell’s Palsy) based on signs, symptoms, and the patient’s time to recovery.2 During that time period, an āšipu was described as a practitioner who followed a philosophy of healing by warding away evil spirits that caused illness and death. They were the opposing profession to other ancient practitioners who embraced objective evidence and treatment, like today’s physicians. But even the more spiritual āšipu Tablet K.2418 contains 26 lines of Akkadian script recognized the signs of stroke and its prognosis. He knew that right- about the medical treatment of stroke. From the sided paralysis with aphasia carries a gloomier outcome compared to library of Ashurbanipal II at Kouyunjik in modern- left-sided paralysis in the stroke patient. day Mosul Governorate, Iraq. Neo-Assyrian period, 7th century BCE. Image: Karim 2018. The āšipu’s recognition of paralysis caused by a mild stroke or transient ischemic attack (TIA) was discovered in a translation of one mof their early writings:2 “If he has a stroke and either his left side or his right side is affected and his shoulder is not released, but he can straighten out his fingers and he can lift his hand and stretch it out and he is not of food or drink-affliction by a ghost of the steppe. Recovery in three days.” The ancient healers also predicted whether the patient was likely to die from stroke after evaluation of the patient’s consciousness, areas affected by paralysis, and responsiveness to stimuli.2 Jumping to the 17th century: The cause and pathophysiology of stroke was not well defined until just a few hundred years ago. Swiss physician Johan Jakob Wepfer (1620–1695) was one of the first physicians specializing in vascular anatomy to observe that the paralysis associated with stroke was caused by cerebral hemorrhage. Page | 3 19th century: Later in the early 19th century, Scottish physician John Abercrombie reported a link between arterial occlusive disease and areas of cerebral softening from infarctions (dead brain tissue).2,3 The pathophysiology behind strokes was now gaining more interest both for the hemorrhagic and ischemic forms. 20th century: During the 1960s, transient ischemic attacks (TIAs) were defined as sudden, focal neurological deficits caused by a vascular problem that lasted less than 24 hours. However, there was no basis for the 24-hour cutoff --- it appeared to be just an arbitrarily-assigned endpoint.3 In other words, just pulled out of the air. The definition then continued where if the signs and symptoms of the TIA persisted beyond seven days, the patient was diagnosed with a stroke.3 Neurological events that lasted between 24 hours and the seven day stroke threshold were classified as a “reversible ischaemic neurological deficit” – a term that’s now obsolete.3 Image: Scottish physician John Abercrombie (October 10, 1780 – November 14, 1844) During this time, a TIA was also considered as a condition with little to no brain injury. Although a full recovery is expected after a TIA, it wasn’t until years later that physicians understood the actual damage experienced during the event. Some brain injury does occur during a TIA with the decreased blood perfusion and symptoms.4 However, the damage may not be extensive enough to produce obvious physical or cognitive disability post-recovery. 21st century: In 2009, the American Heart Association/American Stroke Association™ revised its definition of a TIA to recognize both the injury pattern associated with the condition and to de- emphasize the 24-hour time constraint. A TIA is now defined as, “a transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia, without acute infarction”.5 This definition suggests that a TIA occurs when the patient has signs and symptoms associated with a stroke that do resolve, but brain imaging finds nothing significant enough to support a stroke diagnosis. Conversely, if an infarction did develop in the patient’s brain and was found with imaging (CT scan or MRI), the patient would then be diagnosed with a stroke. Page | 4 The impact of stroke in the United States In short, a stroke refers to damage of the brain caused by a disruption of the cerebral blood supply. This can either be from a clot (thrombus or emboli) blocking an arterial vessel or hemorrhage. In the United States, a stroke is more than just permanent paralysis or weakness --- It’s the 5th leading cause of death.1 1 Stroke Facts Approximately 795,000 people suffer a new or recurrent stroke annually