By Patrick D. Horan Jr
In the time it takes you to read this article, at least one person will have died from a stroke. Strokes are the second leading cause of death in the U.S..
We have taken great strides to educate healthcare professionals, prehospital providers and lay persons to recognize the signs and symptoms of a stroke. If someone presents to a stroke center either by way of EMS or by self presentation with a positive Cincinnati, NIH or some other stroke scale, they are then typically classified as a stroke alert case and receive (rightfully so) preferential treatment including a rapid CT.
The cogs are ever turning when it comes to stroke care. Providers surround the patient and perform a wave of testing including a point-of-care glucose, neurological assessment, and pull a series of lab values.
A CT scan of a suspected stroke patient is paramount in determining the best treatments for these patients. Do we administer Tenecteplase, initiate thrombectomy or simply monitor the patient? Is the patient even having a stroke? It all begins with one of my favorite diagnostic instruments, the “donut of truth,” AKA the CT scanner.
But I believe we have pigeonholed ourselves with the nomenclature that is the “stroke alert.” While I cannot speak for every hospital system in the United States, I will say that typically, patients require a positive stroke assessment to initiate a stroke alert. I believe we are doing a disservice to our patients. There are a myriad of patients having neurological emergencies, including strokes, that present atypically (including a normal stroke assessment). These patients are clearly in desperate need of emergent neurological care and a CT scan, but alas, without that positive scale, they do not qualify for an alert.
Case study: Atypical symptoms
Let’s consider the following case.
David is a 33-year-old male with a fairly unremarkable medical history. David works as a healthcare provider, is overweight and works swing shift. He takes no medications and only complains about seasonal allergies. David woke up one morning and noticed that his vision in his right eye was exceptionally fuzzy. The night before, he attributed fuzziness in both eyes to allergies. This morning, his vision was getting worse but he needed to proctor a BLS exam so he proceeded to leave and teach the course. Over the next 4 hours, the vision would go from fuzzy to complete darkness, isolated to the right eye. Now, David is no slouch – he knew the common signs and symptoms of a stroke and even several atypical symptoms, but something impacting the right eye? Is that possible? His significant other (also a healthcare provider) evaluated the eye and immediately noticed something concerning. David had anisocoria and relative afferent pupillary defect to the right eye and the right eye only. Ultimately, David agreed to be evaluated in the emergency department. It’s important to note even at this point, David refused to believe that this was some life-altering emergency, thinking his symptoms were perhaps allergies a detached retina. As David approached the hospital, reality began to set in.
Looking at the case study above you can see, probably better than David, that he is clearly experiencing a neurological emergency. The concern for many of you rightfully should be the question – is this a stroke? Or, more aptly, did the blood flow to the right eye get disrupted? If David was your patient, would you call a stroke alert?
Could you call a stroke alert in this circumstance? Often, protocols are written to require a positive stroke exam to trigger an alert. The included table shows David’s score for various stroke tests used in the U.S. You may notice that he was negative for almost every test with a score of 2 for NIH.
Limiting delays to care
I think we can also agree that David may have been having a disruption of blood flow through the ophthalmic artery and warranted further investigation. David could also have been suffering from a retinal detachment, ocular trauma, glaucoma, cataracts, retinopathy from diabetes, cancer and so much more. But one thing is for certain, with many of those conditions being time-sensitive, life-altering conditions, David needed a thorough physical exam and a trip to CT.
So, I ask again, would you consult with medical control and advocate for the stroke alert? Better yet, can we as a collective change the way we view neurological emergencies and our approach to patient care by making the stroke alert a CT alert? A high-performance stroke team will have a flow designed to minimize time before getting a scan and limiting delays to care. Why do we reserve this for only the most obvious of strokes?
Changing the name of the alert serves more than just crossing out the name and replacing it with a CT alert. We need to change the way we approach neurological emergencies and give these patients the priority access to CT they need.
David did not trigger a classic stroke, alert. Once he arrived at the hospital, he was registered, and sat in the waiting room for an hour before he was evaluated by an advanced practice provider. The triage nurse and the APP discussed their concerns and ultimately requested an attending physician to weigh in on the matter. Providers became increasingly concerned, finally agreeing that they needed to get David to CT and they needed to do so quickly. Each one of those providers were deeply concerned about their assessment findings and believed David was having a major neurological emergency, but they were faced with the atypical and had to navigate policy and procedure to make the right care happen.
The most efficient way to get David to CT was to call a stroke alert to activate the appropriate protocols.
Once again, I ask that you, as a healthcare professional, change your thought process. Change the way you think about neurological emergencies. By requiring strict criteria to call a stroke alert, we stand to miss more emergencies than we catch. Advocate for your patient and advocate that they get the care they need.
David received his CT and experienced some world class stroke care. Ultimately, it was determined David had a demyelinating disease that resulted in the right eye blindness. He has since regained some vision and returned to work. It all started with recognizing the neurological emergency and even more importantly, recognizing that we needed to rule out the most time-sensitive, life-altering emergencies first, which starts with the patient getting a CT alert.
