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Review: Technology Is Improving Prehospital Triage of Endovascular Stroke

Key findings

  • Social media and other technology-based efforts can be leveraged for education of the public about emergent large vessel occlusion (ELVO) stroke by targeting "influencers" and family/caregivers of high-risk individuals
  • Smartphone apps are currently available to support emergency medical services crews in calculating stroke scales and even using global positioning system data for ambulance routing
  • Mobile stroke units, with on-board computed tomography, point-of-care laboratories and telemedicine transmission technology, can bypass primary stroke centers and take patients who have ELVO directly to a comprehensive stroke center
  • Location-identifying 911 systems, cellular connectivity, text message groups and apps for better communication between ambulances and hospitals are improving prehospital care of patients with ELVO

Now that mechanical thrombectomy is the standard care for stroke with emergent large vessel occlusion (ELVO), reducing the interval from symptom onset to reperfusion is a key goal. Prehospital improvements are needed in three areas:

  1. Education of the public
  2. Ability of emergency medical services (EMS) to detect and grade stroke severity
  3. Improved triage of patients with ELVO to centers that can provide the care they need

In the Journal of NeuroInterventional Surgery, Neurology Resident Juan Carlos Martinez-Gutierrez, MD, and Thabele Leslie-Mazwi, MD, specialist in Neuroendovascular and Neurocritical Care at the Massachusetts General Hospital Department of Neurology, and colleagues recently reviewed how current and future technological options can meet these requirements.

Technology and the Public

Social media platforms such as Facebook and Twitter make it possible to reach billions of future stroke bystanders or patients. Targeting "influencers," individuals whose popularity directs social media attention to particular causes, has not yet been explored for stroke.

Another way to improve the efficiency of outreach is to target educational efforts to the families and caregivers of high-risk individuals, such as those with atrial fibrillation.

Technology and EMS

Smartphone apps are increasingly available to support EMS crews. For instance, the FAST-ED App calculates stroke severity with the FAST-ED scale and uses real-time global positioning system (GPS) data to direct crews to the most accessible endovascular-capable center.

Mobile stroke units are active in many U.S. cities and around the world. These ambulances are distinguished by having an on-board computed tomography (CT) scanner, point-of-care laboratory and telemedicine transmission technology. A patient suspected of ELVO can bypass the primary stroke center and be transported to a center capable of providing mechanical thrombectomy, while still getting early administration of tissue plasminogen activator (tPA).

Taking imaging a step further, some mobile stroke units are performing CT angiography of the head and distal neck. This allows EMS providers to confirm ELVO and notify the comprehensive stroke center, so the patient can be treated immediately after arrival.

Technology and Systems of Stroke Care

Federal regulations for 911 emergency calls now require that carriers provide the location of the cell site or base station that is transmitting the call and/or the latitude and longitude of callers if their phone is properly GPS-equipped. This expanded 911 system may allow faster access to patients by automating dispatch to specified locations.

Telemedicine communications between ambulances and hospitals have relied on broadband connectivity, which is prone to freezing, poor audiovisual quality and disconnection. Cellular connectivity has evolved significantly and may become a reliable alternative, perhaps even enabling the use of tablets or smartphones.

Across the country, teams of EMS responders, emergency department physicians and neurointerventionists are communicating through text message groups, via iMessage, WhatsApp and other platforms. These also allow users to send and receive pictures and video.

Four app platforms, summarized in a table in the article, have been developed for better communication between ambulances and hospitals. Features vary among them but can include:

  • Transmission of images, videos and electrocardiography data
  • Timestamps (e.g., time last seen well, time of tPA administration)
  • Instant messaging platforms
  • GPS tracking

Google Maps and the crowdsourcing app, Waze, provide transportation information in real time from vast numbers of users. This could inform the EMS crew of the most direct route for the ambulance, especially if combined with improvements such as smart traffic lights that can be controlled from the ambulance or the emergency dispatch center.

Not Science Fiction

Currently, the use of prehospital technology to improve triage of endovascular stroke is at a fledgling stage. However, some technologies, such as the use of Internet-based connectivity, are already realities. Clinicians can expect more of these ideas to be adopted widely as prehospital care of ELVO continues to evolve with remarkable potential to improve triage for stroke patients.

Learn more about the Cerebrovascular Program

Learn more about the Department of Neurology

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Thabele M. Leslie-Mazwi, MD, is a specialist in Neuroendovascular and Neurocritical Care at Massachusetts General Hospital. In this video, he discusses the success of the DEFUSE 3 trial and expanding the inclusion of patients that are eligible for thrombectomy.