Seby John, MD

Ankolekar S, Fuller M, Cross I, Renton C, Cox P, Sprigg N, et al. Feasibility of an Ambulance-Based Stroke Trial, and Safety of Glyceryl Trinitrate in Ultra-Acute Stroke: The Rapid Intervention With Glyceryl Trinitrate in Hypertensive Stroke Trial (RIGHT, ISRCTN66434824). Stroke. 2013

Time is brain. This is the sobering reality that every vascular neurologist grapples with when managing acute ischemic stroke (AIS). With the knowledge that millions of neurons are dying each passing minute, it is imperative to deliver treatment quickly. However, delays in diagnosis and treatment initiation are commonplace, with only an estimated 1-3% of AIS patients in the US receiving tPA. There is a desperate need to improve treatment strategies, and this requires a concerted effort among all providers caring for stroke patients.

Paramedics are often the first responders and form a crucial link in the treatment chain. In this study from Nottingham, UK; Ankolekar et al assessed the feasibility of performing a paramedic-delivered ambulance-based prospective randomized controlled trial. Patients with probable AIS (<4 hours) and systolic blood pressure (SBP) >140 mm Hg were randomized to transdermal glyceryl trinitrate (GTN) or no treatment. The GTN treated group had significantly lower SBP at 2 hours and improved functional outcome (shift in mRS by 1). There were no differences in mortality or serious adverse events. 

With only 41 patients recruited, this study was not powered to assess the effect of GTN on functional outcomes and the results likely represent a chance finding. Authors plan to conduct the RIGHT-2 trial to further analyze this. However, the success of the study was the demonstration that paramedics were able to independently screen, consent, randomize, treat and measure outcomes. The median time to randomization from stroke onset was an impressive 55 minutes, and the diagnosis of stroke or TIA was confirmed in 88% of patients. 

With newer paradigms of pre-hospital stroke treatment on the horizon like the mobile stroke unit (ambulance housing CT scanner and utilizing telemedicine); paramedic treatment of AIS in the hyperacute period with thrombolysis and neuroprotectants will soon become a reality. This will be a future game-changer for our patients.