November 3, 2025

This month, we’ll focus on talking about strokes. Although not much has changed in the pre-hospital setting over the last decade or so, I am hopeful that sharing what is new in the inpatient setting will shed new light on the importance of what happens in the pre-hospital environment. Before getting into the new stroke treatment options, we'll review the basics.  

A stroke occurs when blood flow to a portion of the brain is interrupted either by a blockage or rupture of an artery. The brain tissue is deprived of oxygen and nutrients, and within minutes, the cells begin to die. Two million neurons die every second without blood. Due to the time-sensitive nature, stroke is recognized as a medical emergency and should be treated with the same urgency as traumas.  

There are two types of strokes. The most common type, accounting for 85% of all strokes, are ischemic strokes. An ischemic stroke happens when a blood vessel supplying the brain becomes blocked by a blood clot or buildup of plaque. Conversely, a hemorrhagic stroke occurs when a blood vessel in the brain ruptures, causing bleeding into or around the brain. More specifically, bleeding into the brain tissue, or parenchyma, is known as an intracerebral hemorrhage, and bleeding around the brain is known as a subarachnoid hemorrhage. Hemorrhagic strokes make up the remaining 15% of all strokes, with approximately 10% being intracerebral hemorrhage and 5% subarachnoid hemorrhage.  

Transient Ischemic Attack, known as TIAs, are like ischemic strokes, but the blockage or disruption in blood flow is only temporary, and symptoms only last a few minutes. Brain tissue is not permanently damaged, and ischemia will not be found on an MRI. However, TIAs should be treated seriously, as data has demonstrated that 40% of patients with TIAs brought to the emergency room go on to have a stroke in the future. These patients are typically admitted for further testing and risk factor management. Stroke is preventable! 

Each year, about 795,000 people have a stroke in the United States. In 2024, there were 2,898 patients coded with a stroke in University Hospitals Health System. Around 60% of EMS patients transferred in as a brain attack are diagnosed with a stroke, so there is a high likelihood that many paramedics have transported a stroke patient at some point.  

With stroke being the 4th leading cause of death and a top cause of disability, early recognition plays a dramatic role in patient outcomes. Every 15-minute delay in treatment is a loss of a healthy day for a patient. It is vital for all prehospital providers to be proficient at recognizing and managing these patients while in their care.  

A patient’s presentation may suggest the type of stroke the patient is having. Ischemic stroke typically presents with focal neurological deficits, is sudden in onset, and may or may not be accompanied by a headache, whereas a depressed consciousness is uncommon (except for some brainstem infarctions). A patient experiencing an intracerebral hemorrhage often has progressive focal neurological deficits worsening over the minutes to hours since the symptoms start and are commonly accompanied by a sudden increasing headache and will progressively develop a decreased level of consciousness. Patients with a subarachnoid hemorrhage typically complain of the “worst headache of my life,” do not have focal neurological deficits, and experience a decline in consciousness. Syncope is common at the time of onset, and some severe subarachnoid hemorrhages may cause coma.   

The following is a helpful diagram to assist in localizing deficits: 

Posterior circulation strokes present differently and are commonly missed by most stroke assessment tools in the field and in the hospital setting. Brainstem strokes are the most devastating stroke due to the small area and location of nerves that serve critical body functions. These patients often have crossed signs or symptoms found on both sides of the body. Nerve pathways cross in the brainstem, so weakness and sensory loss can occur on one side of the face and the opposite side of the body. The following “D” symptoms are common with posterior circulation strokes:

• Decreased level of consciousness (LOC)

• Dysphagia

• Dysarthria

• Dizziness

• Diplopia or visual field cut

• Dysconjugate gaze

One stroke type of posterior circulation stroke, involving the cerebellum, tends to cause dizziness, inability to walk normally (ataxia), and falling to one side. To help recognize posterior stroke, remember to consider “dizziness +” in patients who are experiencing. Dizziness, along with another neurological symptom, should raise your suspicion of stroke.  

There are many other stroke mimics, the most common is hypoglycemia, so it is essential to check blood glucose in all patients with stroke-like symptoms or altered mental status. Seizures and migraine headaches can also cause patients to experience stroke-like symptoms and are often clinically indistinguishable in the prehospital environment. When in doubt, if there are new neurological symptoms, assume it could be a stroke and activate the pre-hospital notification for a Brain Attack. An additional history of seizure or a history of similar symptoms with migraine headaches can be very important to pass on to the emergency department providers to aid in proper diagnosis.  

Having an understanding of which symptoms are common with various stroke types can give you confidence to activate a brain attack in the field. However, even neurologists must confirm their suspicions with a non-contrast head CT scan before treating stroke. CTs are useful in that they can identify hemorrhage almost instantly, whereas ischemic stroke tissue may take 4-6 hours. The CT scan drives all stroke care in the hospital setting, so getting a patient to the nearest hospital is critical.  

Overall, recognition and timing are the most important aspects for prehospital care. With any suspicion of stroke, paramedics are encouraged to activate a brain attack in the field. Hospital teams expect and welcome overcalls!

Thank you for your care, 

Amanda Opaskar, MD  

Vascular Neurology 

University Hospitals Neurological Institute 

Primary stroke center director, UH St. John Medical Center 

Medical Director, LT4, UH Cleveland Medical Center 

Assistant Professor of Neurology, Case Western Reserve University School of Medicine  

November 10, 2025

Good morning on this snowy Monday,  

Last week, I shared an overview of stroke. Now I’d like to focus on the EMS care in the field and their critical role in the stroke chain of survival and recovery, highlighting the vital importance of pre-hospital stroke recognition and early notification. The care provided before hospital arrival is often the first and most decisive step in a patient’s outcome.  

As we continue to advance the quality of stroke care, we recognize that having a solid foundation of standardized stroke evaluation is crucial to making this possible. Time is of critical importance to preserving neurological function and limiting brain injury, which is why the treatments available for stroke are highly time-dependent and why it is critical to recognize these stroke symptoms early. Otherwise, patients may not be eligible for these treatment opportunities. To ensure every patient receives high-quality stroke care, protocols have been developed to help with early stroke recognition and pre-hospital notification. Take a moment to review University Hospitals EMSI’s Stroke Protocol (Pages 28-29). 

For any patient with a suspicion of stroke, it is important to first assess life-threatening conditions, including ABCs and presenting vital signs. The goal is to maintain blood flow to the brain by allowing permissive hypertension and maintaining oxygenation with an SpO2 > 94%. Supplemental oxygen is not a requirement for all stroke patients, but can be applied if SpO2 is below target.  

High blood pressure is very common in stroke, and is the number one risk factor for both ischemic and hemorrhagic strokes. Hypertension is also a compensatory reaction of the body to perfuse the brain. Permissive hypertension is recommended in stroke to allow the brain to get the blood flow it requires through the brain’s own autoregulatory mechanism. This is tolerated unless the blood pressure is at extreme levels. Blood pressure-lowering treatment in the field may be considered for systolic blood pressures > 220 mm Hg. The standard medication to treat hypertension for stroke is labetalol and can be used as long as the heart rate is above 60. If patients have extreme hypertension, please contact Medical Control to consider treatment.  

Conversely, hypotension is not common with acute stroke. Systolic blood pressures < 90 mm Hg should be treated, and other causes should be considered. It is also recommended to contact Medical Control for these cases.  

Stroke patients have a risk of aspiration, so elevating the HOB at 30 degrees can limit this risk. Next, assess the patient’s ability to handle secretions. Early loss of airway in stroke often suggests a hemorrhage or brainstem stroke.  

Blood glucose is a quick test and should also be part of your initial assessment for these patients. Hypoglycemia is a common stroke mimic and easily corrected. Diabetes is also a common risk factor for stroke patients.  

The Cincinnati Prehospital Stroke Scale (CPSS) remains a cornerstone for initial screening, providing a rapid and reliable method to identify common potential strokes. As you know, this is completed through an assessment of facial asymmetry, arm weakness, and speech abnormalities. Accurate communication of these findings triggers rapid activation of our stroke teams and clears CT scanners before the patient’s arrival for faster treatment. We encourage this assessment to be completed on scene. If the patient has a positive CPSS or if stroke is suspected, identifying the last known well time, gathering pertinent history (i.e., medical history, anticoagulation use, etc.), and identifying a point of contact for a witness on the scene or family member is helpful.  

To summarize the on-scene assessment, the initial evaluation for stroke patients includes ABCs, vitals, POCT glucose, and CPSS, and then activate prehospital notification of a stroke. Due to the time-critical nature of stroke treatments, the goal is to have a scene time of less than 15 minutes. Prehospital notification has a positive impact on treatment times. The hospitals expect and encourage overcalls! 

The stroke care protocol continues en route. If the CPSS is positive, additional neurological assessment can be completed with the vision, aphasia, and neglect (VAN) exam. The VAN assessment is a screening tool to help detect large vessel occlusions. Large vessel occlusions account for 27% of all ischemic strokes, but only 5% of these patients have been eligible for mechanical thrombectomy, which highlights the importance of early recognition and treatment.  

VAN, as mentioned above, refers to vision, aphasia, and neglect. First, check for motor weakness with arm drift. If absent, the test is negative. If the patient does have unilateral arm drift, continue to the other parts of the VAN. Vision assessment will be positive if the patient has double vision, a field cut, or loss of vision. Aphasia exam includes either expressive (word finding) or receptive aphasia (unable to follow commands). Neglect refers to ignoring one side of the body, denying deficits, or the inability to feel both sides at the same time. If any of these three parts are positive, then the VAN exam is positive.  

My previous week’s Monday message highlighted that posterior circulation strokes are frequently missed. To improve identification of these strokes in the field, University Hospitals protocol has included an additional step to the VAN screening tool, referred to as “VAN +”. If a patient is negative for unilateral arm weakness and does not exhibit visual, speech, or neglect deficits, an ataxia assessment should be performed. Ataxia can be evaluated by asking the patient to complete the finger-to-nose and heel-to-shin testing for each limb. This added step aims to improve early recognition of posterior circulation strokes, which may present primarily with coordination deficits, rather than the traditional anterior circulation symptoms.  

An EKG is useful to rule out concurrent complications. Placing an IV before hospital arrival is significantly helpful. Many patients require access before additional scans (such as CT angiograms, CT perfusion scans) and treatment modalities (i.e., IV thrombolysis, IV BP medications). Additionally, several of the UH hospitals can use labs that are drawn in the field.  

Documentation of these findings plays an important role in chart review and process improvement. Take credit for what you do and make sure to document the care you provide. Hospitals enter your documentation into a stroke registry (including the following- documentation of pre-arrival notification, LKW, Blood Glucose, CPSS, and VAN). Your times are compared to other systems and similar geographical locations across the country. We have great metrics in comparison to other hospitals in Ohio, but there are always opportunities to improve, and we believe our protocols are followed more than they are documented.  

Lastly, our program continues to recommend the patient to the nearest designated stroke center. As of January 2025, every hospital in our system has implemented our Telestroke Program, ensuring that every stroke alert patient is rapidly evaluated via live video consultation by a vascular neurologist within minutes of arrival. This process significantly enhances the quality and timeliness of stroke care. These highly trained specialists can promptly determine the most appropriate treatment plan, including candidacy for mechanical thrombectomy. In addition, each facility is now equipped with CT perfusion imaging, allowing for advanced evaluation to confirm whether patients meet thrombectomy criteria before transfer. 

Thank you for the care you provide, 

Amanda Opaskar, MD  

Vascular Neurology 

University Hospitals Neurological Institute 

Primary stroke center director, UH St. John Medical Center 

Medical Director, LT4, UH Cleveland Medical Center 

Assistant Professor of Neurology, Case Western Reserve University School of Medicine  

November 17, 2025

Good Monday Morning,

This week we will be reviewing the two main treatment opportunities for ischemic stroke: intravenous thrombolysis and mechanical thrombectomy.

Before reviewing these treatments, it is important to understand how clinical outcomes are measured in stroke treatment trials. Scales help us define patients’ baseline function and disability, as well as the level of disability patients experience after a stroke. The most commonly utilized scale for clinical stroke trials is called the Modified Rankin Scale or mRS for short. The modified Rankin Scale is a 6-point scale ranging from 0 to 6, with 0 meaning no post stroke disability and 100% back to their functional baseline and 6 being equivalent to death.  A mRS 5 defines the patient as bedridden and care dependent. Most stroke trials designate a modified Rankin of 2 or less as a good outcome for stroke recovery. However, trials enrolling patients with more severe stroke deficits include a modified Rankin score 3 or less as an optimal outcome.

The first standard of care treatment option considered for patients with acute ischemic stroke is IV thrombolysis. This is known as a “clot busting” medication that aims to dissolve the clot and restore blood flow. Clinical trials showed that there were significant improvement in stroke disability at 90 days for patients who were eligible to receive this medication timely. However, trials indicate there is a 3% risk of death and a 6% risk of life-threatening bleeding. Therefore, patients must meet very strict criteria to be able to receive this medication.

In 1996, the initial IV thrombolytic medication that showed benefit for acute ischemic stroke was alteplase also known as tPA. However, at University Hospitals and many hospitals across the country, this medication has recently been replaced with a newer medication called Tenecteplase or tNK. Tenecteplase is very similar to tPA but it is more fibrin specific, or targets the clot more precisely, and has a longer half-life, or stays longer in the body to break down the clot. TNK is also administered quicker in a single bolus instead of the alteplase process in which a bolus is followed by infusion. There is no difference in serious adverse events and the post care management and reversal agent is identical. Tenecteplase also has cost savings. It is important to note that tNK is only used in adult populations and tPA is still the preferred thrombolytic for the pediatric population due to limited clinical data. 

The time window to receive IV thrombolysis is within 4.5 hours of the patients last known well. This timeframe was well established in the initial NINDS trial and ECASS III trial. However, in 2018, new clinical trials were published that extended the time window to include patients who “wake up” with symptoms and have an unknown last known well time. This protocol utilizes advanced imaging with MRI to determine if the ischemic core, area with irreversible damage, is small enough and whether there remains a larger area of at-risk brain tissue that the thrombolytic can safely be given without causing significant bleeding. At UH we have a guideline specific for wake-up thrombolysis consideration that defines specific criteria for eligible patients.

Mechanical thrombectomy or endovascular therapy is an additional treatment opportunity for patients who have large vessel occlusion, a clot located in the internal carotid artery, middle cerebral artery, or basilar artery. Patients that receive thrombolytics may still be eligible for this procedure. Mechanical Thrombectomy is a catheter-based procedure that starts with femoral artery access and threads catheters through the body, up the carotid arteries and into the brain. Once in the brain, contrast dye can be utilized to view the blockage. An aspiration catheter or stent retriever is then deployed to capture and remove the clot. This procedure may be offered to patients meeting certain criteria within 24 hours of last known well. Several clinical trials have demonstrated efficacy of mechanical thrombectomy in large vessel occlusions, specifically the internal carotid artery and first branch of the middle cerebral artery, in both early (within 6 hours) and late window (6-24 hours) of last known well with positive outcomes. This treatment was recently shown to have benefit in patients who present with large core infarcts or where there is already a large area of irreversible damage but still have an area of salvageable brain tissue that can benefit from restoration of blood flow.

Artificial intelligence software and advanced perfusion imaging have been key advances in radiological imaging and interpretation that have helped in determining patients’ eligibility for thrombolysis and thrombectomy. AI algorithms have the ability detect large vessel occlusions within minutes and automatically send alerts to the stroke and thrombectomy teams to expedite earlier activation and treatment. AI algorithms can also automatically calculate the size of intracranial hemorrhages and detect and assess brain aneurysms. Advanced perfusion imaging software can utilize CT or MRI imaging to demonstrate core infarct (dead tissue) vs penumbra (salvageable tissue) which is important in determining treatment eligibility as noted previously.

Currently, approximately 27% of the ischemic stroke population have a large vessel occlusion. Only about 5% of this group meets criteria for a mechanical thrombectomy. New clinical trials are enrolling patients utilizing AI and advanced perfusion imaging to extend the time window even further. We are hopeful that this can allow us to detect and treat more patients with large vessel occlusions in the near future!

Have a great week.

Thank you for the care you provide, 

Amanda Opaskar, MD  

Vascular Neurology 

University Hospitals Neurological Institute 

Primary stroke center director, UH St. John Medical Center 

Medical Director, LT4, UH Cleveland Medical Center 

Assistant Professor of Neurology, Case Western Reserve University School of Medicine  

November 24, 2025

Good Monday Morning, 

As we approach Thanksgiving this week, I am reflecting on all the things I am thankful for, including our excellent healthcare systems in Northeast Ohio and you, the EMS personnel who are the front lines for triaging and treating our patients. Thank you again for all the work that you do for our community. 

To wrap up this fourth letter regarding stroke recognition and treatment, we will review the signs and symptoms of stroke to educate your family and friends, as well as stroke prevention and treatment. 

In the community, we teach the mnemonic BE FAST, which helps to easily recognize the signs of both posterior and anterior circulation stroke:

• B stands for balance. Has there been a sudden change in the person’s ability to stand and walk, which is different from someone who has chronic difficulty ambulating?

• E stands for eyes. Is the patient experiencing any blurry, double vision or loss of vision?

• F is for facial droop.

• A is for one-sided arm weakness.

• S is for changes in speech, such as slurred speech or difficulty saying words patients want to say.

• T is for time to call 911.

Additionally, it is important to know the risk factors for stroke so that we can help keep our community healthy. There are modifiable and non-modifiable risk factors for stroke. Modifiable risk factors include hypertension, hyperlipidemia, prior stroke or transient ischemic attack (TIA), tobacco use, atrial fibrillation, diabetes, carotid stenosis, heart disease, and obstructive sleep apnea. Additional risk factors, primarily in women, include hormone-based therapy with oral estrogen, migraine with aura, and pregnancy-associated risk factors such as a history of preeclampsia, eclampsia, or gestational hypertension.  

Patients should see their primary care provider at least once per year to evaluate for these risk factors and help get them under control, which can lower their risk of stroke in the future. Additionally, once a patient has had a stroke, both primary care providers and neurologists should focus on identifying these risk factors, educating the patient, and prescribing medications to help prevent another stroke or TIA from happening. 

Stroke is the fourth leading cause of death and a major cause of disability in the United States. Please help educate our community on the signs and symptoms of stroke as well as the risk factors for stroke. 

Happy Thanksgiving!

Thank you for all that you do, 

Amanda Opaskar, MD  

Vascular Neurology 

University Hospitals Neurological Institute 

Primary stroke center director, UH St. John Medical Center 

Medical Director, LT4, UH Cleveland Medical Center 

Assistant Professor of Neurology, Case Western Reserve University School of Medicine