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Episode Overview

In this episode, the crew sits down with Kelly Montgomery, the System Stroke Program Manager for University Hospitals, for a deep dive into everything stroke:

• ischemic vs. hemorrhagic stroke

• thrombolytics (TNK vs. TPA)

• stroke center certification levels

• EMS assessment and destination selection

• LVO identification using VAN & VAN+

• mechanical thrombectomy

• STEMI + stroke overlap

• posterior circulation strokes

• stroke mimics

• why time is brain

• trials shaping modern stroke care (DAWN, DEFUSE, SELECT2 & SELECT-LATE)
  
  

This is a high-yield episode for every EMS provider, dispatcher, emergency nurse, and student.

Guest Spotlight: Kelly Montgomery, RN

Kelly shares her journey:

• Kent State nursing graduate

• Early exposure to neuro & stroke patients during clinicals

• Started at University Hospitals on a dedicated stroke unit

• Became a stroke coordinator in 2014, then supervisor at UH Cleveland Medical Center

• Recently advanced to System Stroke Program Manager, overseeing stroke quality, system guidelines, telestroke implementation, and coordination across UH hospitals

• Passion for acute stroke care and strong relationships with EMS teams

Stroke 101 – The Basics EMS Must Know

Ischemic Stroke (≈ 85–87% of cases)

• Caused by a clot blocking a cerebral artery

• Classic contralateral findings:

• • Left brain → right-sided deficits

• • Right brain → left-sided deficits

  • Usually painless

• Driven by modifiable risk factors:

• • Hypertension (No. 1)

• • Diabetes

• • High cholesterol

  • Smoking / vaping

• • Alcohol use

• • Atrial fibrillation

• Prevention = primary care, BP control, cholesterol control, lifestyle change

• TIAs matter — ~40% of TIAs may lead to stroke
  
  

Hemorrhagic Strokes

• Two main types:

• • Intracerebral hemorrhage (ICH): bleeding in the brain

• • Subarachnoid hemorrhage (SAH): bleeding around the brain

• SAH clues:

• • “Worst headache of my life”

• • Sudden onset during exertion

• • Photophobia

• ICH clues:

• • Hypertensive patient

• • Acute collapse

• • Stroke-like symptoms but often more dramatic

• Never give thrombolytics to hemorrhagic strokes

Understanding CT & CTA in Stroke

Non-Contrast CT (“Dry CT”)

Purpose:

• Rule out bleed

• Identify old strokes

• Determine if too much tissue is already infarcted (risk of hemorrhagic conversion)
  
  

CT Angiography (CTA)

Purpose:

• Identify large vessel occlusion (LVO)

• Visualize carotids and intracranial arteries

• Requires a good large-bore IV (AC preferred)

Radiology uses EMS and ED information to target the correct region!

Stroke Centers in Ohio (UH System)

Ohio recognizes:

• Acute Stroke Ready Hospitals (ASR)

• Primary Stroke Centers (PSC)

• Thrombectomy-Capable Stroke Centers (TSC)

• Comprehensive Stroke Centers (CSC)
  
  

At UH:

• UH Cleveland Medical Center = Comprehensive Stroke Center

• • 24/7 neurosurgery

• • Neuro-ICU

• • Thrombectomy

• • Aneurysm clipping/coiling

• PSCs and ASRs can all give thrombolytics (TNK)

• Destination = closest appropriate facility for thrombolytics and time-sensitive care.

Thrombolytics: Why TNK Replaced TPA

What thrombolytics do

• Bust clots in ischemic stroke

• Reduce disability by ~30% when given early

• Time window: 0–4.5 hours (longer in certain trials)

Why UH switched to Tenecteplase (TNK)

• Single IV push (TPA requires weight-based drip)

• Faster door-to-needle times

• Easier for pharmacy & ED workflow

• At least equivalent outcomes; UH data suggests slightly better

• FDA-approved for stroke in 2024

• Increasing adoption nationally

Mechanical Thrombectomy (LVO Intervention)

Kelly and Dr. Hill break down how thrombectomy works:

• Catheter via groin or radial artery

• Guided up to cerebral arteries

• Clot removed via suction or stent-retriever

• Typically used for:

• • MCA (M1/M2)

• • Basilar

• • Proximal large vessels
    
    

Game-changing trials UH was part of

• DAWN Trial

• • Extended window for thrombectomy up to 24 hours

• • UH participated; trial stopped early due to strong outcomes
    
    

• DEFUSE-3 & SELECT2

• • Support for large-core strokes

• SELECT-LATE (ongoing)

• • Exploring thrombectomy beyond 24 hours
    
    

Penumbra

• Tissue at risk but still salvageable

• Modern perfusion imaging helps save more brain than ever

EMS Stroke Care – What Really Matters

Scene Priorities

1. History / Last Known Well

2. Cincinnati Stroke Scale

3. Blood Glucose (must be capillary!)

4. Vitals (especially BP)

5. Rapid extrication — limit scene time to ~15 minutes

6. Load-and-go; deeper neuro exams happen in the truck

During Transport

• O₂ only if SpO₂ < 94%

• Elevate head 30°

• Check 12-lead (stroke + STEMI overlap exists!)

• Establish IV if time allows — but transport > IV

• Monitor BP (do not drop pressures aggressively)

When to call Medical Control

• Mixed stroke/STEMI picture

• Unusual BP management questions

• Hypotension with stroke symptoms

• Concern for dissection

• Atypical neurologic findings

VAN & VAN+ LVO Identification for EMS

VAN = Vision, Aphasia, Neglect

But first:

• Must have arm weakness
   If yes → proceed.

VAN+ adds cerebellar testing

• Finger-to-nose

• Heel-to-shin

Massive value: catches posterior circulation strokes, which are often missed.

Red Flags for Posterior Stroke

• Ataxia

• Leaning or falling to one side

• Severe dizziness (dizziness + something else)

• Disconjugate gaze

• Dysarthria

• Unsteady gait

• Nausea/vomiting

• Sudden visual disturbance

Posterior strokes kill. VAN+ saves lives.

Stroke Mimics (EMS Must Consider)

• Hypoglycemia (most common and dangerous mimic)

• Seizure / Todd’s paralysis

• Complex migraine

• Bell’s palsy

• Infection / sepsis

• Intoxication

• Brain tumor

• Conversion disorder

• Medication errors in SNFs (insulin mix-ups!)

• Stroke recrudescence (old symptoms reappearing during illness)

When in doubt → treat as stroke until proven otherwise.

Pediatric Stroke

• Rare but real
  Often hemorrhagic or congenital cause

• UH CMC handles pediatric stroke/thrombectomy

• Teen example: basilar occlusion → thrombectomy → now back to playing high school soccer

Culture, Relationship, and the EMS–Hospital Team

A major theme of the episode:

• The UH Stroke Program wants EMS over-calls

• Early notification is everything

• EMS should never fear activating a stroke alert

• Telestroke now available across the entire UH system

• Collaboration between EMS, ED, neuro, IR = lives saved

Key EMS Takeaways

• Time is brain — get off scene FAST

• Check glucose on every neuro patient

• Do VAN+ on every suspected stroke

• Posterior strokes hide — test for ataxia

• Stroke + STEMI can coexist → think dissection

• Maintain systolic ≥100; avoid lowering too quickly

• Get last known well early

• Bring the family or phone number

• Bag all home meds, not just a list

• Call Medical Control early when unsure

• Transport to the closest appropriate stroke center

• Overcall strokes — no one gets in trouble for being careful

From The Episode