The stroke patient is one that is commonly seen and transported by EMS providers.  There tends to be a frustration due to the inability to do much for these critically ill patients.  Their quality of life subsides right before our eyes.  There are two types of stroke as I explained in PART 1.  There are treatments available for ischemic strokes that can tremendously benefit the patients if given soon enough.  Thrombolytic therapy could be very effective in treating the ischemic stroke patient in the prehospital environment.  The only problem is that if this treatment was used on a patient suffering from a hemorrhagic stroke, it could tremendously worsen that patient's condition.  There is no way to conclusively differentiate between an ischemic or hemorrhagic stroke in the field without the use of diagnostic equipment.  There are, however, many indicators that could clue you in on the probably etiology.


Risk factors for stroke


Most of the risk factors for stroke are the same for both subtypes.  However, some are more indicative of a specific type.  Knowing these may assist you, along with the presenting signs and symptoms.

More associated with ischemic stroke

• Atrial fibrillation 
• History of TIAs
• Increase in Vitamin K
• Carotid artery disease
• High cholesterol
• Diabetes
• Patent Foramen Ovale

More associated with hemorrhagic stroke

• Severe acute hypertension
• Anticoagulant medications
• Smoking

Similar to risk factors, physical findings are not synonymous with a specific subtype, but they are very good indicators.  These signs may indicate either type of stroke, I cannot stress that enough.  


Signs of Hemorrhagic Stroke

• Airway compromise
• Complete unresponsiveness
• Complete aphasia
• Nausea & vomiting

Signs of Ischemic Stroke

• Expressive aphasia
• Unilateral deficits
• Poor coordination

So it is possible to have a fairly good idea weather the stroke patient you are presented with is suffering from a clot or a bleed, based on a fine assessment.  With advancements in technology, this skill, however, may eventually be unneeded.  There is solid evidence supporting the efficacy of paramedics and the use of prehospital diagnostic equipment.  There are portable brain scanners that are being tested in the field right now.  This may sound like something far-fetched or unnecessary, but I believe otherwise.  With stroke being the time is tissue condition, why not use equipment that may facilitate treatment that could subsequently improve the quality of life, of our patients.  With the ability to conclusively diagnose an ischemic stroke, thrombolysis could be preformed much earlier.  There would be an obvious need to provide research and gain evidence to support this process, but with an exponential probability of benefit, there should be a bigger push to get this done.  The studies advocating hypothermia in the presence of a CVA all appear encouraging as well.  Please read some of the research I have provided below.

Set up and run a thrombolysis service for acute stroke. [1]

Abstract 

Intravenous thrombolysis significantly improves the chance of independent recovery from ischaemic stroke but its benefit is strongly time dependent: present evidence supports effectiveness when delivered up to 4.5 h after symptom onset but the chance of recovery is twice as great when it is given within 90 min compared with 3-4.5 h. Delivery of treatment to a high proportion of patients is possible but requires clinicians to optimise systems for patient transfer, clinical and radiological assessment. A high proportion of patients with stroke already present to UK hospitals within the treatment time window even without specific public awareness or prehospital triage. Establishing a service requires dialogue with all those involved in the patient pathway, including ambulance dispatchers, paramedics, emergency department staff, radiology and colleagues in acute medicine. Most acute stroke teams cross traditional medical disciplines. Thrombolysis should ideally be delivered within an integrated service that seamlessly includes acute stroke unit care and rehabilitation.