Session Report: Current Concepts in Pre-Hospital Stroke Management

This scientific session focused on the rapidly evolving field of pre-hospital stroke care, with an emphasis on early intervention, innovative technologies, and expanding therapeutic strategies. Presentations addressed the logistical, clinical, and technological challenges and opportunities across the pre-hospital stroke pathway.

Professor Philip Bath – University of Nottingham, UK

Professor Bath opened the session by addressing the unique challenges of conducting stroke trials in the pre-hospital setting. He highlighted barriers such as limited research training among paramedics and the complexity of cross-disciplinary collaboration. The motivation and engagement of emergency staff, particularly paramedics, are crucial for successful patient enrollment.

He emphasised the importance of pilot trials to identify logistical issues, including equipment constraints and space limitations in ambulances. Despite these challenges, successful large-scale trials such as FAST-MAG, RIGHT-2, and INTERACT have shown that high-quality evidence for pre-hospital stroke interventions is achievable.

Dr. Tuukka Puolakka – Finland

Dr. Puolakka discussed strategies to reduce door-in-door-out (DIDO) times at primary stroke centers. While current DIDO times can exceed 3 hours, the target is less than 90 minutes. He presented cases where DIDO times were reduced to as little as 15–20 minutes by keeping the same ambulance on standby until the transfer decision is made.

Key enablers of this efficiency include:

• Direct transport of the patient to the CT scanner
• Real-time oral reporting by radiologists
• The use of tenecteplase instead of alteplase
• Simulation training to streamline workflows

Dr. Puolakka encouraged stroke centers to collaborate with emergency medical services (EMS) and develop clear protocols for when the ambulance should remain on-site during evaluation.

Professor Iris Grunwald – University of Dundee, UK

Professor Grunwald gave a comprehensive overview of the evolution and benefits of Mobile Stroke Units (MSUs). Originating from the pioneering work of Klaus Fassbender, MSUs have been scientifically validated to reduce onset-to-needle times and improve outcomes in urban environments.

MSUs allow early identification of large vessel occlusion (LVO), enabling direct transport to angiography-capable centers and significantly reducing door-to-puncture times. She also discussed future innovations:

• AI tools for rapid image interpretation and inter-team communication
• Photon-counting CT, which may differentiate thrombus composition and guide device selection
• Biomarkers, EEG, and video-based AI systems for stroke detection and subtype differentiation

Professor Enrique Leira – University of Iowa, USA

Professor Leira shared preclinical research on the potential neuroprotective effects of low-frequency vibration during helicopter transport in patients receiving intravenous thrombolysis. Using animal models of stroke, his team observed reduced infarct volumes and improved outcomes with low-frequency vibration exposure.

These findings may be explored further through the SPAN consortium, which applies rigorous preclinical testing. If validated, this approach could be translated into clinical practice in the future.

Professor Lili Song – Shanghai, China

Professor Song concluded the session with a review of pre-hospital management of hemorrhagic stroke.
Key points included:

• RIGHT-2 and MR-ASAP trials found no benefit from nitrates in either the full cohort or hemorrhagic stroke subgroup
• The INTERACT-4 trial showed a clear benefit for hemorrhagic stroke patients treated with urapidil
• Hemostatic agents like tranexamic acid have not demonstrated efficacy in trials to date
• The FASTEST trial investigating recombinant factor VIIa (80 µg/kg) is ongoing
• Promising results from the FRONTIER trial (nerinetide) await further validation in intracerebral hemorrhage (ICH)
• Other interventions under investigation include levetiracetam and head positioning in the EAST trial

She concluded by emphasizing the critical need for reliable pre-hospital differentiation between ischemic and hemorrhagic stroke, which remains a major obstacle to tailored early treatment.

Conclusion:
This session provided a comprehensive overview of current concepts in pre-hospital stroke care. Speakers showcased how innovations in clinical workflows, imaging technologies, pharmacological strategies, and preclinical research are reshaping early stroke management. The integration of these advances has the potential to significantly reduce treatment delays and improve outcomes, both for ischemic and hemorrhagic stroke.