Both letters raise important problems regarding the standardized management of stroke patients in the prehospital phase.
R Sabinski comments that the questions in Table 1, which are intended to guide the staff at the medical emergency control center in the diagnosis of stroke, are not consistent with the catalogue of indications for emergency management for emergency physicians in Bavaria (1). This catalogue ticks off the findings of acute paralysis; impaired speech, vision, gait; and hemiparesis.. In our table we attempted greater precision; it is more comprehensive while remaining eminently practicable. For example, it prompts for two additional symptoms of a posterior circulation infarct (double vision, acute vertigo), and one of the lead symptoms of cerebral hemorrhage or subarachnoid hemorrhage (sudden acute onset of severe headache) is put within the immediate clinical context of stroke. Sabinski’s comments regarding the use of an emergency ambulance team are based on a misunderstanding: in consensus with the German Federation of Emergency Medical Services (reg. assoc.), we used the term “emergency medical service” in our article to refer to the totality of services provided by emergency physicians, dispatchers, and emergency ambulance. It is our understanding that the decision of whether an emergency physician is required should not be made on site by the paramedics, but by the authorized head of the emergency team. This approach has been decided explicitly in a joint session of the medical directors of several supraregional emergency medical services.
Dr Broicher criticizes our statement that patients with suspected acute stroke should be given the highest priority for transfer to a specialized stroke unit, although only 10% of patients would be eligible for thrombolysis. This gave cause for concern in terms of economicalness and raised the question of possible contra-indications that may render admissions to a stroke unit obsolete. Broicher is correct in that we did not actually recommend a blanket transfer of all stroke patients to a stroke unit we recommend the admission to a hospital with a stroke unit. In the emergency ambulance, the admitting physician has to decide on a case by case basis about the indication for thrombolysis and treatment in a stroke unit. We do not think that blanket recommendations on the basis of disease entities are the way forward in this setting.
Further, Broicher wrongly assumes that a stroke unit is merely a thrombolysis ward. The positive effects of stroke unit treatment are not, however, based only on initial thrombolysis treatment but rather on proper and competent multiprofessional treatment, in tandem with targeted diagnostic evaluation (2). We explained this in detail in our article. In contrast to Broicher’s comments, patients with a stroke recurrence after a short time would be admitted into a stroke unit as a matter of high priority and urgency, in order to benefit from the great technical expertise.
To conclude, we thank our correspondents for their encouraging responses to our article.
Prof. Dr. med. Dr. h.c. Christof Kessler
Direktor der Neurologischen Universitätsklinik
Conflict of interest statement
Professor Kessler has received conference expenses, travel expenses, and hotel expenses from Boehringer Ingelheim. For preparing talks, he has received honoraria from Boehringer Ingelheim, GlaxoSmithKline, Johnson & Johnson, Janssen-Cilag, Sanofi, and Pfizer. For conducting clinical studies he has received honoraria into a third-party account for the hospital from Servier, Paion, and Ferrer.