Page 23 - Journal of Special Operations Medicine - Fall 2017

Use of Acetylsalicylic Acid in the
Prehospital Setting for Suspected Acute Ischemic Stroke

John Mario Levri, DO *; Armando Ocon ;
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1
Paul Schunk, MD ; Cord Cunningham, MD, MPH 1
1

ABSTRACT
Acute ischemic stroke (AIS) treatment guidelines include vari- Although these statistical trends are similar for young stroke
ous recommendations for treatment once the patient arrives sufferers, there are some important differences, as noted in
at the hospital. Prehospital care recommendations, however, Smaljovi´c’s comprehensive review. Strokes in “young” pa-
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are limited to expeditious transport to a qualified hospital tients make up approximately 10% to 15% of all strokes,
and supportive care. The literature has insufficiently consid- but consensus on the age of a young stroke patient does not
ered prehospital antiplatelet therapy. An otherwise healthy currently exist. Typically, studies consider a young stroke pa-
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30-year-old black man presented with headache for about 3 tient to be between the ages of 45 and 49 years. Marini et
hours, left-sided facial and upper extremity numbness, slurred al. performed a systematic review of 29 studies from 1980 to
speech, miosis, lacrimation, and general fatigue and malaise. 2009 that included 3,589 patients under the age of 45 years
The presentation occurred at a time and location where ap- who had had a first stroke. The ranges for the different types
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propriate resources to manage potential AIS were limited. The of stroke varied significantly. Incidence of ischemic strokes
patient received a thorough physical examination and electro- ranged from 21.0% to 77.9%; of ICH, 3.7% to 38.5%; and
cardiogram. Acetylsalicylic acid (ASA) 325mg was adminis- of SAH, 9.6% to 55.4%. Smaljovi´c et al. found that ischemic
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tered within 15 minutes of history and examination. A local stroke in young adults was diagnosed in 61% of cases, ICH
host-nation ambulance arrived approximately 30 minutes in 17%, and SAH in 22%. Risk factors for strokes in both

after presentation. The patient’s neurologic symptoms had elderly and young patients are similar and include smoking,
abated by the time the ambulance arrived. The patient did not dyslipidemia, and hypertension. However, an unknown etiol-
undergo magnetic resonance imaging (MRI) until 72 hours af- ogy of the stroke for young patients is more common than in
ter being admitted, owing to lack of neurology staff over the elderly patients. 2
weekend. The MRI showed evidence of a left-sided, posterior-
inferior cerebellar artery stroke. The patient was then taken Recently, U.S. Army Aviation units began rotating to Europe
to a different hospital, where he received care for his acute in support of U.S. European Command (EUCOM) Operation
stroke. The patient eventually was prescribed a statin, ASA, Atlantic Resolve, replacing an organically assigned Combat
and an angiotensin-converting enzyme inhibitor. The patient Aviation Brigade. The new rotational forces are now perform-
has no lingering symptoms or neurologic deficits. ing aviation missions and providing support to North Atlanta
Treaty Organization training missions across Europe. As ex-
Keywords: stroke, acute ischemic; prehospital treatment; pected, a transient force within the theater of operation pre-
ace tylsalicylic acid; antiplatelet sented several new medical challenges, including unfamiliarity
with host-nation resources, communication barriers, and dif-
ferent standards of care.
Introduction
This article presents the case of a Soldier in the EUCOM the-
Acute ischemic stroke (AIS) is a significant and well-studied ater who presented with AIS-like symptoms. Because of his
pathological phenomenon. It can affect any demographic or unfamiliarity with the stroke protocols of the local hospital,
age group, although it is much more common in the elderly one of the authors initiated antiplatelet therapy before cranial
than the young. The following pathologies are the most com- imaging with computed tomography (CT) scan or magnetic
mon causes of AIS: atherosclerosis, vasculitis, arterial dis- resonance imaging (MRI).
section, polycythemia, hypercoagulable state, and infection.
The major vessels typically involved are ophthalmic, anterior Case Presentation
cerebral, middle cerebral, vertebral, postero-inferior cerebel-
lar, basilar, and posterior cerebral. AIS is atypical in young, A 30-year-old male Blackhawk pilot presented to a senior flight
otherwise healthy individuals. Ischemic strokes are estimated paramedic at approximately 23:00 on a Friday in his barracks
to make up to 87% of all strokes. Intracerebral hemorrhage having had a headache for about 3 hours, malaise, and ob-
(ICH; approximately 10%) and nontraumatic subarachnoid vious proprioceptive deficits: the Soldier could barely stand
hemorrhage (SAH; approximately 3%) make up the remain- without assistance. The flight paramedic triaged the patient,
der of strokes. 1 including taking his history and obtaining a manual pulse,
*Correspondence to johnlevri@gmail.com
1 Drs Levri, Schunk, and Cunningham are with the 1st Air Cavalry Brigade. Mr Ocon is an emergency medical technician with the 1st Air Cavalry
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Brigade.
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