Mobile Stroke Unit Research Articles

Systematic review of organizational models for intra-arterial treatment of acute ischemic stroke.

Intra-arterial treatment of acute ischemic stroke requires changes to acute stroke services since most hospitals do not have on-site intra-arterial treatment facilities. To identify models for delivery of intra-arterial treatment and to compare process performance and clinical and radiological outcomes of the different models. We systematically searched the literature and contacted experts in the field. We performed a qualitative synthesis to identify models, and a quantitative review and meta-analysis of clinical and radiological outcomes under different organizational models. The searches retrieved 148 publications, of which 27 were used for the identification and description of models, and 9 for the comparison of the different models. We identified four main models: the mother-ship, drip-and ship, mobile interventionist, and mobile stroke unit models. There were no randomized-controlled trials of the different models, but non-randomized comparisons were possible using data from 8 observational studies and 1 randomized-controlled trial of intra-arterial therapy, of a total of 4127 patients. Comparison between the mother-ship and drip-and-ship models showed no difference in survival (OR 0.81; 95% CI 0.63-1.03), favorable functional outcome (OR 0.96; 95% CI 0.73-1.25), or arterial patency (OR 0.89; 95% CI 0.73-1.08). Different organizational models exist for intra-arterial treatment of acute ischemic stroke, but there is insufficient evidence to recommend a particular, universal model. Until one model can be shown to be superior, the choice of model should depend on local factors and patient characteristics.

Mobile Stroke Units - Cost-Effective or Just an Expensive Hype?

Acute stroke is a treatable disease. Nevertheless, only a minority of patients obtain guideline-adjusted therapy. One major reason is the small time window in which therapies have to be administered in order to reverse or mitigate brain injury and prevent disability. The Mobile Stroke Unit (MSU) concept, available for a decade now, is spreading worldwide, comprising ambulances, fully equipped with computed tomography, laboratory unit and telemedicine connection to the stroke centre and staffed with a specialised stroke team. Besides its benefits, this concept adds a relevant amount of costs to health services. The feasibility of the MSU and its impact on reducing treatment times have been proven by several research trials. In addition, pre-hospital stroke diagnosis including computed tomographic angiography analysis facilitates correct triage of patients, needing mechanical recanalization, thereby reducing the number of secondary or inter-hospital transfers. Even so, the concept is not yet fully implemented on a broad scale. One reason is the still open question of cost-effectiveness. There are assumptions based on the randomised trials of MSUs hinting towards an acceptable amount of money per quality-adjusted life years and overall cost-effectiveness. Up to now, neither a prospective analysis nor a consideration of secondary transfer avoidance is available. The MSU concept is an innovative and impactful strategy to improve stroke management, especially in times of constraints in healthcare economics and health care professionals. Prospective information is needed to answer the cost-effectiveness question satisfactorily.

Corrigendum to Prehospital idarucizumab prior to intravenous thrombolysis in a mobile stroke unit.

Corrigendum to Prehospital idarucizumab prior to intravenous thrombolysis in a mobile stroke unit.

Ultraearly Intravenous Thrombolysis for Acute Ischemic Stroke in Mobile Stroke Unit and Hospital Settings.

Background and Purpose- Mobile stroke units (MSUs) are known to increase the proportion of acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT) in the first golden hour (GH) after onset compared with hospital settings (HS). However, because of the low number of AIS patients treated with intravenous thrombolysis within this ultraearly time window in conventional care, characteristics, and outcome of this subgroup of AIS patients have not been compared between MSU and HS. Methods- MSU-GH patients were selected from the Berlin-based MSU (STEMO [Stroke Emergency Mobile]), whereas HS-GH patients were selected from the SITS-EAST (Safe Implementation of Treatments in Stroke-East) registry. The outcome events of interest included the rates of favorable functional outcome (modified Rankin Scale scores of 0 or 1), distribution of the modified Rankin Scale scores, and mortality after 3 months between MSU-GH and HS-GH groups. Results- We identified 117 MSU-GH (38.4% of 305 MSU-treated patients) and 136 HS-GH (0.9% of 15 591 HS-treated patients) eligible patients without prestroke disability. No significant differences were documented in the rates of favorable functional outcome (51.3% versus 46.2%, P=0.487) and mortality (7.7% versus 9.9%, P=0.576) at 3 months, or in the distribution of 3-month modified Rankin Scale scores between the 2 groups ( P=0.196). In multivariable logistic regression analyses, adjusting for potential confounders, MSU treatment was not associated with a significantly different likelihood of favorable functional outcome (odds ratio, 1.84 for MSU patients; 95% CI, 0.86-3.96) or mortality (odds ratio, 0.95; 95% CI, 0.28-3.20) at 3 months. Conclusions- There is no evidence that safety and efficacy of ultraearly intravenous thrombolysis for AIS differs when used in MSUs or in HS.

Geospatial Visualization of Mobile Stroke Unit Dispatches: A Method to Optimize Service Performance

Background: Timely treatment of acute ischemic stroke is crucial to optimize outcomes. Mobile stroke units (MSU) have demonstrated ultrafast treatment compared to standard emergency care. Geospatial analysis of the distribution of MSU cases to optimize service delivery has not been reported. Methods: We aggregated all first-year MSU dispatch occurrences and all cases classified by clinical teams as true stroke by zip code and calculated dispatch and true stroke incidence rates. We mapped dispatch and stroke cases and symbolized incidence rates by standard deviation. We confirmed visual impressions of clusters from map inspection by local Moran’s I, boxplot inspection, and t test. We calculated service areas using drive times to meet dispatch and true stroke need. Results: A significant cluster of high dispatch incident rate was confirmed around our MSU base in urban Memphis within a 5-min driving area supporting the initial placement of the MSU based on 911 activation. A significant cluster of high true stroke rate was confirmed to the east of our MSU base in suburban Memphis within a 10-min driving area. Mean incident longitude of cases of true stroke versus disregarded status was significantly eastward (p = 0.001785). Conclusion: Our findings will facilitate determination of socio-spatial antecedents of neighborhood overutilization of 911 and MSU services in our urban neighborhoods and service delivery optimization to reach neighborhoods with true stroke burden.

Prehospital idarucizumab prior to intravenous thrombolysis in a mobile stroke unit.

Administration of intravenous idarucizumab to reverse dabigatran anticoagulation prior to thrombolysis for patients with acute ischemic stroke has been previously described, but not in the prehospital setting. The speed and predictability of idarucizumab reversal is well suited to prehospital treatment in a mobile stroke unit and allows patients with recent dabigatran intake to access reperfusion therapy. To describe feasibility of prehospital idarucizumab administration prior to thrombolysis on the Melbourne mobile stroke unit. The Melbourne mobile stroke unit is a specialized stroke ambulance servicing central metropolitan Melbourne, Australia and provides prehospital assessment, scanning and treatment with an integrated CT scanner and multidisciplinary stroke team. All cases were identified through the mobile stroke unit treatment registry since launch in November 2017. Of a total of n = 20 thrombolysis cases in the first 4 months of operation, three patients (15%) received intravenous idarucizumab 5 g for dabigatran reversal prior to thrombolysis. Mean time between idarucizumab administration and thrombolysis was approximately 10 minutes. Two of the three patients were shown to have large vessel occlusion on CTA in the mobile stroke unit and proceeded to endovascular thrombectomy. At 24 hours, only one patient had a small amount of asymptomatic petechial hemorrhage on follow-up imaging. All patients demonstrated substantial neurological recovery and were discharged to inpatient rehabilitation. Rapid treatment with prehospital administration of idarucizumab prior to thrombolysis using a mobile stroke unit is feasible and facilitates hyperacute treatment.

The mobile stroke unit and management of acute stroke in rural settings.

KEY POINTS In patients with suspected acute stroke, immediate brain imaging, most frequently with computed tomography (CT), is essential to distinguish between an ischemic lesion and a hemorrhage.[1][1] In ischemic stroke, timely treatment with intravenous tissue plasminogen activator or

A History of Mobile Stroke Units and Review of Literature

Using intravenous tissue plasminogen activator (IV tPA), improved functional outcomes are seen with earlier initiation of treatment. Recent studies have shown endovascular revascularization to be a revolutionary and effective treatment. There have been many initiatives focused on improving public education and awareness of stroke symptoms. The concept of a mobile stroke unit (MSU) was created as a way of bringing treatment to patients. Earlier CT scans, delivery of tPA, proper triage and on-scene goal-directed care were the primary goals with these units. It was thought that rapid implementation would shorten hospital stay and improve outcomes. The University of Saarland found a decrease of 41 minutes from stroke alarm to therapeutic decision when an MSU was used. A second trial found a decrease of 25 minutes in time to treatment, an increase in the rate of thrombolysis utilization, and no change in the rates of intracranial hemorrhage or 7-day mortality when an MSU was employed. In 2016, a Lancet article showed that 3 month modified Rankin Scale (mRS) and 3-month mortality were improved in MSU patients. Finally, starting thrombolytic therapy in the MSU was associated with higher probability of mRS of 0-3 but not an improved 3-month survival rate. Long-term results are thus far not available precluding an effective cost-benefit analysis. Many study results are not generalizable as they compare a single hospital system and specialized MSU team to conventional care delivered by a multiple healthcare systems. Future studies will target these limitations.

Mobile stroke unit use for prehospital stroke treatment-an update.

Acute ischemic stroke is atreatable disease. Moreover, there is increasing evidence supporting mechanical recanalization for large-vessel occlusion, even beyond astrict time window. However, only small numbers of patients receive causal treatment. One of the main reasons that patients do not receive causal therapy is their late arrival at the correct target hospital, which, depending on the type of stroke, is either aregional stroke unit or acomprehensive stroke center for interventional treatment. In order to triage patients correctly, afast and complex diagnostic work-up is necessary, allowing astroke specialist to decide on the best therapy option. As treatment possibilities become more comprehensive with the need for individualized decisions, the gap between treatment options and practical implementation is increasing. The "mobile stroke unit" concept encompasses the administration of prehospital acute stroke diagnostic work-up, therapy initiation, and triage to the correct hospital using aspecially equipped ambulance, staffed with ateam specialized in stroke. The concept, which was conceived and first put into practice in Homburg/Saar, Germany, in 2008, is currently spreading with more than 20 active mobile stroke unit centers worldwide. The use of mobile stroke units can reduce the time until stroke treatment by 50% with atenfold increase of patients treated within the first 60 min of symptom onset. The mobile stroke unit concept for acute stroke prehospital management is spreading worldwide. Intensive research is still needed to analyze the best setting for prehospital stroke management.

World's First 24/7 Mobile Stroke Unit: Initial 6-Month Experience at Mercy Health in Toledo, Ohio.

As the fourth mobile stroke unit (MSU) in the nation, and the first 24/7 unit worldwide, we review our initial experience with the Mercy Health MSU and institutional protocols implemented to facilitate rapid treatment of acute stroke patients and field triage for patients suffering other time-sensitive, acute neurologic emergencies in Lucas County, Ohio, and the greater Toledo metropolitan area. Data was prospectively collected for all patients transported and treated by the MSU during the first 6 months of service. Data was abstracted from documentation of on-scene emergency medical services (EMS) personnel, critical care nurses, and onboard physicians, who participated through telemedicine. The MSU was dispatched 248 times and transported 105 patients after on-scene examination with imaging. Intravenous (IV) tissue plasminogen activator (tPA) was administered to 10 patients; 8 patients underwent successful endovascular therapy after a large vessel occlusion was identified using CT performed within the MSU without post treatment symptomatic hemorrhage. Moreover, 14 patients were treated with IV anti-epileptics for status epilepticus, and 19 patients received IV anti-hypertensive agents for malignant hypertension. MSU alarm to on-scene times and treatment times were 34.7 min (25-49) and 50.6 min (44.4-56.8), respectively. The world's first 24/7 MSU has been successfully implemented with IV-tPA administration rates and times comparable to other MSUs nation-wide, while demonstrating rapid triage and treatment in the field for neurologic emergencies, including status epilepticus. With the rising number of MSUs worldwide, further data will drive standardized protocols that can be adopted nationwide by EMS.

Mobile Stroke Unit Reduces Time to Image Acquisition and Reporting.

Timely administration of thrombolytic therapy is critical to maximizing the likelihood of favorable outcomes in patients with acute ischemic stroke. Although emergency medical service activation overall improves the timeliness of acute stroke treatment, the time from emergency medical service dispatch to hospital arrival unavoidably decreases the timeliness of thrombolytic administration. Our mobile stroke unit, a new-generation ambulance with on-board CT scanning capability, reduces key imaging time metrics and facilitates in-the-field delivery of IV thrombolytic therapy.

Time to Decision and Treatment With tPA (Tissue-Type Plasminogen Activator) Using Telemedicine Versus an Onboard Neurologist on a Mobile Stroke Unit.

Mobile stroke units (MSUs) can speed treatment with intravenous tPA (tissue-type plasminogen activator). We previously showed substantial agreement between a telemedicine-based vascular neurologist (TM-VN) and an onboard vascular neurologist (OB-VN) for the evaluation of patients with stroke for tPA eligibility on an MSU. However, the time efficiency of the telemedicine-based evaluation remained uncertain. In this study, we examined the speed of decision and treatment from MSU arrival for the TM-VN compared with an OB-VN. In 50 consecutive situations, the TM-VN served as the primary decision maker. Times from MSU arrival to tPA decision and tPA bolus were compared with the same metrics for when the OB-VN served as the primary decision maker. Time to tPA decision for the TM-VN was 21 minutes (interquartile range, 16.25-26) versus 18 minutes (interquartile range, 14-22) for the OB-VN (P=0.01). Initiation of tPA bolus was 24 minutes (interquartile range, 19.75-30) for the TM-VN versus 24 minutes (interquartile range, 19-27.75) for the OB-VN (P=0.5). Assessment by a TM-VN is comparable with an OB-VN in making decisions about tPA administration on an MSU and does not lead to treatment delays. URL: https://www.clinicaltrials.gov. Unique identifier: NCT02190500.

Then and Now: Temporal Evolution of a Mobile Stroke Unit (P1.215)

Then and Now: Temporal Evolution of a Mobile Stroke Unit (P1.215)

Bypassing Interhospital Transfers for Large Vessel Occlusions in the Era of Mobile Stroke Units (P4.029)

Bypassing Interhospital Transfers for Large Vessel Occlusions in the Era of Mobile Stroke Units (P4.029)

Unmet Needs and Challenges in Clinical Research of Intracerebral Hemorrhage.

Unmet Needs and Challenges in Clinical Research of Intracerebral Hemorrhage.

Abstract P354: Assessment of Phased Implementation of a Mobile Stroke Unit for Acute Ischemic Stroke Treatment

Introduction: The timing of administering tissue-type plasminogen activator (tPA) in patients with an ischemic stroke is directly related to clinical outcomes. The use of a mobile stroke unit (MSU) is a strategy to provide acute ischemic stroke assessment and treatment in a more rapid fashion compared to standard stroke transport and management. Our program initiated the use of a MSU in 2017 as a part of a phased implementation program. We sought to determine the impact of the MSU on the timing of stroke care in the region as it related to proximity to the hospital. Methods: We collected data during the first 9 months of 2017 on patients who were transported to the hospital as pre-hospital stroke alerts (PHSA) via conventional ambulance or via the MSU. Using a retrospective case-controlled design we compared process metrics associated with the phased implementation of the MSU with conventional pre-hospital stroke alerts as standard of care (SOC). Results: There was a total of 178 stroke alert patients; 72 in the MSU group and 106 in the PHSA group. 35 patients received tPA, 16 in the MSU, 19 in SOC. There was no significant difference in age, body weight, race, gender, and length of stay in the hospital in the two groups. The time from 911 call to arrival on scene was 12.06 min versus 20.4 min in the PHSA and MSU groups, respectively. Despite a longer time for arrival TPA administration for patients within a 5 miles radius of the hospital was 89 ± 25 mins in the SOC group and 78±12 mins in the MSU group (p=0.11). For 911 calls originating 10-20 miles from the hospital, the time for 911 call to tPA was 106 ± 23 mins in the PHSA group (n = 4) and 86 ± 2 mins in the MSU group (n = 4). Conclusion: Our initial results are comparable with previously reported data . Our data suggests the MSU may have a greater impact on reducing time to tPA for those further from the hospital or where transport time is delayed. The role of the MSU for non tPA patients such as mechanical thrombectomy, intracerebral hemorrhage and subarachnoid hemorrhage warrants further investigation.

Imaging selection for acute stroke intervention.

This review summarizes the current state of knowledge regarding the use of imaging to guide stroke treatment. Brain imaging plays a central role in the diagnosis of stroke and identification of the mechanism of stroke, which is relevant to acute treatment, prognosis, and secondary prevention. The chief potential modalities are computed tomography (CT) and magnetic resonance imaging (MRI). Currently, most imaging occurs in hospital but mobile stroke units have expanded CT brain imaging into the prehospital field. The proven therapies for ischemic stroke are based on achieving reperfusion and the DAWN and DEFUSE 3 trials have now firmly established a need for imaging selection based on estimated ischemic core volume to guide reperfusion decisions in patients beyond 6 h of stroke onset. However, data also indicate that estimated ischemic core volume, in conjunction with patient factors and expected time delay to reperfusion, forms one of the most useful prognostic assessments that could alter decision-making for patients within 6 h. Current trials are also investigating agents that aim to achieve neuroprotection, reduction in edema or prevention of hemorrhagic transformation. Imaging may play a role in identifying patients likely to benefit from this next generation of interventions for stroke patients.

Prehospital Advanced Diagnostics and Treatment of Acute Stroke: Protocol for a Controlled Intervention Study

BackgroundAcute ischemic stroke (AIS) is a medical emergency. The outcome is closely linked to the time elapsing from symptom onset to treatment, and seemingly small delays can mean the difference between full recovery and physical and cognitive dysfunction. Recanalization to allow blood to reenter the affected area is most efficient immediately after symptoms occur, and intravenous thrombolysis must be initiated no later than 4.5 hours after the symptom onset. A liable diagnosis is mandatory to administer the appropriate treatment. Prehospital diagnosis and, in cases where contraindications are ruled out, prehospital initiation of intravenous thrombolysis have been shown to significantly decrease the time from alarm to the treatment.ObjectiveThe objective of this paper is to investigate the effectiveness of prehospital thrombolysis as measured by (1) time spent from symptom onset to treatment and (2) the number of patients treated within 4.5 hours. In addition, we want to conduct explorative studies. These will include (1) the use of biomarkers for diagnostic and prognostic use where we will collect blood samples from various time points, including the hyperacute phase and (2) the study of magnetic resonance imaging (MRI) images at day 1 to determine the infarct volume and if the time to thrombolysis has an influence on this.MethodsThis is a prospective controlled intervention study. The intervention will involve a computed tomography (CT) and thrombolysis in a physician-manned ambulance called a mobile stroke unit (MSU). The control will be the conventional pathway where the patient is transported to the hospital for CT, and thrombolysis as per current procedure.ResultsPatient inclusion has started and a total of 37 patients are enrolled (control and intervention combined). The estimated time to completed inclusion is 36 months, starting from May 2017. The results of this study will be analyzed and published at the end of the trial.ConclusionsThis trial aims to document the feasibility of saving time for all stroke patients by providing prehospital diagnostics and treatment, as well as transport to appropriate level of care, in a safe environment provided by anesthesiologists trained in prehospital critical care.Trial RegistrationClinicalTrials.gov NCT03158259; https://clinicaltrials.gov/show/NCT03158259 (Archived by WebCite at http://www.webcitation.org/6wxNEUMUD)

Mobile stroke unit triage of patients with a suspected stroke: a novel solution to reducing suspected stroke admissions in busy emergency departments

BackgroundEvaluation of patients with a suspected stroke is one of the most common neurological emergencies requiring rapid, comprehensive assessment by the stroke service to determine patient eligibility for timely reperfusion...

Abstract WP226: Bypassing Interhospital Transfers for Large Vessel Occlusions in the Era of Mobile Stroke Units

Introduction: Mobile stroke units (MSU) provide prehospital intravenous thrombolysis (IVT) for patients with acute ischemic strokes and transport to thrombectomy-capable stroke centers. Door-in-door-out (DIDO) time is recognized as a measure of efficient workflow for interhospital transfer of patients for thrombectomy. We applied this measure to the MSU and compared with our Primary Stroke Center (PSC) transfer process in patients presenting with large vessel occlusions. Methods: We identified 50 patients who underwent thrombectomy for large vessel occlusion in a retrospective review. Mode of transport included MSU (n=18), conventional ambulance from PSC to Comprehensive Stroke Center (CSC) (n=19), or directly presenting to a CSC (n=13) in 2016-2017. Measured outcomes included times for PSC DIDO, MSU DIDO (MSU door to scene departure), door-to-CT, door-to-needle (DTN), and door-to-groin. Results: Among thrombectomy patients, IVT was more likely to be administered in a MSU (55.6%, n=10), than either a PSC (36.8%, n=7) or CSC (38.5%, n=5). Door-to-CT completed times were significantly lower in the MSU versus PSC (27 vs. 44 minutes, p<0.01). DTN times in MSU were significantly shorter than PSC DTN times (27 vs. 56 minutes, p<0.01), as were the median DTN times between CSC vs. PSC (27 vs. 56 minutes, p=0.09). Median DTN times comparing CSC vs. MSU were the same (27 minutes, p=0.33). DIDO time was reduced for MSU patients compared to PSC patients (27 vs. 87 minutes, p<0.01). Door-to-groin times for MSU patients compared to PSC patients was significantly reduced (97 minutes vs. 171 minutes, p<0.01). Door-to-groin times for CSC patients were comparable to MSU patients (100 minutes vs. 97 minutes, p=0.97). Conclusion: Advanced stroke systems of care which include a MSU are highly efficient in both IVT and transport for potential thrombectomy among patients presenting with large vessel occlusion. We introduce a concept of a MSU functioning as a mobile PSC, thus bypassing interhospital transfers.