Prehospital Stroke Management Optimized by Use of Clinical Scoring vs Mobile Stroke Unit for Triage of Patients With Stroke

Background: Recently, a mobile stroke unit (MSU) was shown to facilitate acute stroke treatment directly at the emergency site. The neuroradiological expertise of the MSU is improved by its ability to detect early ischemic damage via automatic electronic (e) evaluation of CT scans using a novel software program that calculates the electronic Alberta Stroke Program Early CT Score (e-ASPECTS). Methods: The feasibility of integrating e-ASPECTS into an ambulance was examined, and the clinical integration and utility of the software in 15 consecutive cases evaluated. Results: Implementation of e-ASPECTS onto the MSU and into the prehospital stroke management was feasible. The values of e-ASPECTS matched with the results of conventional neuroradiologic analysis by the MSU team. The potential benefits of e-ASPECTS were illustrated by three cases. In case 1, excluding early infarct signs supported the decision to directly perform prehospital thrombolysis. In case 2, in which stroke was caused by large-vessel occlusion, the high e-ASPECTS value supported the decision to initiate intra-arterial treatment and triage the patient to a comprehensive stroke center. In case 3, the e-ASPECTS value was 10, indicating the absence of early infarct signs despite pre-existing cerebral microangiopathy and macroangiopathy, a finding indicating the program's robustness against artefacts. Conclusions: This study on the integration of e-ASPECTS into the prehospital stroke management via a MSU showed for the first time that such integration is feasible, and aids both decision regarding the treatment option and the triage regarding the most appropriate target hospital.

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Telemedicine-enabled ambulances and mobile stroke units for prehospital stroke management

Journal of Telemedicine and Telecare ◽

10.1177/1357633x211047744 ◽

2021 ◽

pp. 1357633X2110477

Author(s):

Stephen W English ◽

Kevin M Barrett ◽

Willam D Freeman ◽

Bart M Demaerschalk

Keyword(s):

Emergency Medical Services ◽

Patient Outcomes ◽

Stroke Unit ◽

Stroke Care ◽

Growth Potential ◽

Stroke Management ◽

Stroke Units ◽

Unit Model ◽

Mobile Stroke Unit ◽

Improve Patient

The recognition and management of stroke in the prehospital setting has become increasingly important to improve patient outcomes. Several strategies to advance prehospital stroke care have been developed, including the mobile stroke unit and the telemedicine-enabled ambulance—or “mini-MSU.” These strategies both incorporate ambulance-based audio-visual telemedicine evaluation with a vascular neurologist to facilitate faster treatment but differ in several areas including upfront and recurring costs, scalability or growth potential, ability to integrate into existing emergency medical services systems, and interoperability across multiple specialties or conditions. While both the mobile stroke unit and mini-mobile stroke unit model are valid approaches to improve stroke care, the authors aim to compare these models based on costs, scalability, integration, and interoperability in order to guide our prehospital leaders to find the best solutions for their communities.

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Review of the Mobile Stroke Unit Experience Worldwide

Interventional Neurology ◽

10.1159/000487334 ◽

2018 ◽

Vol 7 (6) ◽

pp. 347-358 ◽

Cited By ~ 23

Author(s):

Victoria J. Calderon ◽

Brittany M. Kasturiarachi ◽

Eugene Lin ◽

Vibhav Bansal ◽

Osama O. Zaidat

Keyword(s):

Stroke Unit ◽

Time Window ◽

Economic Cost ◽

Current Status ◽

Utilization Rate ◽

Stroke Management ◽

Treatment Benefit ◽

Stroke Treatment ◽

Neurological Emergencies ◽

Mobile Stroke Unit

Background: The treatment of stroke is dependent on a narrow therapeutic time window that requires interventions to be emergently pursued. Despite recent “FAST” initiatives that have underscored “time is brain,” many patients still fail to present within the narrow time window to receive maximum treatment benefit from advanced stroke therapies, including recombinant tissue plasminogen activator (tPA) and mechanical thrombectomy. The convergence of emergency medical services, telemedicine, and mobile technology, including transportable computed tomography scanners, has presented a unique opportunity to advance patient stroke care in the prehospital field by shortening time to hyperacute stroke treatment with a mobile stroke unit (MSU). Summary: In this review, we provide a look at the evolution of the MSU into its current status as well as future directions. Our summary statement includes historical and implementation information, economic cost, and published clinical outcome and time metrics, including the utilization rate of thrombolysis. Key Messages: Initially hypothesized in 2003, the first MSUs were launched in Germany and adopted worldwide in acute, prehospital stroke management. These specialized ambulances have made the diagnosis and treatment of many neurological emergencies, in addition to ischemic and hemorrhagic stroke, possible at the emergency site. Providing treatment as early as possible, including within the prehospital phase of stroke management, improves patient outcomes. As MSUs continue to collect data and improve their methods, shortened time metrics are expected, resulting in more patients who will benefit from faster treatment of their acute neurological emergencies in the prehospital field.

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Retrospective Review and Proof of Concept of Asia’s First Mobile Stroke Unit Experience in Kovai Medical Center and Hospital

Journal of Stroke Medicine ◽

10.1177/2516608520968418 ◽

2020 ◽

Vol 3 (2) ◽

pp. 116-123

Author(s):

Mathew Cherian ◽

Pankaj Mehta ◽

Shriram Varadharajan ◽

Santosh Poyyamozhi ◽

Elango Swamiappan ◽

...

Keyword(s):

Acute Stroke ◽

Retrospective Review ◽

Stroke Unit ◽

Care Pathway ◽

Clinical Care ◽

Stroke Care ◽

First Year ◽

Proof Of Concept ◽

Mobile Stroke Unit ◽

Clinical Care Pathway

Background: We review our initial experience of India’s and Asia’s first mobile stroke unit (MSU) following the completion of its first year of operation. We outline the clinical care pathway integrating the MSU services using a case example taking readers along our clinical care workflow while highlighting the challenges faced in organizing and optimizing such services in India. Methods: Retrospective review of data collected for all patients from March 2018 to February 2019 transported and treated within the MSU during the first year of its operation. Recent case example is reviewed highlighting complete comprehensive acute clinical care pathway from prehospital MSU services to advanced endovascular treatment with focus on challenges faced in developing nation for stroke care. Results: The MSU was dispatched and utilized for 14 patients with clinical symptoms of acute stroke. These patients were predominantly males (64%) with median age of 59 years. Ischemic stroke was seen in 7 patients, hemorrhagic in 6, and 1 patient was classified as stroke mimic. Intravenous tissue plasminogen activator was administered to 3 patients within MSU. Most of the patients’ treatment was initiated within 2 h of symptom onset and with the median time of patient contact (rendezvous) following stroke being 55 mins. Conclusion: Retrospective review of Asia’s first MSU reveals its proof of concept in India. Although the number of patients availing treatment in MSU is low as compared to elsewhere in the world, increased public awareness with active government support including subsidizing treatment costs could accelerate development of optimal prehospital acute stroke care policy in India.

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

Canadian Medical Association Journal ◽

10.1503/cmaj.170999 ◽

2018 ◽

Vol 190 (28) ◽

pp. E855-E858 ◽

Cited By ~ 11

Author(s):

Ashfaq Shuaib ◽

Thomas Jeerakathil

Keyword(s):

Acute Stroke ◽

Stroke Unit ◽

Mobile Stroke Unit ◽

Rural Settings

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Abstract WP72: Early Experience on Intravenous Tissue Plasminogen Activator Delivery in Mobile Stroke Unit Patients with Stroke Mimics

Stroke ◽

10.1161/str.48.suppl_1.wp72 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Lila E Sheikhi ◽

Stacey Winners ◽

Pravin George ◽

Andrew Russman ◽

Zeshaun Khawaja ◽

...

Keyword(s):

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Stroke Unit ◽

Early Experience ◽

Final Diagnosis ◽

Stroke Mimics ◽

Intravenous Tissue Plasminogen Activator ◽

Mobile Stroke Unit ◽

Tissue Plasminogen ◽

Iv Tpa

Background: A mobile stroke unit (MSU) allows for early delivery for intravenous tissue plasminogen activator (IV-tPA). A proportion of IV-tPA treated patients may turn out to be stroke mimics. We evaluated the rate and complications seen in stroke mimics treated with tPA from our early experience on MSU. Methods: Retrospective review of patients treated with IV-tPA on the MSU from 2014 to 2016. Charts were reviewed for confirmed strokes by imaging (MRI or CT) and hemorrhagic transformation. Stroke mimics were defined as those without imaging evidence of infarction and a final diagnosis which was not suspected to be stroke. Results: Among 62 patients treated with IV-tPA, 14 (28.6%) had a final diagnosis consistent with a stroke mimics. The majority of these occurred in the first year of the MSU program. Most common mimics included conversion disorder (n=5) and seizures (n=5). While the last known well to IV-tPA times were similar, the MSU door-to-needle time was significantly longer in stroke mimics (38 vs 31 minutes, p = 0.03). No intracerebral hemorrhages or other IV-tPA related complications were identified in the stroke mimics group. Conclusions: In our early experience with MSU, treatment of stroke mimics occurred without IV-tPA related complications. This does not appear to be due to rushed decision making.

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Abstract WP339: Validation of the Fast-ed Scale Use by Paramedics in a Mobile Stroke Unit

Stroke ◽

10.1161/str.51.suppl_1.wp339 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Diogo C Haussen ◽

Raul G Nogueira ◽

Nirav Bhatt ◽

Carol Flemming ◽

Nicolas Bianchi ◽

...

Keyword(s):

Stroke Unit ◽

Hospital Setting ◽

Final Diagnosis ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Hospital Arrival ◽

Mobile Stroke Unit ◽

Standard Operating ◽

Intravenous Alteplase ◽

Cerebrovascular Imaging

Introduction: FAST-ED scale is a helpful tool to triage stroke patients in the field. However, data on the accuracy of the scale in the pre-hospital setting is lacking. We aim to validate the use of FAST-ED by paramedics in a mobile stroke unit (MSU) covering a metropolis. Methods: As part of standard operating MSU procedures, paramedics clinically evaluated patients. If the event characterized a stroke alert, the FAST-ED score was determined by the paramedic (in-person) upon patient contact, and independently by a vascular neurologist (telemedicine) immediately after the paramedic evaluation. An MSU nurse determined the NIHSS. This will allow testing of the inter-rater agreement of the FAST-ED scoring performance between on-site pre-hospital providers and remotely located vascular neurologists. Results: In the first 13 months of the MSU’s activity 193 stroke-alert patients were evaluated. 103 (53%) patients had a final diagnosis of stroke/TIA (75/28, respectively), 21 (11%) intracranial hemorrhage, and 69 (36%) were considered stroke mimics. 28 (14%) patients received intravenous alteplase. In the first 48 patients, FAST-ED was only scored by the paramedic and in 145 patients by both the physician and paramedic. FAST-ED scores matched perfectly amongst paramedics and physicians in 77 (53%) instances, while there was only 1-point difference in 51 (35%), 2-point difference in 10 (6%) and 3-point difference in two. Correlation between physician and paramedic FAST-ED scores was highly positive (rho 0.898; 2-sided p<0.001), as well as the correlation between physicians FAST-ED score and NIHSS (rho 0.853; 2-sided p<0.001). When the physician recorded FAST-ED score≥3 (n=62), the paramedics also scored FAST-ED≥3 in the vast majority of instances (n=55; 89%). After hospital arrival, cerebrovascular imaging was deemed necessary and performed in 144 patients within 24 hours of arrival. A visible large vessel occlusion was identified in 30 patients; 18 occlusions were identified with a FAST-ED≥3 while 12 were missed (10/12 had NIHSS≤5). Conclusion: The correlation of the FAST-ED scoring between vascular neurologists and paramedics was highly positive, indicating that FAST-ED is accurately and reliably utilized by paramedics in the pre-hospital setting.

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