Review of the Mobile Stroke Unit Experience Worldwide

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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First Automated Stroke Imaging Evaluation via Electronic Alberta Stroke Program Early CT Score in a Mobile Stroke Unit

Cerebrovascular Diseases ◽

10.1159/000446861 ◽

2016 ◽

Vol 42 (5-6) ◽

pp. 332-338 ◽

Cited By ~ 19

Author(s):

Iris Quasar Grunwald ◽

Andreas Ragoschke-Schumm ◽

Michael Kettner ◽

Lenka Schwindling ◽

Safwan Roumia ◽

...

Keyword(s):

Stroke Unit ◽

Stroke Management ◽

Imaging Evaluation ◽

Vessel Occlusion ◽

Stroke Treatment ◽

Stroke Imaging ◽

Mobile Stroke Unit ◽

Potential Benefits ◽

Comprehensive Stroke Center ◽

Stroke Center

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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Abstract TP291: Melbourne Mobile Stroke Unit Increases Stroke Treatment Rates and Treatment Opportunities

Stroke ◽

10.1161/str.50.suppl_1.tp291 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Skye Coote ◽

Henry Zhao ◽

Lauren Pesavento ◽

Francesca Langenberg ◽

Patricia Desmond ◽

...

Keyword(s):

Stroke Unit ◽

Stroke Treatment ◽

Mobile Stroke Unit

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

JAMA Neurology ◽

10.1001/jamaneurol.2019.2829 ◽

2019 ◽

Vol 76 (12) ◽

pp. 1484 ◽

Cited By ~ 17

Author(s):

Stefan A. Helwig ◽

Andreas Ragoschke-Schumm ◽

Lenka Schwindling ◽

Michael Kettner ◽

Safwan Roumia ◽

...

Keyword(s):

Stroke Unit ◽

Stroke Management ◽

Mobile Stroke Unit ◽

Clinical Scoring

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Lessons from Recent Advances in Ischemic Stroke Management and Targeting Kv2.1 for Neuroprotection

International Journal of Molecular Sciences ◽

10.3390/ijms21176107 ◽

2020 ◽

Vol 21 (17) ◽

pp. 6107 ◽

Cited By ~ 1

Author(s):

Chung-Yang Yeh ◽

Anthony J. Schulien ◽

Bradley J. Molyneaux ◽

Elias Aizenman

Keyword(s):

Ischemic Stroke ◽

Time Window ◽

Stroke Therapy ◽

Stroke Management ◽

Preclinical Research ◽

Endovascular Thrombectomy ◽

Stroke Treatment ◽

Cell Death Pathway ◽

To Receive ◽

Neuroprotective Therapies

Achieving neuroprotection in ischemic stroke patients has been a multidecade medical challenge. Numerous clinical trials were discontinued in futility and many were terminated in response to deleterious treatment effects. Recently, however, several positive reports have generated the much-needed excitement surrounding stroke therapy. In this review, we describe the clinical studies that significantly expanded the time window of eligibility for patients to receive mechanical endovascular thrombectomy. We further summarize the results available thus far for nerinetide, a promising neuroprotective agent for stroke treatment. Lastly, we reflect upon aspects of these impactful trials in our own studies targeting the Kv2.1-mediated cell death pathway in neurons for neuroprotection. We argue that recent changes in the clinical landscape should be adapted by preclinical research in order to continue progressing toward the development of efficacious neuroprotective therapies for ischemic stroke.

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“Mobile Stroke Unit” for Hyperacute Stroke Treatment

Stroke ◽

10.1161/01.str.0000075573.22885.3b ◽

2003 ◽

Vol 34 (6) ◽

Cited By ~ 59

Author(s):

Klaus Fassbender ◽

Silke Walter ◽

Yang Liu ◽

Frank Muehlhauser ◽

Andreas Ragoschke ◽

...

Keyword(s):

Stroke Unit ◽

Stroke Treatment ◽

Hyperacute Stroke ◽

Mobile Stroke Unit

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Air-Mobile Stroke Unit for access to stroke treatment in rural regions

International Journal of Stroke ◽

10.1177/1747493018784450 ◽

2018 ◽

Vol 13 (6) ◽

pp. 568-575 ◽

Cited By ~ 12

Author(s):

Silke Walter ◽

Henry Zhao ◽

Damien Easton ◽

Cees Bil ◽

Jonas Sauer ◽

...

Keyword(s):

Rural Areas ◽

Stroke Unit ◽

Systems Of Care ◽

Intravenous Thrombolysis ◽

Rural And Remote ◽

Stroke Patients ◽

Stroke Treatment ◽

Remote Areas ◽

Mobile Stroke Unit ◽

Rural And Remote Areas

Background In recent years, important progress has been made in effective stroke treatment, however, patients living in rural and remote areas have nil or very limited access to timely reperfusion therapies. Aims Novel systems of care to overcome the detrimental treatment gap for stroke patients living in rural and remote regions need to be developed. Summary of review A possible solution to the treatment disparity between stroke patients living in metropolitan and rural areas may involve the use of specially designed aircrafts equipped with the ability to diagnose and treat acute stroke at remote emergency sites. We describe technical solutions for an Air-Mobile Stroke Unit (Air-MSU) concept, where an aircraft is customized with the ability to perform multimodal computed tomography, in addition to onboard laboratory equipment and telemedicine connection. The Air-MSU is envisioned not only to allow intravenous thrombolysis in the field but also to allow prehospital triage to a comprehensive stroke center through use of contrast intracerebral vascular imaging. Several options for the Air-MSU approach are described, and issues regarding the potential medical benefit, optimal operating environment, technical realization, and integration in pre-existing solutions (e.g., flying doctor service) are addressed. Conclusion The Air-MSU may represent a novel tool to reduce treatment disparity for stroke patients in rural and remote areas. However, this approach requires further implementation research to determine the overall benefit to these communities.

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E-112 A single center comparison of stroke treatment times: impact of a mobile stroke unit

10.1136/neurintsurg-2018-snis.188 ◽

2018 ◽

Author(s):

H Shownkeen ◽

M Mohajer-Esfahani ◽

H Crumlett ◽

A Lindstrom

Keyword(s):

Stroke Unit ◽

Single Center ◽

Stroke Treatment ◽

Mobile Stroke Unit

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Economic evaluation of the Melbourne Mobile Stroke Unit

International Journal of Stroke ◽

10.1177/1747493020929944 ◽

2020 ◽

pp. 174749302092994 ◽

Cited By ~ 1

Author(s):

Joosup Kim ◽

Damien Easton ◽

Henry Zhao ◽

Skye Coote ◽

Garveeta Sookram ◽

...

Keyword(s):

Stroke Unit ◽

Standard Care ◽

Stroke Care ◽

Reperfusion Therapy ◽

Sensitivity Analyses ◽

Local Data ◽

Endovascular Thrombectomy ◽

Stroke Treatment ◽

Mobile Stroke Unit ◽

Life Years

Background The Melbourne Mobile Stroke Unit (MSU) is the first Australian service to provide prehospital acute stroke treatment, including thrombolysis and facilitated triage for endovascular thrombectomy. Aims To estimate the cost-effectiveness of the MSU during the first full year of operation compared with standard ambulance and hospital stroke care pathways (standard care). Methods The costs and benefits of the Melbourne MSU were estimated using an economic simulation model. Operational costs and service utilization data were obtained from the MSU financial and patient tracking reports. The health benefits were estimated as disability-adjusted life years (DALYs) avoided using local data on reperfusion therapy and estimates from the published literature on their effectiveness. Costs were presented in Australian dollars. The robustness of results was assessed using multivariable (model inputs varied simultaneously: 10,000 Monte Carlo iterations) and various one-way sensitivity analyses. Results In 2018, the MSU was dispatched to 1244 patients during 200 days of operation. Overall, 167 patients were diagnosed with acute ischemic stroke, and 58 received thrombolysis, endovascular thrombectomy, or both. We estimated 27.94 DALYs avoided with earlier access to endovascular thrombectomy (95% confidence interval (CI) 15.30 to 35.93) and 16.90 DALYs avoided with improvements in access to thrombolysis (95% CI 9.05 to 24.68). The MSU was estimated to cost an additional $30,982 per DALY avoided (95% CI $21,142 to $47,517) compared to standard care. Conclusions There is evidence that the introduction of MSU is cost-effective when compared with standard care due to earlier provision of reperfusion therapies.

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Abstract T P200: Feasibility of Telemedicine on a Mobile Stroke Treatment Unit

Stroke ◽

10.1161/str.46.suppl_1.tp200 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Sung Cho ◽

Russell Cejero ◽

Ather Taqui ◽

Ahmed Itrat ◽

Megan M Donohue ◽

...

Keyword(s):

Emergency Department ◽

Ct Scan ◽

Stroke Unit ◽

Registered Nurse ◽

Clinical Care ◽

Control Group ◽

Treatment Unit ◽

Stroke Treatment ◽

Mobile Stroke Unit ◽

Patient Side

Background: Mobile stroke treatment unit (MTSU) with on-site treatment team that includes a stroke physician can provide thrombolysis successfully in pre-hospital setting more quickly than traditional treatment in hospital. We report our initial experience of mobile stroke unit with remote physician presence by telemedicine. Methods: We implemented a MSTU at our institution starting July 18 th , 2014. The unit includes a registered nurse, paramedic, emergency medical personnel, CT technologist. Stroke physician evaluated patient via telemedicine (InTouch RP-Lite) and neuroradioloigst remotely assessed images obtained by Ceretom mobile CT. Data were entered in medical records and a prospective registry. The evaluation and treatment in the first 3 weeks of implementation of MSTU was compared to a control group of patients brought to emergency department (ED) via a traditional ambulance in the preceding 2 months. Times were measured from patient arrival entering the “door” of MSTU or emergency department (ED). Results: Twenty three patients were evaluated by MSTU. All patients were evaluated successfully with CT scan, IV placement, neurologic exam and NIH Stroke scale evaluation over telemedicine, and CT interpretation. Duration of telemedicine evaluation was median 21 minutes (IQR: 17-34 minutes). There was a single 44 second interruption of telemedicine connection that did not affect clinical care. The Median NIHS Stroke Scale was 7 (IQR 2 to 11) and was successfully completed in all 23 patients with assistance of a registered nurse by patient side. The time from door to CT scan completion was similar between MSTU and ED (median 21 minutes and 20 minutes, p=0.70). The time from CT completion to radiologist report to stroke physician was similar between MSTU and ED (median 6 minutes and 4.5 minutes, p=0.18). Conclusion: Mobile stroke unit using telemedicine is feasible and as time efficient as traditional ED evaluation.

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