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Impact of Mobile Stroke Units Cerebrovascular disease J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp-2020-324005 on 25 May 2021. Downloaded from Review Impact of mobile stroke units Klaus Fassbender ,1 Fatma Merzou ,1 Martin Lesmeister ,1 Silke Walter,1 Iris Quasar Grunwald,2,3 Andreas Ragoschke- Schumm,1 Thomas Bertsch,4 James Grotta5 1Department of Neurology, ABSTRACT examined these articles with a focus on originality, Saarland University Medical Since its first introduction in clinical practice in 2008, timeliness and relevance to the scope of this review. Center, Homburg, Saarland, Germany the concept of mobile stroke unit enabling prehospital 2Department of Neuroscience, stroke treatment has rapidly expanded worldwide. This The MSU concept: ‘bringing the hospital to the Medical School, Anglia Ruskin review summarises current knowledge in this young field patient’ University, Chelmsford, UK of stroke research, discussing topics such as benefits in 3Division of Imaging Science At present, acute stroke management guide- reduction of delay before treatment, vascular imaging- and Technology, School of lines recommend that, after first assessment and Medicine, University of Dundee, based triage of patients with large-vessel occlusion in stabilisation, patients who had a stroke should Dundee, UK the field, differential blood pressure management or 4 rapidly be transported to the nearest stroke-ready Institute of Clinical Chemistry, prehospital antagonisation of anticoagulants. However, hospital for diagnostic work- up and acute treat- Laboratory Medicine and before mobile stroke units can become routine, several 8 9 Transfusion Medicine, Paracelsus ment. However, effective treatments are now Private Medical University— questions remain to be answered. Current research, available that could, in principle, be adminis- Nuremberg Campus, therefore, focuses on safety, long-term medical benefit, tered directly at the emergency site. Therefore, in Nuremberg, Bayern, Germany best setting and cost- efficiency as crucial determinants contrast to the current practice of awaiting patients 5Department of Neurology, for the sustainability of this novel strategy of acute stroke to arrive at the hospital before diagnosis and treat- Memorial Hermann Hospital, management. Houston, Texas, USA ment can begin, a scientific concept for the delivery of stroke treatment directly at the emergency site 10 Correspondence to was first published in 2003 and was first intro- Professor Klaus Fassbender, duced in clinical practice in 2008.11 12 This concept Department of Neurology, BACKGROUND was made possible by the implementation of all copyright. Saarland University Medical Stroke is an important cause of mortality and Center, 66421 Homburg, required equipment for diagnosis and treatment in disability, with severe medical and economic conse- an ambulance, including CT, point-of - care (POC) Saarland, Germany; Klaus. 1 Fassbender@ uks. eu quences. Efficient causal treatments for acute laboratory, telemedicine connection to hospitals 2 stroke are thrombolysis and intra- arterial therapy and advanced stroke medications. 3 Received 30 January 2021 (IAT), however, both are extremely time-sensitive. Apart from a reduction in treatment delays by Revised 1 April 2021 Many studies showed improved outcomes when Accepted 7 April 2021 cutting transport times and reducing the number of delays before treatment were reduced. For example, crucial interfaces between groups of various health- in the Highly Effective Reperfusion Evaluated in care professionals, an equally important advantage Multiple Endovascular Stroke trial, 10 min earlier of MSUs is the option of diagnosis- based triage thrombectomy estimated to gain 39 disability- free decision- making with regard to transport to the http://jnnp.bmj.com/ 4 days. individually required target hospital. The MSU, In addition to decreasing the effectiveness of acting synergistically with hospital- based stroke recanalising strategies, delays also preclude many units, was aimed to extend specialised stroke care patients from receiving such treatment at all. to the prehospital phase of stroke management.10 This fact is reflected in the low reported rates of treatment: in US registries, approximately 10% of Technical aspects patients who had an acute ischaemic stroke were on September 27, 2021 by guest. Protected treated with thrombolysis and approximately 2% MSU ambulance with IAT.5 6 The main reasons for treatment delays The ambulance, the basis of the MSU, varies world- are related to arriving too late in the hospital for wide with regard to dimensions according to the treatment, indicating the urgency for reconfigura- specific needs of the various regions and health- tion of current systems of care.7 care systems. Some MSUs focus on small and light- © Author(s) (or their This review focuses on current advances in weight standard solutions, thereby reducing costs, employer(s)) 2021. Re- use prehospital stroke treatment and the recently devel- facilitating speed, allowing access to narrow roads permitted under CC BY- NC. No oped mobile stroke units (MSUs) aimed at enabling and increasing acceptance by Emergency Medical commercial re- use. See rights Services (EMS) healthcare professionals, who find and permissions. Published a timely delivery of acute stroke treatment. by BMJ. their familiar working environment. However, larger vehicles may be advantageous in other specific To cite: Fassbender K, Search strategy and selection criteria settings. For example, providing extra space allows Merzou F, Lesmeister M, et al. We searched the PubMed database for articles relatives to accompany the patient in the MSU to J Neurol Neurosurg Psychiatry Epub ahead of print: [please containing the term stroke in combination with provide history and informed consent for later include Day Month Year]. prehospital or Mobile Stroke Unit and published medical procedures. They may also incorporate doi:10.1136/jnnp-2020- between 1 January 2015 and 31 December 2020. larger scanners, and their more robust construction 324005 The search yielded 787 published articles. We allows coping with challenging street conditions. Fassbender K, et al. J Neurol Neurosurg Psychiatry 2021;0:1–8. doi:10.1136/jnnp-2020-324005 1 Cerebrovascular disease J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp-2020-324005 on 25 May 2021. Downloaded from field has been shown to allow rapid detection of LVO, a precon- dition for correct decision- making for or against transfer to a thrombectomy-capable stroke centre14–17 (figure 1A,B). Automated imaging assessment software The presence of early infarct signs indicating that ischaemic injury has existed already for some hours is an important predictor of poorer response to thrombolysis and of a higher rate of worse events.18 As a solution to the problem of high inter- rater variability in detecting those signs, the Alberta Stroke Program Early CT Score (ASPECTS) was developed to provide a standardised topographic system for scoring CT scans in acute stroke management. Because determination of ASPECTS requires substantial experience, automated image analysis tools have been devel- oped more recently.19 During MSU missions, such software can support decision- making for or against thrombolysis in the field, as previously shown.20 Apart from ischaemic brain damage, they may also allow detection of LVO, even on non-contrast CT scans, thereby potentially contributing to improve prehospital triage decision- making.21 Prehospital POC laboratory MSUs contain a complex POC laboratory for performing labora- tory tests in the field. Quantification of haematological, clinical Figure 1 Prehospital unenhanced CT scans (A) and CT angiography chemistry and coagulation markers can be obtained with small, images (B) of a patient who had an acute stroke caused by large- commercially available portable laboratory devices. Before such vessel occlusion of the left middle cerebral artery (arrow), enabling a equipment was implemented in the MSU, a study showed that triage decision to transport a patient to a CSC for intra- arterial therapy. the results of POC testing indeed agreed with those of analyses 22 copyright. Prehospital unenhanced CT scanning (C) and CT angiography images in centralised hospital laboratories. The POC laboratory plat- (D) of a patient with a hypertensive intracerebral haemorrhage in the form can also quantify renal function markers, which are rele- 16 basal ganglia with a ‘spot sign’ (arrow), indicating ongoing bleeding and vant for the performance of CT angiography. To the best of enabling a triage decision to transport to a CSC for neurointensive care. our knowledge, only the first randomised trial in Homburg, CSC, comprehensive stroke centre. Germany, performed between 2008 and 2011, placed the same set of POC laboratory devices found in the MSU also in the hospital; this similarity served to improve the comparability of 14 Imaging the study groups. Imaging is the cornerstone of acute stroke treatment. It provides the answers to two key questions: (1) whether the patient is Telecommunication between MSU and hospital a candidate for tissue plasminogen activator (tPA), that is, by Telecommunication between the MSU and the hospital is a crucial http://jnnp.bmj.com/ exclusion of intracranial haemorrhage, and (2) whether the component of the MSU.23 Telemedical interaction includes real- patient should undergo IAT in a comprehensive stroke centre time bidirectional audio–video communication and exchange of (CSC) because of large-
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