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Introduction: Rural, remote, and Indigenous stroke patients have worse stroke outcomes than urban Australians. This may be due to lack of timely access to expert facilities. Objectives: We aimed to describe the characteristics of patients who underwent aeromedical retrieval for stroke, estimate transfer times, and investigate if flight paths corresponded with the locations of stroke units (SUs) throughout Australia. Methods: Prospective review of routinely collected Royal Flying Doctor Service (RFDS) data. Patients who underwent an RFDS aeromedical retrieval for stroke, July 2014-June 2018 (ICD-10 codes: I60-I69), were included. To define the locations of SUs throughout Australia, we accessed data from the 2017 National Stroke Audit. The main outcome measures included determining the characteristics of patients with an in-flight diagnosis of stroke, their subsequent pickup and transfer locations, and corresponding SU and imaging capacity. Results: The RFDS conducted 1,773 stroke aeromedical retrievals, consisting of 1,028 (58%) male and 1,481 (83.5%) non-Indigenous and 292 (16.5%) Indigenous patients. Indigenous patients were a decade younger, 56.0 (interquartile range [IQR] 45.0-64.0), than non-Indigenous patients, 66.0 (IQR 54.0-76.0). The most common diagnosis was "stroke not specified," reflecting retrieval locations without imaging capability. The estimated median time for aeromedical retrieval was 238 min (95% confidence interval: 231-244). Patients were more likely to be transferred to an area with SU and imaging capability (both p < 0.0001). Conclusion: Stroke patients living in rural areas were younger than those living in major cities (75 years, Stroke Audit Data), with aeromedically retrieved Indigenous patients being a decade younger than non-Indigenous patients. The current transfer times are largely outside the time windows for reperfusion methods. Future research should aim to facilitate more timely diagnosis and treatment of stroke.

Acute stroke is one of the most common causes of disability worldwide and numbers are projected to increase. Modern and successful recanalizing treatments are available, but timely access to these treatments is most often restricted to urban populations. This disparity affects nearly half of the world's population, particularly those living in rural and remote areas, and most often affects people with indigenous background. We provide information on this disparity in acute stroke care between rural, remote, and urban areas. We discuss potential new management strategies which could facilitate the timely delivery of acute stroke care to those residents beyond the better serviced urban areas. We focus on the concept of a mobile stroke unit (MSU), especially an Air-MSU. This aircraft solution could provide an imaging capability and immediate clinical expertise via linked telemedicine to diagnose and treat acute stroke patients at the emergency site. The Air-MSU is not only envisioned to allow intravenous thrombolysis in the field but also to allow pre-hospital triage to comprehensive stroke centres through use of contrast imaging to diagnose large vessel occlusion, facilitating endovascular thrombectomy. Moreover, issues regarding optimal operating environment as well as novel imaging and diagnostic devices, which could facilitate the implementation of an Air-MSU are discussed. Innovative health care solutions are urgently needed to close the treatment gap for stroke patients living in rural and remote regions worldwide.

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