Melbourne Mobile Stroke Unit and Reperfusion Therapy

Abstract

Background and Purpose— Mobile stroke units (MSUs) are increasingly used worldwide to provide prehospital triage and treatment. The benefits of MSUs in giving earlier thrombolysis have been well established, but the impacts of MSUs on endovascular thrombectomy (EVT) and effect on disability avoidance are largely unknown. We aimed to determine the clinical impact and disability reduction for reperfusion therapies in the first operational year of the Melbourne MSU. Methods— Treatment time metrics for MSU patients receiving reperfusion therapy were compared with control patients presenting to metropolitan Melbourne stroke units via standard ambulance within MSU operating hours. The primary outcome was median time difference in first ambulance dispatch to treatment modeled using quantile regression analysis. Time savings were subsequently converted to disability-adjusted life years avoided using published estimates. Results— In the first 365-day operation of the Melbourne MSU, prehospital thrombolysis was administered to 100 patients (mean age, 73.8 years; 62% men). The median time savings per MSU patient, compared with the control cohort, was 26 minutes ( P <0.001) for dispatch to hospital arrival and 15 minutes ( P <0.001) for hospital arrival to thrombolysis. The calculated overall time saving from dispatch to thrombolysis was 42.5 minutes (95% CI, 36.0–49.0). In the same period, 41 MSU patients received EVT (mean age, 76 years; 61% men) with median dispatch-to-treatment time saving of 51 minutes ([95% CI, 30.1–71.9], P <0.001). This included a median time saving of 17 minutes ([95% CI, 7.6–26.4], P =0.001) for EVT hospital arrival to arterial puncture for MSU patients. Estimated median disability-adjusted life years saved through earlier provision of reperfusion therapies were 20.9 for thrombolysis and 24.6 for EVT. Conclusions— The Melbourne MSU substantially reduced time to reperfusion therapies, with the greatest estimated disability avoidance driven by the more powerful impact of earlier EVT. These findings highlight the benefits of prehospital notification and direct triage to EVT centers with facilitated workflow on arrival by the MSU.

European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management

“…This result was mainly achieved by bypassing the local non-MT centres. 47 Future research will add more evidence for patients suffering from LVO and other strokes (e.g. acute ICH) and the MSU concept might facilitate the identification of novel diagnostic and therapeutic approaches that may provide benefit from ultra-early administration.…”

Effect of prehospital workflow optimization on treatment delays and clinical outcomes in acute ischemic stroke: A systematic review and meta‐analysis

“…The Newcastle Ottawa Scale was used to assess methodologic quality across the included studies (Table 4). All but three studies 17,19,20 obtained a score of >7, suggesting overall sound methodologic quality. In terms of risk of funding bias, several studies were authored by individuals with industry funding outside of the research of interest, highlighted in Table 4.…”

“…Furthermore, MSUs equipped with CTA can identify and diagnose LVO stroke patients within the MSU, allowing for accurate and appropriate triage to CSCs offering EVT. The MSUs used in the studies by Zhao et al, 20 Helwig et al, 34 and Czap et al 35 all incorporated CTA and were predominantly associated with an improvement in DTP and CTP times for MSU patients. The study by Czap et al 35 compared MSUs equipped with and without CTA for EVT patients and found a significant improvement to DTP times for the CTA equipped cohort.…”

“…Moreover, It has been noted in several studies that LVO stroke patients who present directly at CSCs for EVT have significantly improved functional outcomes,11 providing support to the superior efficacy of the LVO bypass intervention. Only five studies provided data on functional outcomes; further studies are required Various prehospital optimizations investigated in the included studies Zhao et al20 (2020) Bath et al52 (2019) Abbreviations: IVT, intravenous thrombolysis; LVO, large-vessel occlusion; MSU, mobile stroke unit; PSC, primary stroke center. before an assessment of the effect of PSWOs on functional outcomes can be ascertained.…”

Emergency medical dispatchers’ ability to identify large vessel occlusion stroke during emergency calls

“…A suspicion of LVO noted already during the emergency call could change the EMS’ stroke protocol. For example, sending a mobile stroke unit to the scene would give a definitive answer regarding whether the patient should be directed primarily to a comprehensive stroke centre bypassing the primary stroke centre [ 16 ]. Activation of a helicopter EMS unit to remote missions with suspected LVO could be a valuable method to decrease prehospital delays before LVO recanalization [ 17 ].…”