Mobile stroke care expedites intravenous thrombolysis and endovascular thrombectomy

Bender, Matthew T.; Mattingly, Thomas; Rahmani, Redi; Proper, Diana; Burnett, Walter A; Burgett, Jason; Lesperance, Joshua; Cushman, Jeremy T.; Pilcher, Webster H.; Benesch, Curtis; Kelly, Adam G.; Bhalla, Tarun

doi:10.1136/svn-2021-001119

Cited by 10 publications

(5 citation statements)

References 25 publications

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“…These metrics lack external validity because of variable dispatch and transport criteria. To illustrate, Grunwald et al had the highest rate of transportation/dispatch but transported a much lower percentage of patients with a final cerebrovascular diagnosis (39.7%) than we have previously reported (59%) ( 7 , 23 ).…”

Section: Thrombolysis Metricsmentioning

confidence: 46%

“…Since mobile stroke units (MSU) were first described in 2003 in Germany, numerous studies have shown MSU care expedites intravenous thrombolysis and mechanical thrombectomy compared to standard emergency medical services ( 1 – 7 ). Recently, two large, prospective controlled trials have shown improved clinical outcomes 90 days after presentation with acute ischemic stroke in patients receiving MSU care as compared to traditional emergency medical services ( 8 , 9 ).…”

Section: Introductionmentioning

confidence: 99%

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Mobile Stroke Unit Operational Metrics: Institutional Experience, Systematic Review and Meta-Analysis

et al. 2022

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BackgroundThe available literature on mobile stroke units (MSU) has focused on clinical outcomes, rather than operational performance. Our objective was to establish normalized metrics and to conduct a meta-analysis of the current literature on MSU performance.MethodsOur MSU in upstate New York serves 741,000 people. We present prospectively collected, retrospectively analyzed data from the inception of our MSU in October of 2018, through March of 2021. Rates of transportation/dispatch and MSU utilization were reported. We also performed a meta-analysis using MEDLINE, SCOPUS, and Cochrane Library databases, calculating rates of tPA/dispatch, tPA-per-24-operational-hours (“per day”), mechanical thrombectomy (MT)/dispatch and MT/day.ResultsOur MSU was dispatched 1,719 times in 606 days (8.5 dispatches/24-operational-hours) and transported 324 patients (18.8%) to the hospital. Intravenous tPA was administered in 64 patients (3.7% of dispatches) and the rate of tPA/day was 0.317 (95% CI 0.150–0.567). MT was performed in 24 patients (1.4% of dispatches) for a MT/day rate of 0.119 (95% CI 0.074–0.163). The MSU was in use for 38,742 minutes out of 290,760 total available minutes (13.3% utilization rate). Our meta-analysis included 14 articles. Eight studies were included in the analysis of tPA/dispatch (342/5,862) for a rate of 7.2% (95% CI 4.8–9.5%, I2 = 92%) and 11 were included in the analysis of tPA/day (1,858/4,961) for a rate of 0.358 (95% CI 0.215–0.502, I2 = 99%). Seven studies were included for MT/dispatch (102/5,335) for a rate of 2.0% (95% CI 1.2–2.8%, I2 = 67%) and MT/day (103/1,249) for a rate of 0.092 (95% CI 0.046–0.138, I2 = 91%).ConclusionsIn this single institution retrospective study and meta-analysis, we outline the following operational metrics: tPA/dispatch, tPA/day, MT/dispatch, MT/day, and utilization rate. These metrics are useful for internal and external comparison for institutions with or considering developing mobile stroke programs.

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Section: Thrombolysis Metricsmentioning

confidence: 46%

Section: Introductionmentioning

confidence: 99%

Mobile Stroke Unit Operational Metrics: Institutional Experience, Systematic Review and Meta-Analysis

et al. 2022

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“…MSU safety and efficacy have been reported in several studies [140][141][142]. Moreover, MSU seems to expedite IVT to facilitate EVT for patients with LVO [143]. However, the true impact of MSU on clinical outcomes is unclear, since most MSU studies have not reported clinical outcomes [143].…”

Section: Telemedicine and Mobile Stroke Unitsmentioning

confidence: 99%

“…Moreover, MSU seems to expedite IVT to facilitate EVT for patients with LVO [143]. However, the true impact of MSU on clinical outcomes is unclear, since most MSU studies have not reported clinical outcomes [143]. Two recent studies, a non-RCT and an RCT, reported that in patients with acute stroke who were eligible for rtPA, global disability at 3 months was lower with MSU compared to in-person professional stroke care [144, 145].…”

Section: Telemedicine and Mobile Stroke Unitsmentioning

confidence: 99%

Treatments in Ischemic Stroke: Current and Future

Mosconi¹,

Paciaroni²

2022

Eur Neurol

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Background and Aim: Despite progress made over the last 30 years, stroke is still a leading cause of disability and mortality; likewise, its burden is expected to increase over the next decades, due to population growth and aging. The development of drugs with better safety-efficacy profiles as well as strategies able to improve ischemic stroke management from the pre-hospital setting is needed. Summary: The pathophysiology of ischemic stroke involves multiple pathways resulting in cerebral artery obstruction and brain tissue ischemia. To date, the only approved drug for acute ischemic stroke is intravenous thrombolytic alteplase. Intravenous thrombolysis (IVT) can be administered alone or in combination with endovascular treatment (EVT) with mechanical thrombectomy, in case of large vessel occlusion and generally within 6 h from symptoms onset. The risk of potential bleeding complications, especially symptomatic intracerebral hemorrhage, is one of the reasons for the reluctance to administer IVT. Tenecteplase is a promising alternative fibrinolytic agent, having a better safety profile than alteplase. Moreover, recent evidences have allowed an extension of the IVT ± EVT time window for patients with unknown onset time and for those with a known onset time thanks to the new “tissue-window” approach guided by advanced neuroimaging techniques, which also helps in collateral circulation estimation. Regarding primary-secondary prevention, researchers are focused on improving the efficacy of antithrombotic drugs with a “hemostasis-sparing” approach. Neuroprotective agents are also under development, particularly stem cells. The COVID-19 pandemic has critically stressed global healthcare systems, with collateral damage resulting in access delivery of only emergency care, such as ischemic stroke. Regarding telemedicine, it has had a minor role in acute stroke management, and with the onset of COVID-19, this role will most likely be adopted to increase access and delivery in stroke assessment, but also in the follow-up.

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“…First introduced in Germany in 2003 (2), MSUs are specialized ambulances equipped with stroke care teams, CT scanners and pointof-care laboratory testing devices, which allow for the prehospital diagnosis and treatment of acute stroke. In recent years, MSU utilization has been demonstrated to positively impact various dimensions of stroke care such as the speed and frequency of intravenous thrombolysis (IVT), and stroke outcome (3)(4)(5). So far, MSU services have been confined to research settings in either large metropolitan areas or sparsely populated rural regions and have been highly individualized according to local conditions, regulations and restrictions.…”

Section: Introductionmentioning

confidence: 99%

Establishing an MSU service in a medium-sized German urban area—clinical and economic considerations

Rink,

Tollens,

Tschalzev

et al. 2024

Front. Neurol.

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Background and purposeMobile stroke units (MSU) have been demonstrated to improve prehospital stroke care in metropolitan and rural regions. Due to geographical, social and structural idiosyncrasies of the German city of Mannheim, concepts of established MSU services are not directly applicable to the Mannheim initiative. The aim of the present analysis was to identify major determinants that need to be considered when initially setting up a local MSU service.MethodsLocal stroke statistics from 2015 to 2021 were analyzed and circadian distribution of strokes and local incidence rates were calculated. MSU patient numbers and total program costs were estimated for varying operating modes, daytime coverage models, staffing configurations which included several resource sharing models with the hospital. Additional case-number simulations for expanded catchment areas were performed.ResultsMedian time of symptom onset of ischemic stroke patients was 1:00 p.m. 54.3% of all stroke patients were admitted during a 10-h time window on weekdays. Assuming that MSU is able to reach 53% of stroke patients, the average expected number of ischemic stroke patients admitted to MSU would be 0.64 in a 10-h shift each day, which could potentially be increased by expanding the MSU catchment area. Total estimated MSU costs amounted to € 815,087 per annum. Teleneurological assessment reduced overall costs by 11.7%.ConclusionThis analysis provides a framework of determinants and considerations to be addressed during the design process of a novel MSU program in order to balance stroke care improvements with the sustainable use of scarce resources.

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Mobile stroke care expedites intravenous thrombolysis and endovascular thrombectomy

Cited by 10 publications

References 25 publications

Mobile Stroke Unit Operational Metrics: Institutional Experience, Systematic Review and Meta-Analysis

Mobile Stroke Unit Operational Metrics: Institutional Experience, Systematic Review and Meta-Analysis

Treatments in Ischemic Stroke: Current and Future

Establishing an MSU service in a medium-sized German urban area—clinical and economic considerations

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