By Matthew E. Fink, MD
Louis and Gertrude Feil Professor and Chair, Department of Neurology, Associate Dean for Clinical Affairs, New York Presbyterian/Weill Cornell Medical College
Dr. Fink reports no financial relationships relevant to this field of study.
SOURCE: Holodinsky JK, Kamal N, Zerna C, et al. In what scenarios does a mobile stroke unit predict better patient outcomes? A modeling study. Stroke 2020;51:1805-1812.
It is well established that in the treatment of acute ischemic stroke, time and speed of diagnosis and treatment with thrombolysis or mechanical thrombectomy are critically important. A recent advance in ischemic stroke treatment is the mobile stroke unit, an ambulance outfitted with specialized equipment, computed tomography for brain imaging, and a specialized team with a stroke neurologist available either onboard or via telemedicine. Intravenous thrombolytics can be administered at the scene with the patient on the ambulance.
Multiple groups around the world have demonstrated that response to an acute stroke emergency by the mobile stroke unit results in more rapid treatment with intravenous thrombolysis. Several groups also have demonstrated better outcomes compared to standard ambulance transport. However, there is a controversy related to the triage of patients. Should an acute stroke patient suspected of having a large vessel occlusion be transported immediately to a thrombectomy-ready center and bypass treatment at a primary stroke center or on a mobile stroke unit?
The investigators developed eight separate scenarios for dispatch of the mobile stroke unit from an endovascular center to model which scenarios would result in the best outcomes. Overall, there is a very small relative difference in benefit between the deployment of the mobile stroke unit from the endovascular center compared to conventional ambulance transport. This depends predominantly on the difference in time it takes to reach a patient and administer thrombolysis. Each comprehensive stroke center needs to evaluate its own community and create a local model to determine if use of a mobile stroke unit will be of benefit to its local community. This will vary from urban to rural areas and will be very dependent on population density and traffic congestion. It is impossible to predict in advance in any particular geographic area if deployment of a mobile stroke unit will be helpful without detailed modeling of the community surrounding each endovascular center.