Mobile Stroke Units: Taking the Emergency Room to the Patient

Abstract

Treatment of ischemic infarcts has historically been restricted to supportive measures with the majority of innovations, research, and treatment focused on prevention. Since the development of intravenous tissue plasminogen activator (tPA) as an effective treatment for acute ischemic stroke, it has been found that functional outcome is improved when treatment occurs within 4.5 h of stroke onset and treatment benefits are greater with earlier treatment. Endovascular revascularization is also an effective treatment for acute ischemic stroke and again earlier is better. The axiom “time is brain” refers to the approximately two million neurons lost every minute in an acute ischemic stroke. The Get With The Guidelines Stroke registry found that less than one-third of treatment-eligible acute ischemic stroke patients receive intravenous tPA within 60 min of hospital arrival. There have been many initiatives to improve public education and awareness of stroke symptoms, as well as the emergent nature of seeking evaluation to decrease time to presentation. The concept of a mobile stroke unit was first published as a way of “bringing treatment to the patient rather than the patient to the treatment.” Earlier computed tomography scans, delivery of tPA, proper triage, and on-scene goal-directed care were the primary goals of mobile stroke units. It was postulated that these early benefits would improve long-term outcomes in patients treated in mobile stroke units. Accumulating evidence indicates that mobile stroke units reduce time from stroke alarm to treatment by 25–40 min and increase the rate of intravenous tPA use without an increase in hemorrhage risk. In addition, 3-month favorable outcome (modified Rankin Scale [mRS] score 0–3) is increased. Robust long-term data are still being elucidated and so effective cost–benefit analysis is lacking. The concept of mobile stroke units likely will evolve further and be used for other acute neurologic disorders, help triage patients for endovascular therapy and be incorporated into systems of care in remote areas. Further studies are awaited to fully understand the overall medical and health economic benefit of mobile stroke units.