ABSTRACT
IMPORTANCE: So far, uncertainty remains as to whether there is sufficient cumulative evidence that mobile stroke unit (MSU; specialized ambulance equipped with computed tomography scanner, point-of-care laboratory, and neurological expertise) use leads to better functional outcomes compared with usual care. OBJECTIVE: To determine with a systematic review and meta-analysis of the literature whether MSU use is associated with better functional outcomes in patients with acute ischemic stroke (AIS). DATA SOURCES: MEDLINE, Cochrane Library, and Embase from 1960 to 2021. STUDY SELECTION: Studies comparing MSU deployment and usual care for patients with suspected stroke were eligible for analysis, excluding case series and case-control studies. DATA EXTRACTION AND SYNTHESIS: Independent data extraction by 2 observers, following the PRISMA and MOOSE reporting guidelines. The risk of bias in each study was determined using the ROBINS-I and RoB2 tools. In the case of articles with partially overlapping study populations, unpublished disentangled results were obtained. Data were pooled in random-effects meta-analyses. MAIN OUTCOMES AND MEASURES: The primary outcome was excellent outcome as measured with the modified Rankin Scale (mRS; score of 0 to 1 at 90 days). RESULTS: Compared with usual care, MSU use was associated with excellent outcome (adjusted odds ratio [OR], 1.64; 95% CI, 1.27-2.13; P < .001; 5 studies; n = 3228), reduced disability over the full range of the mRS (adjusted common OR, 1.39; 95% CI, 1.14-1.70; P = .001; 3 studies; n = 1563), good outcome (mRS score of 0 to 2: crude OR, 1.25; 95% CI, 1.09-1.44; P = .001; 6 studies; n = 3266), shorter onset-to-intravenous thrombolysis (IVT) times (median reduction, 31 minutes [95% CI, 23-39]; P < .001; 13 studies; n = 3322), delivery of IVT (crude OR, 1.83; 95% CI, 1.58-2.12; P < .001; 7 studies; n = 4790), and IVT within 60 minutes of symptom onset (crude OR, 7.71; 95% CI, 4.17-14.25; P < .001; 8 studies; n = 3351). MSU use was not associated with an increased risk of all-cause mortality at 7 days or at 90 days or with higher proportions of symptomatic intracranial hemorrhage after IVT. CONCLUSIONS AND RELEVANCE: Compared with usual care, MSU use was associated with an approximately 65% increase in the odds of excellent outcome and a 30-minute reduction in onset-to-IVT times, without safety concerns. These results should help guideline writing committees and policy makers.
Subject(s)
Brain Ischemia , Ischemic Stroke , Stroke , Brain Ischemia/diagnostic imaging , Brain Ischemia/therapy , Fibrinolytic Agents/therapeutic use , Humans , Mobile Health Units , Stroke/diagnostic imaging , Stroke/therapy , Thrombolytic Therapy/methods , Treatment OutcomeABSTRACT
Prehospital management of acute stroke patients. In France, prehospital management of patients with suspected acute stroke relies on emergency medical communication centers (Samu), which provides first-line telephone assessment and dispatches the most appropriate emergency vehicle. Such tasks are not straightforward because many clinical symptoms may correspond to stroke and alternative diagnoses - stroke mimics - are common. It is crucial to reduce both prehospital and hospital delays in patients eligible for reperfusion therapies, namely intravenous thrombolysis and/or mechanical thrombectomy. Because mechanical thrombectomy only applies to patients with acute ischemic stroke and large-vessel occlusion, prehospital triage is important. However, clinical prediction of large-vessel occlusion is difficult and whether a specific patient should be sent to the nearest primary stroke center (drip and ship paradigm) or a comprehensive stroke center with thrombectomy capability (mothership paradigm) remains uncertain. Prehospital notification of the hospital-based stroke teams by the emergency medical system crews is crucial in reducing delays to achieve reperfusion.
Prise en charge préhospitalière des accidents vasculaires cérébraux. La prise en charge préhospitalière de patients ayant une suspicion d'accident vasculaire cérébral (AVC) repose sur une régulation téléphonique médicale effectuée par le Samu-centre 15, qui permet le déclenchement de la réponse la mieux adaptée à l'état du patient et son orientation vers une unité neurovasculaire (UNV). Cette régulation est difficile car les AVC peuvent être révélés par des signes cliniques très variés, et les diagnostics différentiels (stroke mimics) sont fréquents. Il est impératif de réduire les délais de prise en charge des patients qui auront besoin d'un traitement de reperfusion (thrombolyse intraveineuse et/ou thrombectomie mécanique). La démonstration du bénéfice majeur de la thrombectomie chez des patients sélectionnés ayant un infarctus cérébral avec occlusion artérielle proximale soulève les questions de l'évaluation préhospitalière, de la probabilité d'une occlusion proximale et de la stratégie d'orientation vers l'UNV de proximité (drip and ship) ou bien directement vers l'UNV de recours disposant d'un plateau de thrombectomie (mothership). Enfin, l'anticipation de l'arrivée du patient au sein de la structure hospitalière, préalablement prévenue par le médecin régulateur du Samu, est un élément crucial pour la réduction du délai symptômes-reperfusion cérébrale.
