By Antonella Macerollo
For April 2021, we have selected: Ebinger M. et al. Association Between Dispatch of Mobile Stroke Units and Functional Outcomes Among Patients With Acute Ischemic Stroke in Berlin. JAMA. 2021; 325: 454-466. doi: 10.1001/jama.2020.26345.
It is very well known that time is the most crucial factor impacting on the clinical outcome of thrombolysis treatment for ischaemic strokes.
Our paper of the month has dealt with this issue testing whether ambulances turned into mobile stroke units [MSUs] might be produce better clinical outcomes for patients with acute ischemic stroke. Indeed, in this scenario, patients would receive thrombolysis before arriving to the hospital and, thus, will reduce significantly the time to treatment.
Ebinger et al. conducted a prospective, nonrandomized, controlled intervention study in Berlin, Germany, from February 1, 2017, to October 30, 2019 comparing the functional outcomes of patients with final diagnosis of acute cerebral ischemia eligible for thrombolysis or thrombectomy based on the initial dispatch after the emergency call of both MSU and conventional ambulance (749 cases) or conventional ambulance only (794 cases). The patients were evaluated with the modified Rankin Scale (mRS) and this score at 3 month follow-up was the primary outcome of the study.
The coprimary outcome was a 3-tier disability scale at 3 months (none to moderate disability; severe disability; death).
1543 patients (mean age, 74 years; 723 women [47%]) were recruited in our study of the month.
The authors found that patients treated in a MSU had lower median mRS scores at month 3 (p<0.001) and lower 3-month coprimary disability scores compared to the patients that were collected by a conventional ambulance and, thus, had the thrombolysis in the hospital. In particular, 80.3% (vs 78%) of patients had none to moderate disability; 12.6% (vs 13.3 %) had severe disability and only 7.1% (8.8%) had died in the group with an MSU (vs patients without an MSU).
Of note, there was an absolute difference of 8.6% for survival without any disability (mRS, 0-1) and 4% for survival without moderate to severe disability (mRS, 0-3) between the two groups in favour of the MSU dispatch group.
These results are very likely related to two factors: the higher rate of thrombolysis and the lower median dispatch-to-thrombolysis time among patients with an MSU dispatch than among patients without an MSU dispatch.
Overall, our paper of the month showed that the dispatch of mobile stroke units, compared with conventional ambulances alone, was significantly associated with lower global disability at 3 months in the Berlin region with consequently improvement of healthcare costs for the system.
Multicentre studies involving other German centres and hospitals in other countries are necessary to confirm these results as well as to explore potential challenges and cost-effectiveness analysis in developing MSUs as routine service in different countries.