Special Ambulance Delivers Vital Stroke Care More Quickly

Patients were six times more likely to get clot-busting drug within 'golden' hour of first symptoms in German study

Friday, November 21, 2014

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FRIDAY, Nov. 21, 2014 (HealthDay News) -- Stroke outcomes are better when patients are treated in an ambulance by a neurologist equipped with a CT scanner and clot-busting drugs, German researchers report.

The sooner patients get the clot dissolver -- tissue plasminogen activator (tPA) -- the better the outcome after a stroke, the researchers noted. For the best outcome, the drug needs to be given within the first hour after stroke symptoms start, the researchers said.

"The so-called 'golden hour' is associated with improved patient outcomes in terms of hospital discharge," said lead researcher Dr. Martin Ebinger, from the Center for Stroke Research at Charite-Universitatsmedizin in Berlin.

"Our findings emphasize the importance of fast treatment in acute stroke," he said. Giving clot-busting drugs in a stroke emergency mobile unit (STEMO) substantially increases the number of stroke patients who get that care in the golden hour, Ebinger said.

For the study, Ebinger and his colleagues looked at how fast clot-busting drugs could be given before patients got to the hospital and how well they did afterwards.

Specifically, they looked at slightly more than 3,000 patients with a suspected stroke treated in a STEMO between May 2011 and January 2013, and compared them with almost 3,000 similar patients when STEMO wasn't available.

Of the 614 patients who suffered a stroke when a STEMO unit was available, 32.6 percent got tPA in the ambulance. Among the 330 stroke patients seen when the special ambulance was not available, 22 percent were given the drug once they got to the hospital.

Patients treated in the STEMO unit got tPA 24.5 minutes sooner than patients given the drug in the hospital. The number given tPA within the golden hour was six times higher with STEMO, according to the report published online Nov. 17 in the journal JAMA Neurology.

Moreover, patients treated with STEMO had no increase in death in the week or three months after their stroke, and they were able to leave the hospital sooner than patients given tPA in the hospital, the researchers found.

"Every effort should be made to reduce delays from symptom onset to treatment," Ebinger said.

Dr. Ralph Sacco, chairman of neurology at the University of Miami Miller School of Medicine, said, "Now we have objective evidence that STEMO not only leads to an increase in the proportion of stroke patients treated with tPA, but also can gets it accomplished much faster, with a six-fold increase in the number of stroke patients treated in the golden hour."

Prototype units are being used and evaluated in Houston and will likely be available in other parts of the United States, he said. "The stroke mobile unit is no longer a fantasy but a reality worthy of further study and consideration," Sacco said.

Dr. Steven Warach is executive director of the Seton/UT Southwestern Clinical Research Institute in Austin, Texas, and author of an accompanying journal editorial. He said, "The mobile stroke unit could be a revolutionary breakthrough in treating stroke victims, but more research is needed to understand how and where to deploy this emergency room on wheels."

It is rare that stroke victims can be treated this quickly, he said. "Patients treated this early in this study were more likely to be able to return to their homes from the hospital and less likely to need go to nursing homes," Warach said.

If these results are confirmed and generalize to other countries and cities, it will be a tremendous advance in helping the victims of stroke, he said.

"But there are many questions still to be answered," Warach said. "STEMO is expensive and the CT scanner won't be needed for most ambulances. Where is it best to have STEMO -- in a city with many strokes but many hospitals nearby or in rural settings far away from hospitals but with fewer strokes?"

According to Warach, the cost can range from around $750,000 to up to $2 million, depending on the components and whether a standard ambulance truck is used or is customized. The CT scanner itself is about $500,000. Also, the ongoing costs of personnel need to be considered, he said.

"To be financially sustainable, the costs of these units must be offset by the benefits they provide, measured in terms of preventing long-term disabilities and deaths," Warach said.

SOURCES: Martin Ebinger, M.D., Center for Stroke Research, Charite-Universitatsmedizin, Berlin, Germany; Steven Warach, M.D., Ph.D., professor, neurology, executive director of the Seton/UT Southwestern Clinical Research Institute in Austin, Texas; Ralph Sacco, M.D., chairman, neurology, University of Miami Miller School of Medicine; Nov. 17, 2014, JAMA Neurology, online

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