The document describes the benefits of mobile stroke units (MSUs) for treating acute ischemic stroke patients. It discusses how MSUs are equipped to perform on-site diagnosis and treatment, including CT scans, lab tests, and thrombolysis. A study in Berlin found that dispatching an MSU in addition to a conventional ambulance resulted in better functional outcomes for patients. Specifically, patients receiving initial MSU response had lower 3-month disability scores and better chances of little to no disability compared to those treated with just a conventional ambulance. The results support the ability of MSUs to more rapidly treat stroke patients and improve patient outcomes.

1. MOBILE STROKE UNIT IN INDIA
FUTURE DIRECTION TOWARDS
PATIENT OUTCOME
DR.PRAMOD MEENA
SR NEUROLOGY
GMC KOTA

2. INTRODUCTION
• first proposed and studied in Homburg, Germany—2008
• THE MSU is equipped with a small-bore portable CT scanner, a point-of-care
laboratory, stroke medication & telemedicine.
• IN point of-care laboratory, hematological parameters (thrombocytes, erythrocytes,
leukocytes, hemoglobin), coagulation parameters [INR, aPTT],chemistry
parameters (gamma-GGT, pancreatic amylase, creatinine, glucose).
• 2 million brain cells are damaged every minute someone is suffering from a
stroke

3. BRINGING THE HOSPITAL to the patient: the mobile
stroke unit
• The approach of administering treatment directly at the emergency
site (termed the MSU concept) was developed in 2003 & in clinical
reality in 2008.
• The MSU concept reducing prehospital and in-hospital transport
times.
• At one location, a single, specialised, inter disciplinary team,
consisting of paramedics, physicians, nurses, and technicians,
performs the complete diagnostic work-up and acute treatment in a
parallel workflow.
WALTER S, KOSTOPOULOS P,HAASS A, ETAL. BRINGING THEHOSPITAL TO THE PATIENT: FIFI RSTTREATMENT OFSTROKEPATIENTS AT THE
EMERGENCY SITE. PLOS ONE2010;5: E13758.

5. MOBILE STROKE UNIT :

6. COMPONENTS IN MSU
1. MSU AMBULANCE
2. IMAGING
3. AUTOMATED IMAGING ASSESSMENT SOFTWARE
4. PREHOSPITAL POC LABORATORY
5. TELECOMMUNICATION BETWEEN MSU AND HOSPITAL
6. STAFFING AND DISPATCH OF MSUS
7. TEAM APPROACH AND EFFICIENCY AT INTERSECTIONS
8. INTERACTION BETWEEN EMS AND MSU

7. PRINCIPALAIM OF MSU
• FASTER
THROMBOLYSIS
ENDOVASCULAR THROMBECTOMY
TREATMENT OF INTRACEREBRAL HEMORRHAGE
EUROPEAN STROKE ORGANISATION (ESO) EXECUTIVE COMMITTEE, ESO WRITING COMMITTEE. GUIDELINES FOR
MANAGEMENT OF ISCHAEMIC STROKE AND TRANSIENT ISCHAEMIC ATTACK 2008.

8. MSU AMBULANCE
• Small vehicles reducing costs, facilitating speed, allowing access to narrow
roads and increasing acceptance.
• Larger vehicles may be advantageous in other specific settings.
• They providing extra space allows relatives to accompany the patient in the
msu to provide history and informed consent for later medical procedures.
• They may also incorporate larger scanners, and their more robust
construction allows coping with challenging street conditions.

9. IMAGING
• exclusion of ICH by ct-head plain.
• The patient undergo or not IAT in a comprehensive stroke centre
because of large-vessel occlusion (LVO).
• CT angiography to allow rapid detection of LVO, a precondition for
correct decision-making for or against transfer to a thrombectomy-
capable stroke centre.
• disadvantage inability to scan below the C2 vertebra; such a
capability could be relevant for assessing obstructions of proximal
neck vessels.
Austein F, Riedel C, Kerby T, et al. Comparison of perfusion CT software to predict the
final infarct volume after thrombectomy. Stroke 2016;47:2311–7.

10. PrehospitalunenhancedCT scans (A) and CT angiographyimages (B) of a patient who had an acute stroke
causedby large vesselocclusionofthe left middle cerebralartery (arrow), enabling a triage decisionto transport
a patient to a CSC for intra-arterial therapy.
PrehospitalunenhancedCT scanning (C) and CT angiography images (D) of a patient with a hypertensive
intracerebralhaemorrhage in the basalganglia with a ‘spot sign’(arrow), indicating ongoing bleeding and
enabling a triage decisionto transport to a CSC

11. AUTOMATED IMAGING ASSESSMENTSOFTWARE
• The presence of early infarct signs indicating that ischaemic injury.
• ASPECTS was developed to provide a standardized topographic
system for scoring CT scans in acute stroke management.
• They may also allow detection of LVO even on non-contrast CT scans,
thereby potentially contributing to improve prehospital triage
decision-making.
• Different commercial perfusion CT software packages 1.Philips ,
2.Siemens, and 3.RAPID to predict the final infarct volume (FIV) after
and before mechanical thrombectomy.
Olive-Gadea M, Crespo C, Granes C, et al.Deep learningbased softwareto
identify largevessel occlusion on noncontrastcomputed tomography. Stroke
2020;51:3133–7.

12. PREHOSPITAL POC LABORATORY
• MSUs contain
haematological, biochemistry and coagulation markers.
• It also quantify renal function markers-for the performance of CT
angiography.
Walter S, Kostopoulos P, Haass A, et al. Point-of-care laboratory halves door-to
therapy-decision time in acute stroke. Ann Neurol 2011;69:581–6.

13. TELECOMMUNICATION BETWEEN
MSU AND HOSPITAL
• Telecommunication between the MSU and the hospital is a crucial component of
the MSU.
• It includes real time bidirectional audio–video communication and exchange of
videos, CT scans and other potentially relevant information
• Telemedicine connection enables the MSU team to obtain valuable guidance from
hospital experts.
• Studies have shown that telemedical assessments were successful for 99 of 100
patients (99%) and achieved a success rate of 100% for 11 treated patients.
Fassbender K, Balucani C, Walter S, et al. Streamlining of prehospital stroke
management: the golden hour. Lancet Neurol 2013;12:585–96

14. STAFFING AND DISPATCH OF MSUS
• Initially a vascular neurologist or a neuroradiologist had to be part
of the MSU personnel for compliance with regional regulations.
• Later on paramedics, nurses and technicians who were guided
remotely by hospital experts via telemedicine.
• In some settings, however, MSUs with a vascular physician on-board
act alone when the EMS code ‘stroke’ is activated.
Itrat A, TaquiA, Cerejo R, et al. Telemedicine in prehospital stroke evaluation and
thrombolysis: taking stroke treatment to the doorstep. JAMA Neurol 2016;73:162–8.

15. INTERACTION BETWEEN EMS AND MSU
• The mode of interaction between a conventional EMS ambulance
and MSU is heterogeneous in the current programmed.
• The dispatch of MSUs, the correct identification of stroke symptoms
is crucial.
• In many regions, stroke recognition in the dispatch office is based
on standard questions that are in turn based on stroke scales, such
as the Face, Arm, Speech, Time (FAST) Scale.
Helwig SA, Ragoschke-Schumm A, Schwindling L, et al. Prehospital stroke management optimized by use of clinical scoring
vs mobile stroke unit for triage of patients with stroke: a randomized clinical trial. JAMA Neurol 2019;76:1484–92.

16. MSU-BASED STROKE MANAGEMENT COMPARED WITH
CONVENTIONAL STROKE MANAGEMENT
Lancet Neurol 2017; 16: 227–37 neurology on February 15, 2017 Department of Neurology,
University Hospital of the Saarland, Homburg, Germany

17. TEAM APPROACH AND EFFICIENCY AT INTERSECTIONS
• Whereas in the hospital various members of the stroke rescue chain
are subsequently activated and interact, separated by different
locations. By 7Ds
DETECTION:EARLY RECOGNITION
DISPATCH: EARLY EMS ACTIVATION
DELIVERY: TRANSPORT& MANAGEMENT
DOOR: ED TRIAGE
DATA: ED EVALUATION & MANAGEMENT
DECISION: SPECIFIC THERAPIES
DRUG: THROMCOLYTIC OR OTHER AGENTS

19. BASELINE DEMOGRAPHICSOF t-PA ELIGIBLE PATIENTS

22. BEST MSU CONCLUSIONS
• 17% more treated with tPA (97% vs 80%)
• 30% more treated within first “golden hour” from EMS (33% vs 3%)
• Significantly improved patient-centered outcome (p=0.002)
• 10% more patients went home with Zero Disabilities
• No safety issues…9% mimics and 2% sICH in each group
Downstream Benefits:
➢Access to acute stroke care pre hospital
➢Allows First Responders to return to service

23. APPLICATIONS BEYOND THROMBOLYSIS
• MSUs also triage for other stroke patients, large vessel occlusions
(LVO) and intracranial hemorrhage (ICH).
• IV antihypertensive medications, hemostatic agents (i.e., prothrombin
complex concentrate, tranexamic acid, activated factor VII).
• Reversal agents for specific medications (i.e., idarucizumab for
dabigatran, andexanet alfa for factor Xa inhibitors).
• Subsequently after medication administration, ICH patients can be
transported directly to centers with neurosurgery departments via
MSUs.

24. • Traumatic ICH and acute neurological emergencies (i.e., status epileptics, brain
tumors, increased intracranial pressure crisis, etc.) may be preferentially triaged to
centers with neurosurgical and neuroscience critical care capabilities.
• MSU demonstrated that it is feasible and safe to administer tPA through an
intraosseous route.
• This is important because obtaining reliable and timely IV access can be
challenging.
Wendt M, Ebinger M, Kunz A, et al;STEMO Consortium. Improved prehospitaltriage of patientswith stroke in a
specialized stroke ambulance:results of the pre-hospitalacute neurologicaltherapyand optimization ofmedical
care in stroke study. Stroke 2015;46 (03):740–745

25. Association Between Dispatch of Mobile Stroke Units and Functional
Outcomes Among Patients With Acute Ischemic Stroke in Berlin
• Abstract: Effects of thrombolysis in acute ischemic stroke are time-dependent. Ambulances that can administer thrombolysis
(mobile stroke units) before arriving at the hospital have been shown to reduce time to treatment.
• This prospective, nonrandomized, controlled intervention study was conducted in Berlin, Germany, from February 1, 2017, to
October 30, 2019.
• If an emergency call prompted suspicion of stroke, both a conventional ambulance and an MSU, when available,were dispatched.
Functional outcomes of patients with final diagnosis of acute cerebral ischemia who were eligible for thrombolysis or thrombectomy
were compared based on the initial dispatch (both MSU and conventional ambulance or conventional ambulance
only) Simultaneous dispatch of an MSU(n = 749) vs conventional ambulance alone (n = 794).
• Results: Patients with an MSU dispatched had lower median mRS scores at month 3 (1; interquartile range [IQR], 0-3) than did
patients without an MSU dispatched (2; IQR, 0-3; common OR for worse mRS, 0.71; 95% CI, 0.58-0.86; P < .001). Similarly,
patients with an MSU dispatched had lower 3-month primary disability scores: 586 patients (80.3%) had none to moderate
disability; 92 (12.6%) had severe disability; and 52 (7.1%) had died vs patients without an MSU dispatched: 605 (78.0%) had none
to moderate disability; 103 (13.3%) had severe disability; and 68 (8.8%) had died (common OR for worse functional outcome, 0.73,
95% CI, 0.54-0.99; P = .04).
• Conclusions and relevance: In this prospective, nonrandomized, controlled intervention study of patients with acute ischemic
stroke in Berlin, Germany, the dispatch of mobile stroke units, compared with conventional ambulances alone, was significantly
associated with lower global disabilityat 3 months.
2021 FEB 2;325(5):454-466.JAMA

26. PIVOTAL TRIAL EVALUATING THE EFFICACY AND SAFETY OF MOBILE STROKE UNIT

27. MOBILE STROKE UNIT IN INDIA
COIMBATORE MARCH 4, 2017: KOVAI MEDICAL CENTRE

28. • Stroke incidence rate of 119 to 152/100000, stroke has a case fatality rate of 19 to
42% in the country.
• In INDIA MSU - first in Asia at coimbatore 4 march 2017,Launched at Tamil
Nadu-based Kovai Medical Centre and Hospital (KMCH),By KMCH Chairman
Dr Nalla G Palanisamy lauched it.
• And second by The Indian Council of Medical Research [ICMR] initiated to
provide stroke treatment through our state-of-the-art Mobile Stroke Unit in
Tezpur and Dibrugarh area of Assam, which was inaugurated on 28th
September 2020 by health minister of india.

29. • The vehicle was built with cooperation from the Atomic Energy Commission to
ensure that it was safe to perform CT scanning on the move.
• Faster diagnosis and treatment holds the key for recovery among stroke
patients.
• which was specifically developed for Indian roads, from Schiller after holding
several rounds of talk Coimbatore-based KMCH ordered the Rs 6 crore/unit.
• It is based on the concept of “TIME IS BRAIN.”

30. ICMR'S MOBILE STROKE CARE UNIT FOR NORTH EAST REGION INAUGURATED BY DR.
HARSH VARDHAN, HON'BLE UNION MINISTER MOHFW, GOI ON SEPTEMBER 28, 2020

34. TIMINGS
• The median “symptom onset to MSU code call” time was 69.0 min (range: 15-345).
• The “call to MSU dispatch”time was under 10 min in all cases.
• MSU rendezvous points were dependenton the location;hence, the median durationof MSU to
rendezvous time was 55 min (range 15-210).
• The time between arrival at the rendezvous point and CT scan, although not critically documented,
was negligible (<2 min) in all cases.
• The duration between arrival/CT and initiation of thrombolysis was 14 min.
• The median “symptom onset to management” time was 2 h, which was well within the
established recommendations.
Tong D, Reeves MJ, Hernandez AF, et al. Times from symptom onset to hospital arrival in the get with the guidelines–stroke program 2002 to 2009:
temporal trends and implications.Stroke. July 2012;43(7):1912-1917

35. Telemedicine/Telestroke (MSU Communication
for Specialist Support)
• For cost-effective and efficient communication (applicableeven in remote areas), a simple texting
app (“WhatsApp”in our case) is used for sharing in a group consisting of interventional
radiologists, neuroradiologist, otherspecialists (from neurology, critical care/anesthesiaand
emergency medicine).
• During stroke calls the on-call IR fellow accompanies the MSU personnelto the stroke victim and
relays clinical and imaging details (after sufficient anonymization of patient details) to the texting
app which is seen by all the specialists and the appropriatemanagement is discussed with their
relevant inputs.

36. PROTOCOL USE IN
KMCH
1. MSU base station and rendezvous point:
24/7 MSU vehicle is stationed at our tertiary care hospital. Petrol bunks (gas stations) are the most ideal
rendezvous points in a suburban setup, Rendezvous point is determined midway between our facility and the
patient location.
2. Stroke call:
Individuals/local ambulance services/ suburban hospitals (with no access to CT scan) recognize and notify
the emergency department of our hospital (KMCH) about potential strokes by phone and mobile no.is
(09566595665).
3. MSU rendezvous with stroke victim:
Stroke victim transported via ambulance (or equivalent) to the predetermined rendezvous point. Stroke
victim shifted to MSU. The MSU team assumes care of stroke victim.
4. Stroke management:
A patient is assessed and imaged by an on-board CT scanner. The case is then discussed with specialists using
“group-text app.” Appropriate medication is administered immediately. The stoke victim is shifted to the most
appropriate destination for further management

37. CASESCENARIO
HOW IT WORKIN INDIA
• 14:00 h (Stroke Clock 00:00)
It was a routine day for a middle-aged female, Mrs X. She was doing her routine afternoon household
activities when suddenly she was not able to move left side of her body. She tried calling for help and realized
her speech was slurred. Patient and close relatives with only basic school education failed to recognize that these
were symptoms of acute stroke.
• 17:21 h (Stroke Clock 03:21)
By this time her more educated spouse arrived and realized something was wrong, she was taken to a nearby
hospital which happened to be our branch hospital (spoke), without CT scan facilities, approx. 10 km away from
our main hospital (hub).
The emergency physician diagnosed this as a stroke and immediately alerted the team at KMCH MSU. Hub and
spoke models have been proven effective in other places as well as in other health conditions even in India. This
requires government-initiated prehospital policies combining other popular models of care

38. • 17:30 h (Stroke Clock03:30)
• MSU arrived at the spoke hospital and intravenous thrombolysis was initiated after imaging within MSU. The
reports revealed ischemic stroke along with right MCA occlusion following which it was decided to transfer the patient to
the main hub hospital for thrombectomy. Apart from alteplase, in India, tenecteplase has also been approved for
thrombolysis in stroke at a dose of 0.2 mg/ kg.
• 17:45 h (Stroke Clock03:45)
• MRI was taken after reaching main KMCH hospital which confirmed large vessel occlusion (right MCA-M1 segment)
with diffusion ASPECTS score of 8.
• As the patient was within window period for mechanical thrombectomy, we proceeded with digital subtraction
angiography (DSA) followed by mechanical thrombectomy in our neurointerventional DSA lab. DSA revealed occluded
vessel in the right side of her brain (M1 segment of right MCA), which opened up fully with one pass of aspiration catheter
(complete distal revascularization within 30 mins). Patient’s power improved drastically over next few days and was
discharged with minimal residual deficit

39. Contrast CT MSU Images Showing Right MCA Occlusion (Top Row) and DSA Images
(Bottom Row) Showing Recanalization Following Successful Mechanical Thrombectomy

40. Gu G, Jiang J, Zheng B, Du X, Huang K, Yue Q and Wang J (2021) Building a Mobile Stroke
Unit Based on 5G Technology – A Study Protocol.
CONVENTIONAL EMERGENCY MEDICAL SYSTEM

41. MOBILE STROKE UNIT

42. Challenges of Setting up an MSU in India
• Novice Startup-it was obvious that setting up a pioneering MSU
program in India (Asia).
• Indian Regulations-MSUs to be lined with 2 mm of lead along the
walls of the CT unit as per their guidelines, to protect individuals
around the vehicle from harmful “X-ray” radiation.
• Ground Clearance
• Patient loading
• Short Emergency Number
• Cost

43. Barriers to mobile stroke unit implementation & their solution

44. NAMASTE FOR STROKE AWARENESS
• A traditional NAMASTE involves flexion with abduction at shoulder, flexion at
elbows and extension of the wrist with palms facing each other. This can used to
test arm drift. If the patient is asked to press palms and fingers against each other
for testing the grip.
• Also asked to smile and say NAMASTE during the assessment. This can detect
any facial droop, asymmetry or slurring of speech. Further, in order to simplify
the process, synonyms in local languages can be used to mean the same (e.g.,
Vanakkam in Tamil).
• This can be used as a simple prehospital screening method in early detection
of strokes.
• Stroke is a national epidemic as recent statistics show and the first step towards
curbing it is to increase the public awareness about stroke and to disseminate
education regarding the importance of its early detection
Gourie-Devi M. Epidemiology of neurological disorders in India: Review of background, prevalence and incidence of epilepsy,
stroke, Parkinson’s disease and tremors. Neurol India 2014;62:588-98

45. CONCLUSION
• 2 million brain cells are damaged every minute someone is suffering from a
stroke.
• MSU concept reducing prehospital and in-hospital transport times.
• more patients treated within first “golden hour” by this MSU.
• The median “symptom onset to management” time was 2 h, which was well
within the established recommendations.
• NAMASTE use for stroke awareness as a simple prehospital screening
method in early detection of strokes.
• Stroke is a national epidemic as recent statistics show and the first step
towards curbing it is to increase the public awareness about stroke and to
disseminate education,

46. REFRENCES
1.Walter S, Kostopoulos P, Haass A, Keller I, Lesmeister M, Schlechtriemen T, et al. Diagnosis and treatment of patients with stroke in a mobile
stroke unit versus in hospital: a randomised controlled trial. Lancet Neurol. (2012)
2. Fassbender K, Walter S, Liu Y, Muehlhauser F, RagoschkeA, Kuehl S, et al. “Mobile stroke unit” for hyperacute stroke treatment. Stroke.
(2003) 34:e44.
3.Walter S, Ragoschke-SchummA, Lesmeister M, Helwig SA, Kettner M, Grunwald IQ et al (2018) Mobile stroke unit use for prehospital
stroke treatment: an update. Radiologe 58(1):24–28
4.Walter S, Kostopoulos P, Haass A, Keller I, Lesmeister M, Schlechtriemen T et al (2012) Diagnosis and treatment of patients with stroke in a
mobile stroke unit versus in hospital: a randomised controlled trial. Lancet Neurol 11(5):397–404
5.Olive-Gadea M, Crespo C, Granes C, et al. Deep learning based software to identify large vessel occlusion on noncontrast computed
tomography. Stroke 2020;51:3133–7.
6.Gu G, Jiang J, Zheng B, Du X, Huang K, Yue Q and Wang J (2021) Building a Mobile Stroke Unit Based on 5G Technology – A Study
Protocol.
7.Gourie-Devi M. Epidemiology of neurological disorders in India: Review of background, prevalence and incidence of epilepsy, stroke,
Parkinson’s disease and tremors. Neurol India 2014;62:588-98
8.Tong D, Reeves MJ, Hernandez AF, et al. Times from symptom onset to hospital arrival in the get with the guidelines–stroke program 2002 to
2009: temporal trends and implications.Stroke. July 2012;43(7):1912-1917
9.WendtM, Ebinger M, Kunz A, et al;STEMO Consortium. Improved prehospitaltriageof patients with strokein a specialized strokeambulance:
results of the pre-hospitalacute neurological therapy and optimization of medical carein strokestudy. Stroke2015;46 (03):740–745

47. THANK YOU