Mobile Stroke Units—the Changing Face of Emergency Medicine Stroke Management

  • Charles R. WiraIIIEmail author
  • Ani Aydin
Neurologic Emergencies (J Miller, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Neurologic Emergencies


Purpose of Review

To provide a summary of mobile stroke unit (MSU) utilization within Emergency Medicine stroke systems.

Recent Findings

MSUs have been deployed around the world into prehospital stroke systems demonstrating the ability to differentiate stroke subtypes and to initiate thrombolysis in eligible patients with shorter symptom onset to treatment times than conventional systems. MSU technology may enable the administration of other standard interventions or future experimental agents in the hyperacute time window. It is conceivable that MSU technology may be extended to other disease states in resource-limited areas without immediate access to an emergency department.


MSUs can identify key stroke subtypes and offer promising reductions in treatment times for the time-sensitive condition of acute ischemic stroke. Further research is necessary to guide optimal utilization within stroke systems.


Acute ischemic stroke Mobile stroke unit Emergency medical services Prehospital stroke treatment Thrombolysis Stroke emergency mobile 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Saver JL. Time is brain–quantified. Stroke. 2006;37:263–6.CrossRefGoogle Scholar
  2. 2.
    Miller JB, Heitsch L, Siket MS, Schrock JW, Wira CR 3rd, Lewandowski C, et al. The emergency medicine debate on tPA for stroke: what is best for our patients? Efficacy in the first three hours. Acad Emerg Med. 2015;22(7):852–5.CrossRefGoogle Scholar
  3. 3.
    Goyal M, Jadhav AP, Bonafe A, Diener H, Mendes Pereira V, Levy E, et al. Analysis of workflow and time to treatment and the effects on outcome in endovascular treatment of acute ischemic stroke: results from the SWIFT PRIME randomized controlled trial. Radiology. 2016;279:888–97.CrossRefGoogle Scholar
  4. 4.
    Adeoye O, Nystrom KV, Yavagal DR, Luciano J, Nogueira RG, Zorowitz RD, et al. Recommendations for the establishment of stroke systems of care: a 2019 update: a policy statement from the American Stroke Association. Stroke. 2019;50:e187–210.CrossRefGoogle Scholar
  5. 5.
    Smith EE, Kent DM, Bulsara KR, Leung LY, Lichtman JH, Reeves MJ, et al. Accuracy of prediction instruments for diagnosing large vessel occlusion in individuals with suspected stroke: a systematic review for the 2018 guidelines for the early management of patients with acute ischemic stroke. Stroke. 2018;49:e111–22.PubMedGoogle Scholar
  6. 6.
    Calderon VJ, Kasturiarachi BM, Lin E, Bansal V, Zaidat OO. Review of the mobile stroke unit experience worldwide. Interv Neurol. 2018;7:347–58.CrossRefGoogle Scholar
  7. 7.
    Fassbender K, Walter S, Liu Y, Muehlhauser F, Ragoschke A, Kuehl S, et al. “Mobile stroke unit” for hyper-acute stroke treatment. Stroke. 2003;34:e44.CrossRefGoogle Scholar
  8. 8.
    Zhou H, Coote S, Pesavento L, Langenberg F, et al. The Melbourne Mobile Stroke Unit substantially improves thrombolysis times and pre-hospital triage. J Neurol Neurosurg Psychiatry. 2018;89(6):e5–6.Google Scholar
  9. 9.
    Parker SA, Bowry R, Wu TC, Noser EA, Jackson K, Richardson L, et al. Establishing the first mobile stroke unit in the United States. Stroke. 2015;46:1384–91.CrossRefGoogle Scholar
  10. 10.
  11. 11.
    Rasmussen P. Stroke management and the impact of mobile stroke treatment units. Cleve Clin J Med. 2015;82(12 suppl 2):S17–21.CrossRefGoogle Scholar
  12. 12.
    Walter S, Kostopoulos P, Haass A, Keller I, Lesmeister M, Schlechtriemen, et al. Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial. Lancet Neurol. 2012;11:397–404.CrossRefGoogle Scholar
  13. 13.
    Weber JE, Ebinger M, Rozanski M, Waldschmidt C, Wendt M, Winter B, et al. Prehospital thrombolysis in acute stroke: results of the PHANTOM-S pilot study. Neurology. 2013;80:163–8.CrossRefGoogle Scholar
  14. 14.
    •• Ebinger M, Winter B, Wendt M, Weber JE, Waldschmidt C, Rozanski M, et al. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA. 2014;311:1622–31 The largest trial to date evaluating the implementation of mobile stroke units demonstrating a reduction in thrombolytic treatment times compared with controls. CrossRefGoogle Scholar
  15. 15.
    Bowry R, Parker S, Rajan SS, Yamal JM, Wu TC, Richardson L, et al. Benefits of stroke treatment using a mobile stroke unit compared with standard management: the BEST-MSU study run-in phase. Stroke. 2015;46:3370–4.CrossRefGoogle Scholar
  16. 16.
    Itrat A, Taqui A, Cerejo R, Briggs F, Cho SM, Organic N, et al. Telemedicine in prehospital stroke evaluation and thrombolysis: taking stroke treatment to the doorstep. JAMA Neurol. 2016;73:162–8.CrossRefGoogle Scholar
  17. 17.
    Taqui A, Cerejo R, Itrat A, Briggs FB, Reimer AP, Winners S, et al. Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis. Neurology. 2017;88:1305–12.CrossRefGoogle Scholar
  18. 18.
    Helwig SA, Ragoschke-Schumm A, Schwindling L, Kettner M, Roumia S, Kulikovski J, 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. Scholar
  19. 19.
    Kunz A, Ebinger M, Geisler F, Rozanski M, Waldschmidt C, Weber JE, et al. Functional outcomes of pre-hospital thrombolysis in a mobile stroke treatment unit compared with conventional care: an observational registry study. Lancet Neurol. 2016;15:1035–43.CrossRefGoogle Scholar
  20. 20.
    Tsivgoulis G, Geisler F, Katsanos AH, Korv J, Kunz A, Mikulik R, et al. Ultraearly intravenous thrombolysis for acute ischemic stroke in mobile stroke unit and hospital settings: a comparative analysis. Stroke. 2018;49:1996–9.CrossRefGoogle Scholar
  21. 21.
    Czap AL, Grotta JC, Parker SA, Yamal JM, Bowry R, Sheth SA, et al. Emergency department door-to-puncture time since 2014 observations from the BEST-MSU study. Stroke. 2019;50:1774–80.CrossRefGoogle Scholar
  22. 22.
    •• Yamal JM, Rajan SS, Parker SA, Jacob AP, Gonzolez MO, Gonzoles NR, et al. Benefits of stroke treatment delivered using a mobile stroke unit trial. Int J Stroke. 2018;13(3):321–7 Description of the design of an ongoing multi-centered MSU clinical trial utilizing as its primary outcome measure neurological function. CrossRefGoogle Scholar
  23. 23.
    SGEM Debate on Stroke ambulances, Accessed 9/26/19.
  24. 24.
    Rajan SS, Baraniuk S, Parker S, Wu TC, Bowry R, Grotta JC. Implementing a mobile stroke unit program in the United States: why, how, and how much? JAMA Neurol. 2015;72:229–34.CrossRefGoogle Scholar
  25. 25.
    Dietrich M, Silke W, Ragoschke-Schumm A, Helwig S, Levine S, Balucani C, et al. Is prehospital treatment of acute stroke too expensive? An economic evaluation based on the first trial. Cerebrovasc Dis. 2014;38:457–63.CrossRefGoogle Scholar
  26. 26.
    Mathur S, Walter S, Grunwald IQ, Helwig SA, Lesmeister M, Fassbender K. Improving prehospital stroke services in rand underserved settings with mobile stroke units. Front Neurol. 2019;10:e1–11.CrossRefGoogle Scholar
  27. 27.
    Feigin VL, Norrving B. A new paradigm for primary prevention strategy in people with elevated risk of stroke. Int J Stroke. 2014;9:624–6. Scholar
  28. 28.
    Nogueira RG, Jadhav AP, Haussen DC, Bonofe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378:11–21.CrossRefGoogle Scholar
  29. 29.
    Austein F, Riedel C, Kerby T, Meyne J, Binder A, Lindner T, et al. Comparison of perfusion CT software to predict the final infarct volume after thrombectomy. Stroke. 2016;47:2311–7.CrossRefGoogle Scholar
  30. 30.
    Grunwald IQ, Ragoschke-Schumm A, Kettner M, Schwindling L, Roumia S, Helwig S, et al. First automated stroke imaging evaluation via electronic Alberta Stroke Program Early CT Score in a mobile stroke unit. Cerebrovasc Dis. 2016;42:332–8.CrossRefGoogle Scholar
  31. 31.
    Bowry R, Parker SA, Yamal JM, Hwang H, Appana S, Rangel-Gutierrez N, et al. Time to decision and treatment with tPA (tissue-type plasminogen activator) using telemedicine versus an onboard neurologist on a mobile stroke unit. Stroke. 2018;49(6):1528–30.CrossRefGoogle Scholar
  32. 32.
    Wu TC, Parker SA, Jagolino A, Yamal JM, Bowry R, Thomas A, et al. Telemedicine can replace the neurologist on a mobile stroke unit. Stroke. 2017;48(2):493–6.CrossRefGoogle Scholar
  33. 33.
    Hov MR, Røislien J, Lindner T, Zakariassen E, Bache KCG, Solyga VM, et al. Stroke severity quantification by critical care physicians in a mobile stroke unit. Eur J Emerg Med. 2019;26(3):194–8.CrossRefGoogle Scholar
  34. 34.
    Hov MR, Zakariassen E, Lindner T, Nome T, Bache KG, Røislien J, et al. Interpretation of brain CT scans in the field by critical care physicians in a mobile stroke unit. J Neuroimaging. 2018;28(1):106–11.CrossRefGoogle Scholar
  35. 35.
    • Hov MR, Ryen A, Finsnes K, Storflor J, Lindner T, Gleditsch. Pre-hospital ct diagnosis of subarachnoid hemorrhage. J Scand J Trauma Resusc Emerg Med. 2017;25(1):21 Publication demonstrating the identification of subarachnoid hemorrhage in an MSU. CrossRefGoogle Scholar
  36. 36.
    Gomes JA, Ahrens CL, Hussain MS, Winners S, Rasmussen PA, Uchino K, et al. Prehospital reversal of warfarin-related coagulopathy in intracerebral hemorrhage in a mobile stroke treatment unit. Stroke. 2015;46:e118–20.CrossRefGoogle Scholar
  37. 37.
    • Rhudy JP, Alexandrov AW, Rike J, Bryndziar T, Hossein ZM, Swatzell V, et al. Geospatial visualization of mobile stroke unit dispatches: a method to optimize service performance. Interv Neurol. 2018;7:464–70 Publication from the Tennessee group discussing how to optimize utilization of a mobile stroke unit within a system of care. CrossRefGoogle Scholar
  38. 38.
    Nagel S, Bouslama M, Krause LU, Küpper C, Messer M, Petersen M, et al. Mechanical thrombectomy in patients with milder strokes and large vessel occlusions. Stroke. 2018;49(10):2391–7.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Authors and Affiliations

  1. 1.Department of Emergency MedicineYale School of MedicineNew HavenUSA
  2. 2.Department of Neurology, Division of Vascular NeurologyYale School of MedicineNew HavenUSA

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