‘Ambu-lysis’ edges closer for stroke patients

By Eleanor McDermid, Senior medwireNews Reporter

A pilot trial of giving suitable stroke patients intravenous thrombolysis before their arrival in hospital has produced promising results.

Some aspects of the system have been tested previously, but this trial - the Pre-Hospital Acute Neurological Treatment and Optimization of Medical care in Stroke (PHANTOM-S) study - is the first in which suitable patients actually received thrombolysis in the ambulance.

Although a pilot study, the results indicate that the approach could significantly cut onset-to-treatment time, say lead researcher Joachim Weber (Charité-Universitätsmedizin Berlin, Germany) and team. The average time between the call to the emergency services and receipt of thrombolysis was 62 minutes in the 23 patients who ultimately received tissue plasminogen activator (tPA).

By comparison, the average call-to-thrombolysis time for 50 consecutive patients treated at the same center before the study began was 98 minutes.

The dedicated ambulance, or stroke emergency mobile unit (STEMO), was fitted with a computed tomography (CT) scanner, point-of-care laboratory, and a teleradiology system; operated by a neurologist, paramedic, and radiographer; and was dispatched whenever a stroke was suspected.

Over a period of just under 3 months, the STEMO attended 152 stroke patients, of whom 77 consented to inclusion in the study. Of these, 45 had an acute ischemic stroke with 23 eligible patients given tPA, although one patient was treated on hospital arrival because the STEMO-based CT scanner malfunctioned.

"Although tPA was restricted to patients able to give informed consent, we managed to treat 23 patients in a short time period of 52 days," comment Weber et al in Neurology. "The high frequency of specific stroke treatment is relevant when taking into account the significant financial and personnel efforts of such a new infrastructure."

The study did not raise any particular safety concerns, notes the team. Two patients given tPA developed symptomatic intracranial hemorrhage within 7 days of treatment. One of these patients died, but of an unrelated cause (sepsis).

In a related editorial, Lee Schwamm (Massachusetts General Hospital, Boston, USA) and Sidney Starkman (University of California, Los Angeles, USA) say that the main question is whether the findings can be replicated in other countries and healthcare systems.

"The level of training and experience in the vehicle will be challenging to replicate in a sustainable manner in urban centers, much less in rural areas," they say.

But they suggest: "As long as the number of patients treated by this new model of 'ambu-lysis' generates sufficient quality-adjusted life-years at acceptable cost and without dramatic disparities in access to care, adoption is likely to occur."

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