Background: An ambulance equipped with a computed tomography (CT) scanner, a point-of-care laboratory, and telemedicine capabilities (mobile stroke unit [MSU]) has been shown to enable the delivery of thrombolysis to stroke patients directly at the emergency site, thereby significantly decreasing time to treatment. However, work-up in an MSU that includes CT angiography (CTA) may also potentially facilitate triage of patients directly to the appropriate target hospital and specialized treatment, according to their individual vascular pathology. Methods: Our institution manages a program investigating the prehospital management of patients with suspicion of acute stroke. Here, we report a range of scenarios in which prehospital CTA could be relevant in triaging patients to the appropriate target hospital and to the individually required treatment. Results: Prehospital CTA by use of an MSU allowed to detect large vessel occlusion of the middle cerebral artery in one patient with ischemic stroke and occlusion of the basilar artery in another, thereby allowing rational triage to comprehensive stroke centers for immediate intra-arterial treatment. In complementary cases, prehospital imaging not only allowed diagnosis of parenchymal hemorrhage with a spot sign indicating ongoing bleeding in one patient and of subarachnoid hemorrhage in another but also clarified the underlying vascular pathology, which was relevant for subsequent triage decisions. Conclusion: Defining the vascular pathology by CTA directly at the emergency site may be beneficial in triaging patients with various cerebrovascular diseases to the most appropriate target hospital and specialized treatment.

Keywords:
Stroke, Computed tomography, Angiography, Large vessel occlusion, Intra-arterial treatment, Subarachnoid, Aneurysm, Triage
1.
Saver JL, Fonarow GC, Smith EE, Reeves MJ, Grau-Sepulveda MV, Pan W, Olson DM, Hernandez AF, Peterson ED, Schwamm LH: Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA 2013; 309: 2480–2488.
2.
Lees KR, Bluhmki E, von Kummer R, Brott TG, Toni D, Grotta JC, Albers GW, Kaste M, Marler JR, Hamilton SA, Tilley BC, Davis SM, Donnan GA, Hacke W; ECASS, ATLANTIS, NINDS and EPITHET rt-PA Study Group, Allen K, Mau J, Meier D, del Zoppo G, De Silva DA, Butcher KS, Parsons MW, Barber PA, Levi C, Bladin C, Byrnes G: Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 2010; 375: 1695–1703.
3.
Khatri P, Yeatts SD, Mazighi M, Broderick JP, Liebeskind DS, Demchuk AM, Amarenco P, Carrozzella J, Spilker J, Foster LD, Goyal M, Hill MD, Palesch YY, Jauch EC, Haley EC, Vagal A, Tomsick TA; IMS III Trialists: Time to angiographic reperfusion and clinical outcome after acute ischaemic stroke: an analysis of data from the Interventional Management of Stroke (IMS III) phase 3 trial. Lancet Neurol 2014; 13: 567–574.
4.
Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CB, Dippel DW, Campbell BC, Nogueira RG, Demchuk AM, Tomasello A, Cardona P, Devlin TG, Frei DF, du Mesnil de Rochemont R, Berkhemer OA, Jovin TG, Siddiqui AH, van Zwam WH, Davis SM, Castaño C, Sapkota BL, Fransen PS, Molina C, van Oostenbrugge RJ, Chamorro Á, Lingsma H, Silver FL, Donnan GA, Shuaib A, Brown S, Stouch B, Mitchell PJ, Davalos A, Roos YB, Hill MD; HERMES Collaborators: Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA 2016; 316: 1279–1288.
5.
Yperzeele L, Van Hooff RJ, De Smedt A, Valenzuela Espinoza A, Van de Casseye R, Hubloue I, De Keyser J, Brouns R: Prehospital stroke care: limitations of current interventions and focus on new developments. Cerebrovasc Dis 2014; 38: 1–9.
6.
Fassbender K, Grotta JC, Walter S, Grunwald IQ, Ragoschke-Schumm A, Saver JL: Mobile stroke units for prehospital thrombolysis, triage, and beyond: benefits and challenges. Lancet Neurol 2017; 16: 227–237.
7.
Walter S, Kostopoulos P, Haass A, Helwig S, Keller I, Licina T, Schlechtriemen T, Roth C, Papanagiotou P, Zimmer A, Viera J, Körner H, Schmidt K, Romann MS, Alexandrou M, Yilmaz U, Grunwald I, Kubulus D, Lesmeister M, Ziegeler S, Pattar A, Golinski M, Liu Y, Volk T, Bertsch T, Reith W, Fassbender K: Bringing the hospital to the patient: first treatment of stroke patients at the emergency site. PLoS One 2010; 5:e13758.
8.
Kostopoulos P, Walter S, Haass A, Papanagiotou P, Roth C, Yilmaz U, Körner H, Alexandrou M, Viera J, Dabew E, Ziegler K, Schmidt K, Kubulus D, Grunwald I, Schlechtriemen T, Liu Y, Volk T, Reith W, Fassbender K: Mobile stroke unit for diagnosis-based triage of persons with suspected stroke. Neurology 2012; 78: 1849–1852.
9.
Walter S, Kostopoulos P, Haass A, Keller I, Lesmeister M, Schlechtriemen T, Roth C, Papanagiotou P, Grunwald I, Schumacher H, Helwig S, Viera J, Körner H, Alexandrou M, Yilmaz U, Ziegler K, Schmidt K, Dabew R, Kubulus D, Liu Y, Volk T, Kronfeld K, Ruckes C, Bertsch T, Reith W, Fassbender K: 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.
10.
Ebinger M, Winter B, Wendt M, Weber JE, Waldschmidt C, Rozanski M, Kunz A, Koch P, Kellner PA, Gierhake D, Villringer K, Fiebach JB, Grittner U, Hartmann A, Mackert BM, Endres M, Audebert HJ; STEMO Consortium: Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA 2014; 311: 1622–1631.
11.
Bowry R, Parker S, Rajan SS, Yamal JM, Wu TC, Richardson L, Noser E, Persse D, Jackson K, Grotta JC: Benefits of stroke treatment using a mobile stroke unit compared with standard management: the BEST-MSU Study Run-In Phase. Stroke 2015; 46: 3370–3374.
12.
Itrat A, Taqui A, Cerejo R, Briggs F, Cho SM, Organek N, Reimer AP, Winners S, Rasmussen P, Hussain MS, Uchino K; Cleveland Pre-Hospital Acute Stroke Treatment Group: Telemedicine in prehospital stroke evaluation and thrombolysis: taking stroke treatment to the doorstep. JAMA Neurol 2016; 73: 162–168.
13.
John S, Stock S, Cerejo R, Uchino K, Winners S, Russman A, Masaryk T, Rasmussen P, Hussain MS: Brain imaging using mobile CT: current status and future prospects. J Neuroimaging 2016; 26: 5–15.
14.
Rumboldt Z, Huda W, All JW: Review of portable CT with assessment of a dedicated head CT scanner. AJNR Am J Neuroradiol 2009; 30: 1630–1636.
15.
John S, Stock S, Masaryk T, Bauer A, Cerejo R, Uchino K, Winners S, Rasmussen P, Hussain MS: Performance of CT angiography on a mobile stroke treatment unit: implications for triage. J Neuroimaging 2016; 26: 391–394.
16.
Grunwald IQ, Ragoschke-Schumm A, Kettner M, Schwindling L, Roumia S, Helwig S, Manitz M, Walter S, Yilmaz U, Greveson E, Lesmeister M, Reith W, Fassbender K: First automated stroke imaging evaluation via electronic alberta stroke program early CT score in a mobile stroke unit. Cerebrovasc Dis 2016; 42: 332–338.
17.
Turc G, Maïer B, Naggara O, Seners P, Isabel C, Tisserand M, Raynouard I, Edjlali M, Calvet D, Baron JC, Mas JL, Oppenheim C: Clinical scales do not reliably identify acute ischemic stroke patients with large-artery occlusion. Stroke 2016; 47: 1466–1472.
18.
Demchuk AM, Dowlatshahi D, Rodriguez-Luna D, Molina CA, Blas YS, Dzialowski I, Kobayashi A, Boulanger JM, Lum C, Gubitz G, Padma V, Roy J, Kase CS, Kosior J, Bhatia R, Tymchuk S, Subramaniam S, Gladstone DJ, Hill MD, Aviv RI; PREDICT/Sunnybrook ICH CTA study group: Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT): a prospective observational study. Lancet Neurol 2012; 11: 307–314.
19.
Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, Duldner JE Jr, Harbaugh RE, Patel AB, Rosenwasser RH; American Heart Association: Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 2009; 40: 994–1025.
20.
Steiner T, Juvela S, Unterberg A, Jung C, Forsting M, Rinkel G; European Stroke Organization: European stroke organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis 2013; 35: 93–112.
© 2017 S. Karger AG, Basel
2017
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.