Andrew Micieli, MD
The phrase “time is brain” refers to the rapid identification and potential administration of reperfusion therapy (thrombolysis and/or endovascular therapy) in the setting of ischemic stroke. However, this phrase is also applicable to intracerebral hemorrhage (ICH). At the present time, treatment of ICH is targeted at early diagnosis with neuroimaging followed by therapy targeted at preventing hematoma expansion. This includes early lowering of blood pressure, reversal of coagulopathy or anticoagulation, critical care management and potential surgical options. Time is critical, as hematoma expansion is a strong determinant of neurological deterioration and worse clinical outcomes. This treatment paradigm lends itself well to the mobile stroke unit (MSU).
This study by Cooley et al. looked at the MSU experience with ICH in Melbourne. Over a two-year period, the MSU managed 49 patients with ICH (16% of total cases) with a last known well time <24 hours and average NIHSS of 17. CT scans were performed in the MSU. Intravenous antihypertensive agents were given in 47% of patients with ICH, antiemetics (in 41%), airway management (in 16%) and intubation (in 12%) was performed on the MSU. 33% bypassed the nearest primary stroke center to a comprehensive/neurosurgical center. Looking at time metrics, compared with patients with MSU-ischemic strokes, patients with MSU-ICH had faster onset-to-emergency-call, and onset-to-scene-arrival times, at the median and 75th percentiles — likely reflecting stroke severity.
This study identifies opportunities for the MSU in the early management of ICH, which includes rapid identification and targeted treatment against hematoma expansion. Reversal of anticoagulation (warfarin, direct oral anticoagulation, or heparin) is an important contributing factor in hematoma expansion. There are current trials underway looking at antidote/reversal agents including: the FASTEST trial (recombinant factor VIIa administered within 120 min), and ANNEXA-I (Andexanet for factor Xa-associated ICH), which may change best-practice and ideal for administration in the MSU.
