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Stroke Special Report Mobile Stroke Unit Hits the Road in Houston James C Grotta, MD Director of Stroke Research, Clinical Innovation and Research Institute, Memorial Hermann-Texas Medical Center; Director, Mobile Stroke Unit Consortium, Houston, Texas, US Abstract After 1 year of preparation, the nation’s first Mobile Stroke Unit (MSU) delivering acute stroke treatment with tissue plasminogen activator (tPA) in the prehospital setting was launched in mid 2014. The unit is being operated as part of a clinical trial comparing MSU management to standard management to determine how much faster patients can be treated, how much better patients do if treated in the first hour after symptom onset than if treated later, if the physician on board the MSU can be replaced by a remote physician via telemedicine, and the costs and quality-adjusted life years saved by the MSU approach. We are treating on average over two patients per week with intravenous tPA, with more than 30 % treated within the first hour of symptom onset. Keywords Stroke, tissue plasminogen activator, thrombolysis, ambulance, EMS, prehospital, computed tomography, telemedicine Disclosure: The Mobile Stroke Unit (MSU) and research project have been funded by donations from local philanthropists, as well as grants from Covidien, Frazer Ltd, and Genentech. James C Grotta, MD, has no conflicts of interest to declare. No funding was received for the publication of this article. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit. Received: December 27, 2015 Accepted: January 21, 2015 Citation: US Neurology, 2015;11(1):59–61 Correspondence: James C Grotta, MD, Director of Stroke Research, Clinical Innovation and Research Institute, Memorial Hermann Hospital-TMC, Houston, TX 77030, US. E: yvette.sanders@uth.tmc.edu The nation’s first Mobile Stroke Unit (MSU) was launched in February, 2014 by James Grotta, MD, and colleagues at the Texas Medical Center in Houston. The concept, pioneered by Marie Curie when she loaded an X-ray machine onto an ambulance during World War I, is logical: to take emergency care to the patient in order to allow accurate diagnosis and urgent treatment earlier when it may do more good. Now 100 years later, instead of a physicist and X-ray machine, it is a vascular neurologist (VN) and computed tomography (CT) scanner. Time is particularly important in acute stroke therapy. Data from primates and rodents show that if recanalization occurs during the first hour after arterial occlusion, cerebral infarction might be completely avoided except in the ‘core’ of distal carotid or proximal middle cerebral artery occlusions. 1 Surprisingly, the initial National Institute of Neurological Disorders and Stroke (NINDS) tissue plasminogen activator (tPA) study results did not seem to reflect this relationship. But once it was recognized that patients with the most severe strokes presented to the emergency department (ED) earlier and stroke severity was factored into the calculation, it became clear that the sooner tPA was given, the better the clinical response to tPA. 2 The same relationship exists with endovascular mechanical reperfusion, 3 and probably efforts to reduce bleeding by blood pressure lowering or coagulopathy reversal after intracerebral hemorrhage. While the use of tPA is increasing (now 5–10  % of all stroke patients; 10–20  % in most stroke centers), treatment usually occurs 2–5 hours Tou ch MEd ica l MEdia after symptom onset even if patients or bystanders do the right thing and call 911. 4 In the NINDS study, none of the 302 patients who were randomized within the first 90 minutes actually were treated within the first 60 minutes from onset. 5 Current national databases show that less than 5 % of treatments occur in the first hour. 4 The delay is multifactorial and includes delay in calling 911, mobilizing emergency medical services (EMS) and transporting patients to the right ED, and, finally, the ED door to needle time, which stubbornly averages 50–60 minutes in even our best stroke centers, largely taken up by time to obtain the CT scan and having the decision-maker (usually the neurologist on call) look at it and make a decision after weighing all the variables. The MSU cuts out the entire door-to-needle-time delay by putting the CT scanner and decision-maker on the ambulance. The initial studies conducted in Germany and published over the past 2 years demonstrated anywhere from 25–80 minute time savings, and over 30 % treated within the first hour after symptom onset, without excess complications. 6–8 In 2013, after visiting Drs Fassbender and Audebert who pioneered the MSU concept in Germany, Dr Grotta decided to implement an MSU in Houston. There were three basic principles that guided how this project would be carried out. First, we understood that no funding was available from UT Medical School, Memorial Hermann Hospital, or the City of Houston to underwrite this project. Second, we needed to operate within the current EMS transportation and triage system, which delivered acute stroke patients 59