Mobile Stroke Units Can Change Lives
It was a lovely July day in 2023 – perfect for sailing. So Bill Buckles was delighted to join a friend and fellow sailor to crew for a race on Lake Erie.
They set off and were underway. After performing several maneuvers, the captain asked Buckles to adjust the sails on the 30-foot boat. But Buckles needed a moment. His right hand had fallen asleep, he told the crew. Then, a moment later, his right foot had fallen asleep, too, he told them.
The captain’s wife, a nurse in the heart department at Cleveland Clinic, took charge. “Drop the sails! Turn on the motor!” she ordered. They were exiting the race and rushing back to shore. Buckles heard her on the radio telling a dispatcher to send help to meet them at the shore. She was clear about what was needed: “No EMS. I want a stroke vehicle.”
A “stroke vehicle” is a mobile stroke unit, or MSU, a specially equipped ambulance designed to deliver urgent care to stroke patients. Along with imaging technology and special medicines, the unit carries a technologist, a critical care nurse trained to treat strokes, along with medics. A vascular neurologist can examine the patient on the unit or via telemedicine.
When Buckles’s boat reached shore, the MSU, sometimes called a mobile stroke treatment unit (MSTU), was waiting. Medics put him in the unit and ran a CT scan – one of the key capabilities separating stroke units from regular ambulances.
It showed bleeding on his brain from a burst blood vessel – a hemorrhagic stroke. After learning he was on blood thinners, the team administered medicine to reverse the effects and gave Buckles oxygen – all within 30 minutes of his first symptoms, he says.
After 5 days in the hospital, the accomplished sailor went to rehab for another 5. He was getting around without a walker by the time he was discharged. A couple of weeks later, he was allowed to drive again – a tremendous recovery after a hemorrhagic stroke.
Buckles is doing great, says Blake Buletko, MD, a vascular neurologist at Cleveland Clinic, who was part of Buckles’s recovery team. He still has issues with his right side (Buckles describes it as “tingly”), but his recovery is “pretty remarkable,” the doctor says.
“This bleed could’ve been extremely devastating,” Buletko says. “It could’ve been fatal.”
For Buckles, there’s no doubt the MSU provided quicker treatment than he otherwise would have received – a vital factor in successful stroke treatment.
“The vehicle saved me because they had everything I needed at that time,” says Buckles, 85, who lives in Wooster, OH.
Experts have known for more than a decade that MSUs help improve outcomes for ischemic stroke (caused by a blockage), where powerful clot-busting drugs can stop a stroke’s progression. But research released at the International Stroke Conference in February shows MSUs can also deliver faster treatment for hemorrhagic stroke, the type Buckles had.
Hemorrhagic stroke patients were assessed faster and received some elements of care more quickly – among them, CT scans (by 19 minutes), clotting reversal (by 40 minutes), and meds to lower blood pressure (by 24 minutes). They also reached target blood pressure 16 minutes faster.
There’s a saying in stroke care: Time is brain. With ischemic stroke – which accounts for almost 90% of strokes – every minute that passes without care destroys millions of neurons, billions of synapses, and miles of myelinated fibers carrying information through the central nervous system. The brain ages 3.6 years every hour, and brain damage unfolds inside minutes, as do the chances of permanent paralysis and impaired mental skills.
A 2021 review of seven U.S. cities showed better outcomes for ischemic stroke after 90 days, including fewer bedridden patients and fewer patients with incontinence or moderate or severe disability – and more patients who were able to walk and look after their own affairs without assistance.
Since 2014, Cleveland Clinic’s unit has transported 2,600 patients – a patient roughly every day or two. Ischemic stroke patients were treated in the “golden” first hour 33% of the time, compared to 3% in the emergency room. They also received treatment 36 minutes faster and had better outcomes.
Another time-saving benefit: “Mobile stroke units allow us to bypass places that can’t handle this and go straight to a comprehensive stroke center or thrombectomy-capable center,” says Buletko.
And yet, despite these results and the fact that stroke is a top cause of death and long-term disability in the country, Cleveland is one of just 21 U.S. cities with MSUs. That’s unfortunate, says James Grotta, MD, director of stroke research for the Clinical Institute for Research and Innovation at Memorial Hermann-Texas Medical Center.
“If the mobile stroke unit was a drug,” he says, “every single hospital would be doing it.”
Leaning on the success of MSUs in the pioneering German cities of Berlin and Homburg, Grotta spearheaded efforts to establish the first stateside unit in Houston, in 2014, and co-authored numerous studies outlining their potency.
Widespread adoption has been slow, he says.
The issue is cost. Not only do the units require about $1 million to build and another $1 million annually to operate, but Medicare and most insurance won’t cover them.
They rely on the generosity of donors or institutions. Grotta found benefactors for Houston, which is hoping to expand its program this year, but many medical centers simply lack the funding to start or maintain an MSU. A hospital system in Toledo, an Ohio city about three-quarters the size of Cleveland, took its MSU out of commission in 2022, after 6 years.
Buletko and Grotta feel insurance companies could save downstream – as a result of less spending on hospital stays, rehab, and long-term care – but ultimately, Grotta says, “until there is adequate reimbursement, we are not going to see widespread proliferation.”
No one needs to convince Buckles that MSUs work. He knows he’s fortunate to be able to laugh about the day his race ended early: “The big joke on board was I had a stroke because we were in second.”
Seven months later, the octogenarian remains independent, living with a roommate. He was back on the water racing in the fall and recently traveled to watch two sailors, who he coached in grade school, race in Florida.
His right hand still feels asleep, and he struggles to pick up small things or hold utensils while cooking, a favorite pastime.
“But hey, when I look at other people [who have had strokes], I’m just happier than hell. I want to be out racing. Spring’s coming up soon,” Buckles says.
“That vehicle made it possible for me to enjoy life, to continue sitting and being with the people I enjoy being with.”
