for the Berlin_PRehospital Or Usual Delivery in stroke care (B_PROUD) study group IMPORTANCE Effects of thrombolysis in acute ischemic stroke are time-dependent. Ambulances that can administer thrombolysis (mobile stroke units [MSUs]) before arriving at the hospital have been shown to reduce time to treatment. OBJECTIVE To determine whether dispatch of MSUs is associated with better clinical outcomes for patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTSThis prospective, nonrandomized, controlled intervention study was conducted in Berlin, Germany, from February 1, 2017, to October 30, 2019. If an emergency call prompted suspicion of stroke, both a conventional ambulance and an MSU, when available, were dispatched. Functional outcomes of patients with final diagnosis of acute cerebral ischemia who were eligible for thrombolysis or thrombectomy were compared based on the initial dispatch (both MSU and conventional ambulance or conventional ambulance only).EXPOSURE Simultaneous dispatch of an MSU (computed tomographic scanning with or without angiography, point-of-care laboratory testing, and thrombolysis capabilities on board) and a conventional ambulance (n = 749) vs conventional ambulance alone (n = 794). MAIN OUTCOMES AND MEASURESThe primary outcome was the distribution of modified Rankin Scale (mRS) scores (a disability score ranging from 0, no neurological deficits, to 6, death) at 3 months. The coprimary outcome was a 3-tier disability scale at 3 months (none to moderate disability; severe disability; death) with tier assignment based on mRS scores if available or place of residence if mRS scores were not available. Common odds ratios (ORs) were used to quantify the association between exposure and outcome; values less than 1.00 indicated a favorable shift in the mRS distribution and lower odds of higher levels of disability. RESULTSOf the 1543 patients (mean age, 74 years; 723 women [47%]) included in the adjusted primary analysis, 1337 (87%) had available mRS scores (primary outcome) and 1506 patients (98%) had available the 3-tier disability scale assessment (coprimary outcome). Patients with an MSU dispatched had lower median mRS scores at month 3 (1; interquartile range [IQR], 0-3) than did patients without an MSU dispatched (2; IQR, 0-3; common OR for worse mRS, 0.71; 95% CI, 0.58-0.86; P < .001). Similarly, patients with an MSU dispatched had lower 3-month coprimary disability scores: 586 patients (80.3%) had none to moderate disability; 92 (12.6%) had severe disability; and 52 (7.1%) had died vs patients without an MSU dispatched: 605 (78.0%) had none to moderate disability; 103 (13.3%) had severe disability; and 68 (8.8%) had died (common OR for worse functional outcome, 0.73, 95% CI, 0.54-0.99; P = .04). CONCLUSIONS AND RELEVANCEIn this prospective, nonrandomized, controlled intervention study of patients with acute ischemic stroke in Berlin, Germany, the dispatch of mobile stroke units, compared with conventional ambulances alone, was significantly associated with lower global ...

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Background and Purpose-We assessed whether the presence, number, and distribution of cerebral microbleeds (CMBs) on pre-intravenous thrombolysis MRI scans of acute ischemic stroke patients are associated with an increased risk of intracerebral hemorrhage (ICH) or poor functional outcome. Methods-We performed an individual patient data meta-analysis, including prospective and retrospective studies of acute ischemic stroke treated with intravenous tissue-type plasminogen activator. Using multilevel mixed-effects logistic regression, we investigated associations of pre-treatment CMB presence, burden (1, 2-4, ≥5, and >10), and presumed pathogenesis (cerebral amyloid angiopathy defined as strictly lobar CMBs and noncerebral amyloid angiopathy) with symptomatic ICH, parenchymal hematoma (within [parenchymal hemorrhage, PH] and remote from the ischemic area [remote parenchymal hemorrhage, PHr]), and poor 3-to 6-month functional outcome (modified Rankin score >2). We performed a large-scale pooled individual patient data meta-analysis of quality observational studies to test the following hypotheses: (1) there is a relationship between increasing CMB burden and ICH risk 8,9 ; (2) strictly lobar CMBs (reflecting possible or probable cerebral amyloid angiopathy [CAA]) and mixed or strictly deep CMBs (likely associated with hypertensive arteriopathy) have different effects on ICH risk; (3) CMBs are associated more strongly with the risk of remote ICH than other ICH types 10 ; and (4) CMBs are associated with worse functional outcome. Results-In Methods Study Design and Inclusion CriteriaWe identified prospective or retrospective studies that assessed pretreatment MRI-defined CMBs, ICH, and 3-to 6-month functional outcome after acute ischemic stroke, treated solely with intravenous tPA from a systematic review prepared according to Preferred Reporting Items for Systematic Review and Meta-Analyses 7,11 (updated August 1, 2015). We searched PubMed for micro(-)bleed*, or micro(-)h(a) emorrhag*, or gradient-echo, or susceptibility-weighted in association with thromboly* or tPA, or tissue plasminogen activator 7 ; reference lists; and authors' own files. Figure I in the online-only Data Supplement shows a flow diagram.We collected anonymized individual patient detailed clinical data and CMB counts in lobar, deep, and infratentorial regions according to standardized definitions 6,12,13 using standardized report forms. A prespecified protocol was circulated to collaborators but not published. OutcomesWe defined ICH according to ECASS-2 (European Cooperative Acute Stroke Study II), 14,15 including hemorrhagic infarction, parenchymal hemorrhage (PH), and sICH 16 (acute intracerebral blood and associated increase in National Institutes of Health Stroke Scale ≥4 points, except 1 study 17 that used the definition in the PROACT-II trial [Prolyse in Acute Cerebral Thromboembolism]).18 Remote parenchymal hemorrhage (PHr) was defined as ICH remote from the symptomatic ischemic area. 10 We defined poor outcome at 3 to 6 months as modified...