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Good examples of this are Australia and Canada, both high-income nations with the lowest population
2
density globally (3 and 4 inhabitants/km respectively). In Australia, only 3% of the acute stroke patients in
rural regions are able to access a stroke unit compared to around 70% in urban regions, many of them
travelling over 200 km to reach a hospital with adequate stroke care [13,14] . Further, the majority of patients
living in rural areas world-wide are less likely to receive brain imaging within 24 h, carotid imaging, or
consultation with a stroke physician. In Australia, most emergency retrievals are performed by the
Australian Royal Flying Doctor Service (RFDS), the largest such aeromedical retrieval service world-wide,
with a fleet of almost 80 aircraft. In a recent study, it was found that most retrieval locations lacked brain
imaging capability, significantly delaying stroke diagnosis and treatment . An unpublished analysis of
[15]
access to radiological imaging in Australia shows that hospitals with computed tomography (CT) scanners
are mainly located in the south-eastern coastal areas [Figure 1], leaving many areas lacking service. The lack
of imaging availability in rural and remote areas directly translates to a lower number of patients receiving
the modern, time sensitive stroke interventions enjoyed by urban Australians. This paucity of service
intervention is particularly important in the case of endovascular treatment, one of the most effective
[16]
interventions in modern medicine, which can only be performed at highly specialised stroke centres .
Most of these comprehensive stroke centres are located in metropolitan centres .
[17]
In Canada, the numbers are similar where 20% of the Canadian population lives in rural areas . Only 11%
[18]
of the rural hospitals in Canada are equipped with a CT scanner, and 40% of these rural hospitals are more
than 300 km from a comprehensive stroke centre. Access to acute stroke service strongly depends on the
area of stroke incidence. A recent geospatial analysis has shown that in some areas, such as Saskatchewan,
Newfoundland, and Labrador, less than half of the population could reach a stroke centre within 3.5 h with
[19]
emergency transport . Not surprisingly, the 30-day stroke mortality is higher for patients treated in rural
compared to urban hospitals [20,21] .

This geographical inequity in acute stroke care is not a problem which is likely to improve in the near
future. A recent analysis of the rural vs. urban disparity in stroke thrombolysis, including 914,500 acute
ischaemic stroke patients in the USA, revealed that geographic disparity in alteplase use is actually
[22]
increasing . This emphasises the need to narrow this unacceptable gap with novel disease management
ideas and strategies. While the strategies suggested in this review are being, or more likely to be,
implemented in developed nations, the lessons learned may become quite relevant for developing nations.

MOBILE STROKE UNITS - A HYPERACUTE SOLUTION FOR HYPERACUTE STROKE
TREATMENT
Mobile stroke units (MSU) are acute specialist ambulances, equipped with computed tomography (CT)
scanners, point-of-care laboratory units, and telemedicine capabilities for interaction with experts in the
hospital. They have been implemented to enable immediate diagnosis and administration of thrombolysis
for eligible stroke patients directly at the emergency site [23,24] . In many countries, pre-hospital stroke
diagnosis and treatment have validated this MSU concept. Randomised studies have shown that MSU-based
stroke management can reduce the time to treatment and substantially increase the number of treated
patients. More importantly, golden hour thrombolysis, namely treatment within the first 60 min after
symptom onset, with highest chances of full recovery, is far more commonly achieved in the MSU group
compared to the control group [25-27] . Indeed, a recent prospective interventional study (B-Proud) with acute
ischaemic stroke patients showed that the dispatch of a MSU was significantly associated with a better
[28]
clinical outcome as assessed with the modified Ranking score after 90 days .