Endovascular Clot Retrieval by Hub-and-Spoke Service Delivery is Feasible Compared with Direct-to-Mothership

Endovascular clot retrieval (ECR) improves outcomes for acute ischaemic stroke with large artery occlusion. However, the provision of ECR requires resource-intensive comprehensive stroke centres (CSC), which are impractical to establish in regional hospitals. An alternative is a "hub-and-spoke" model, whereby ischaemic strokes are triaged at the regional primary centres and where eligible, transferred to a CSC. We aimed to compare the outcomes of patients directly admitted to a CSC with patients treated in the "hub-and-spoke" model. We hypothesize that there are no significant differences in clinical outcomes between the 2 systems.

We included patients undergoing ECR at a CSC. Patients were categorised into 2 groups; the first group included patients directly admitted to the CSC and the second group included patients in the "hub-and-spoke" model. Good clinical outcome was defined as modified Rankin Scale 0-2 and the difference between the 2 groups was tested by logistic regression.

Of 178 patients, 50 (28%) presented directly to CSC and 128 (72%) were transferred from a referring hospital. The median age was 70 (interquartile range 58-77) and 61% were male. Thrombolysis in ischaemic cerebral-infarction 2b/3 recanalisation was achieved in 79% of patients. Of the direct group, 63% (95% CI 48-77%) achieved good clinical outcomes compared to 52% (95% CI 43-61%) in the "hub-and-spoke" group (p = 0.233).

This state-wide service model demonstrates comparable clinical outcomes to that described in clinical trials. We found no significant difference in outcome between patients directly admitted to CSC and those with "hub-and-spoke" service delivery.