Personalized Prehospital Triage in Acute Ischemic Stroke

Area of Science:

• Neurology
• Emergency Medicine
• Health Services Research

Background:

• Prehospital transportation for acute ischemic stroke (AIS) involves a trade-off between rapid endovascular treatment access and potential delays in intravenous thrombolysis.
• Optimizing patient transfer strategies is crucial for improving outcomes in AIS.

Purpose of the Study:

• To determine the optimal prehospital transportation strategy for AIS patients.
• To identify factors influencing the decision between primary stroke centers and more distant intervention centers.

Main Methods:

• A decision tree model was developed to compare outcomes based on patient characteristics, location, and workflow times.
• Scenarios included base case (20 vs. 45 min), urban (10 vs. 20 min), and rural (30 vs. 90 min) driving times.
• Sensitivity analyses considered door-to-needle, door-to-groin, and door-in-door-out times.

Main Results:

• Direct transport to an intervention center improved outcomes when the probability of large vessel occlusion (LVO) was >33% in the base case.
• At 66% LVO likelihood, direct transport yielded a benefit of 0.10 quality-adjusted life years (36 days).
• Urban and rural scenarios showed LVO risk thresholds of 24% and 49% respectively for direct intervention center transport benefit.

Conclusions:

• The optimal prehospital stroke triage strategy is personalized, depending on LVO likelihood, travel duration, and hospital workflow efficiency.
• A decision model can guide personalized prehospital triage, particularly beneficial for remote populations.