Direct Transport to a Thrombectomy Center Accelerates Acute Stroke Reperfusion Therapies in Nonurban Settings

In the United States, the impact of bypassing the nearest local stroke center to facilitate direct transport of nonurban patients to a thrombectomy-capable center (TCC) for mechanical thrombectomy (MT) remains unclear. We compared intravenous thrombolysis and MT treatment times between patients transferred directly to a TCC and those transported initially to a local stroke center and undergoing MT.

In this retrospective observational study within an academic health care system with integrated telestroke and transport services, we included consecutive nonurban patients (ground transport ≥15 minutes to TCC) who were transported via emergency medical services and underwent MT between January 2021 and October 2024. Patients were categorized into those transported directly to TCC or those initially taken to 1 of 12 telestroke-supported local stroke centers and subsequently transferred to TCC. These groups were compared using inverse probability of treatment weighting. Outcomes included first medical contact-to-intravenous thrombolysis, first medical contact-to-arterial puncture, and first medical contact-to-arrival times, among others. All times are expressed as median (IQR).

Among 304 patients (transported directly to TCC, 174; initial transport to local stroke center, 130; median age, 72 [IQR, 62-82] years; median National Institutes of Health Stroke Scale score, 16 [IQR, 12-22]; 36.5% air transported), first medical contact-to-intravenous thrombolysis (75 [IQR, 65-89] versus 86 [IQR, 72-110] minutes; P<0.001), door-to-needle time (40 [IQR, 28-45] versus 63 [IQR, 47-80] minutes; P<0.01) and first medical contact-to-arterial puncture (117 [IQR, 103-138] versus 197 [IQR, 164-271] minutes; P<0.001) times were shorter in transport directly to TCC, despite longer FMC-to-arrival (36 [IQR, 30-43] versus 27 [IQR, 22-36] minutes; P<0.001) and door-to-puncture (74 [IQR, 65-93] versus 25 [IQR, 16-61] minutes; P<0.001) times.

Among nonurban patients undergoing MT, direct transport to a TCC accelerated treatment times and may improve clinical outcomes. Our study highlights inefficiencies in regional systems of care.