Functional outcomes after retransfer following endovascular thrombectomy in a hub-and-spoke stroke network

BACKGROUND: Endovascular thrombectomy (EVT) is a time-sensitive treatment for acute ischemic stroke, and hub-and-spoke systems have expanded patient access to this intervention. However, overcrowding at comprehensive stroke centers (CSCs) remains a significant challenge, particularly in regions with limited resources. Immediate retransfer of patients to spoke hospitals after EVT could help alleviate capacity strain, yet evidence on the safety and outcomes of this practice is limited. METHODS: We conducted a retrospective analysis of consecutive patients who underwent EVT at a tertiary stroke center in Bucharest, Romania, between June 2024 and October 2025, all of whom were transferred from regional spoke hospitals. Patients were classified as 'retransferred' if they returned immediately to the referring hospital, or as 'kept' if they remained at the CSC. The primary outcome was the 3-month modified Rankin Scale (mRS) score, analyzed as an ordinal variable. Inverse probability of treatment weighting (IPTW) was used to adjust for confounding by indication, and secondary outcomes included functional independence (mRS 0-2), mortality, and symptomatic intracranial hemorrhage (sICH). RESULTS: Of 305 patients, 194 (63.6%) were retransferred and 111 (36.4%) remained at the CSC. Transfer distance was the strongest differentiator between groups. After IPTW adjustment that included transport distance, no significant difference was observed in the ordinal mRS distribution (adjusted common OR 1.30, 95% CI 0.95 to 1.77, P=0.104). Functional independence rates (26.3% vs 34.7%, P=0.250) and sICH rates (13.0% vs 16.9%, P=0.579) were comparable between groups. CONCLUSION: Immediate retransfer to spoke centers after EVT did not result in a significant difference in functional outcomes. Further larger studies that include data on hemodynamic stability and respiratory status are needed to establish definitively the safety of retransfer after thrombectomy.