Direct Transport to a Comprehensive Stroke Center May Offer Outcome Benefits in Metropolitan Thrombectomy Networks

Background and Purpose: The optimal prehospital transport strategy for patients eligible for mechanical thrombectomy remains debated. We evaluated how direct versus secondary transfer to a comprehensive stroke center (CSC) influences outcomes in a large metropolitan stroke network. Methods: This prospective registry-based cohort study included all patients undergoing thrombectomy between 2015 and 2022 in a city of 1.7 million inhabitants. The network comprised 11 primary stroke centers (PSCs) referring to a single CSC, all reachable within 60 minutes. Among 2,017 patients, 242 (12.0%) were transported directly to the CSC, whereas 1,775 (88.0%) were secondarily transferred after initial assessment at a PSC. Functional outcome was assessed using the modified Rankin Scale (mRS) at 90 days. Multivariable logistic and Cox regression models were used to identify independent predictors of good functional outcome and survival. Results: The median onset-to-CSC admission time was shorter after direct versus secondary transfer (101 [7-1,071] vs. 240 [40-1,411] min, P<0.001). A good functional outcome (mRS 0-2) was more frequent after direct transport (50.3% vs. 40.5%, P=0.015). After adjustment for age, National Institutes of Health Stroke Scale score, thrombolysis, posterior circulation stroke, and comorbidities, direct transport independently predicted good functional outcome (odds ratio: 1.74; 95% confidence interval [CI] 1.25-2.42; P=0.001). Among patients receiving combined thrombolysis and thrombectomy (n=1,110), direct transport was associated with improved long-term survival (log-rank P=0.026; adjusted hazard ratio: 0.67; 95% CI 0.47-0.95; P=0.026). Conclusions: Even within a metropolitan network with 1-hour access, direct transport to a CSC shortens treatment delays, improves functional recovery, and enhances survival among patients undergoing combined reperfusion therapy.