Direct Transport to Stroke Center Best Prehospital Triage Strategy for Suspected Stroke

By Reuters Staff

July 09, 2019

NEW YORK (Reuters Health) - For patients with suspected acute ischemic stroke, direct transport to a comprehensive stroke center (the "mothership" strategy) is the best prehospital triage strategy for most geographic settings, researchers from Germany report.

Patients with acute ischemic stroke and cerebral proximal large vessel occlusion (LVO) fare better with mechanical thrombectomy than with intravenous thrombolysis alone. But the presence of LVO cannot be determined reliably in the prehospital setting, note Dr. Ludwig Schlemm from Charite-Universitaetsmedizin, in Berlin, and colleagues in the Journal of the American Heart Association, online June 18.

The team used mathematical modeling to estimate the impact of 10 increasingly complex prehospital-triage-strategy paradigms on the reduction of population-wide stroke-related disability and mortality.

In most geographic settings, the mothership strategy led to significantly greater reductions in population-wide stroke-related disability and mortality than did transport to the nearest primary stroke center ("drip-n-ship" strategy).

The total amount of disability-adjusted life-years (DALY) gained with the mothership strategy over the drip-n-ship strategy ranged from eight to 18 in specific real-world geographic scenarios.

Additional gains of DALY could be achieved with more complex strategies that rely on various algorithms. The greatest benefit (up to four DALY) was associated with the use of optimal variable stroke-severity cutoff scores.

Triage-strategy paradigms based on a fixed cutoff score (i.e., consideration of vessel status on a dichotomous scale) were associated with additional benefit over less complex strategies only in rural scenarios under the assumption of a short door-out time of 15 minutes.

"The optimal prehospital triage strategy paradigm for a given region depends on region-specific parameters, such as geographic location of primary and comprehensive stroke centers and treatment time performance metrics (door-to-needle, door-to-groin, door-in-door-out)," the researchers note.

They add that a formal cost-effectiveness analysis is currently planned.

Dr. Schlemm did not respond to a request for comments.


J Am Heart Assoc 2019.