Severity-Based Triage for Direct Transportation to Nearest Comprehensive Stroke Center: A Systematic Review and Meta-Analysis.
Thies Ingwersen, Patrick Eder, Rafael Bourry et al.
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In 30 seconds
This systematic review and meta-analysis assessed prehospital bypass of the nearest stroke center for direct transport to a more distant comprehensive stroke center in patients with suspected stroke. It included 18 studies and 14,516 patients, with high risk of bias in nonrandomized studies. Bypass was associated with earlier groin puncture and greater odds of functional independence at 90 days (modified Rankin Scale 0–2; OR 1.23, 1.04-1.45), while thrombolysis was delayed in randomized trials. The authors concluded that evidence is insufficient to support routine bypass protocols.
Key findings
- Bypass was associated with earlier groin puncture (median difference -63.9 minutes, 95% CI -84.1 to -43.7).
- Functional independence at 90 days was more frequent with bypass (OR 1.23, 1.04-1.45).
- In randomized trials, time to needle was longer with bypass (median delay 34 minutes, 23.1-44.9 minutes).
- Among patients with intracerebral hemorrhage, bypass was associated with increased mortality (risk ratio 1.30, 1.02-1.64).
Why it matters
Prehospital destination decisions may affect access to thrombectomy and the timing of thrombolysis, with potential consequences for functional outcomes. The findings suggest a trade-off: bypass was associated with faster access to endovascular treatment and better functional independence, but also with delayed thrombolysis in randomized trials and higher mortality among patients with intracerebral hemorrhage. These results underscore the importance of identifying which patients may benefit from direct transport.
What to keep in mind
Risk of bias was high in nonrandomized studies, and the evidence combined randomized and observational designs. The authors state that evidence is insufficient to recommend routine bypass protocols.