Effect of Direct Transportation to Thrombectomy-Capable Center vs Local Stroke Center on Neurological Outcomes in Patients With Suspected Large-Vessel Occlusion Stroke in Nonurban Areas
Authors: Pérez de la Ossa Natalia , Abilleira Sònia , Jovin Tudor G. , García-Tornel Álvaro , Jimenez Xavier , Urra Xabier , Cardona Pere , Cocho Dolores , Purroy Francisco , Serena Joaquin , San Román Manzanera Luis , Vivanco-Hidalgo Rosa Maria , Salvat-Plana Mercè , Chamorro Angel , Gallofré Miquel , Molina Carlos A. , Cobo Erik , Davalos Antoni , Ribo Marc ,   RACECAT Trial Investigators, Abella Jane , Abrio Sheila , Acera Teresa , Aguilar Ada , Aguirre Sonia , Alastrue Laura , Almodovar Consuelo , Alonso Marne Cristina , Aloy Angels , Alvarez Miriam , Alvarez Miguel , Alvarez Jeannette , Alvarin Celia , Ameller Maria Vanessa , Andujar Estefania Remedios , Arambudo Anna , Ares Villagrasa Vilella , Arrufat Lorena , Auladell Silvia , Azcarate Izaskun , Aznar Vanessa , Baena Andres , Bagaria Marc , Bañuelos Joan , Barnés Andreu , Basany Nuria , Beltran Cristina , Benavent Sergio , Biesot Silvia , Blanch Roser , Boluda Ariadna , Bonet Victor , Bonilla Isabel , Borch Gemma , Boullon Raquel , Bru Nuria , Brugues Stella , Buhils Estel , Burgos Antonio , Burnat Laia , Caballero Salvador , Calafell Jordi , Calvet Miriam , Calvo Arnau , Campo Francisco , Campos Olga , Camps Iren , Campuzano Maria Del Mar , Cano Bresme Nuria , Capdevila Montserrat , Carballo Antonio , Carcelen Daniel , Cardus Jaume , Carmona Francisco Jose , Caro Marc , Carre Clara Isabel , Carretero Alexander , Casajuana Gemma , Casasas Teresa , Castanedo Cristina , Castello Maria Gloria , Castillo Paramio , Castrillo Gonzalo , Castro Rosa Maria , Castro M Elena , Català Xavier , Catells Monica , Catena Dolors , Cazorla Sergio , Cerdeña Sandra , Chacon Alexandre , Claustre Sunyer , Clave Enric , Closa Alejandro , Colomina Esther , Comes Montserrat , Cora Loste , Corrales Estefani , Cortes Lidia , Cortit Rita , Cregut Pere Lluis , Daroca Nuria , Delhomme Carles , Delofeu Anna , Descalzo Carlos , Deulofeu Anna , Diaz Maneiro Andrea Lucia , Diaz Carmen , Diego Herrero Navarro , Diego-Javier Cucurell 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Victoria , Salazar Talavera Augusto , Salleres Nuñez Fernando , Salvador Esther , Salvat Plana Mercè , Samaniego Daniela , Sambrano David , Sanahuja Montesinos Jordi , Sanchez Almudena , Sanchez Francisco , Sánchez Elena , Sánchez Cervilla Pablo , Sánchez del Valle Raquel , Sánchez Zambrana Modesto , Sanchez-Ojanguren Josep , Sanjuan Estela , Sanjurjo Golpe Eduardo , Sansa Gemma , Santamarina Estevo , Santana Katherine , Saura Salvado Júlia , Serena Leal Joaquín , Seró Laia , Serrano Marcos , Silva Blas Yolanda , Simó Marta , Socolich César , Solà Nuria , Solà Muñoz Silvia , Sola Soto Lucia , Solano Vila Berta , Sonia Huertas Folch Sonia , Sorrentino Agustín , Soteras Martínez Íñigo , Soultana Rashida , Subirana Teresa , Suescun Ribas Beatriu , Teixidor Silvia , Téllez Marín Elisabeth , Terceño Izarra Mikel , Teresa Peris Morales Maria , Tomás Cano Orgaz Antonio , Tomas Chaume Laia , Torres Mónica , Torvisco Zulma Itzaina , Trenado Alvarez Josep , Tudela Teresa Benito , Urdangarin Etxetxikia Jaione , Urra Nuin Xabier , Ustrell Roig Xavier , Valencia Molina Juan , Valentina Vérez Santamaria Patricia , Valenzuela Sebastian , Van Eendenburg Cecile , Vaqueiro Lorenzo Alicia , Vargas Martha , Vaz Lopes Cristina , Vázquez Daniel , Velásquez Dulce , Velázquez John , Vélez Paola , Verdera García Xavier , Vergés i Sala Margarida , Vicente Hervás José , Vicente Pascual Mikel , Vidal Nuria , Vidal Silvia Montserrate , Vila Guillem , Vilà Panés Inés , Vila Planavila Montserrat , Villaescusa Urbaneja MaCristina , Viñas Antoni , Viñas i Gaya Jaume , Yataco Lizbeth , Yoselin Ferrini Yosmairy , Zamarreño Javi , Zaragoza Josep , Zhu Nuole , Zidane Bukaei Muhammad , Zubizarreta Irati 
Published: May 2022

Importance

In nonurban areas with limited access to thrombectomy-capable centers, optimal prehospital transport strategies in patients with suspected large-vessel occlusion stroke are unknown.

Objective

To determine whether, in nonurban areas, direct transport to a thrombectomy-capable center is beneficial compared with transport to the closest local stroke center.

Design, Setting, and Participants

Multicenter, population-based, cluster-randomized trial including 1401 patients with suspected acute large-vessel occlusion stroke attended by emergency medical services in areas where the closest local stroke center was not capable of performing thrombectomy in Catalonia, Spain, between March 2017 and June 2020. The date of final follow-up was September 2020.

Interventions

Transportation to a thrombectomy-capable center (n = 688) or the closest local stroke center (n = 713).

Main Outcomes and Measures

The primary outcome was disability at 90 days based on the modified Rankin Scale (mRS; scores range from 0 [no symptoms] to 6 [death]) in the target population of patients with ischemic stroke. There were 11 secondary outcomes, including rate of intravenous tissue plasminogen activator administration and thrombectomy in the target population and 90-day mortality in the safety population of all randomized patients.

Results

Enrollment was halted for futility following a second interim analysis. The 1401 enrolled patients were included in the safety analysis, of whom 1369 (98%) consented to participate and were included in the as-randomized analysis (56% men; median age, 75 [IQR, 65-83] years; median National Institutes of Health Stroke Scale score, 17 [IQR, 11-21]); 949 (69%) comprised the target ischemic stroke population included in the primary analysis. For the primary outcome in the target population, median mRS score was 3 (IQR, 2-5) vs 3 (IQR, 2-5) (adjusted common odds ratio [OR], 1.03; 95% CI, 0.82-1.29). Of 11 reported secondary outcomes, 8 showed no significant difference. Compared with patients first transported to local stroke centers, patients directly transported to thrombectomy-capable centers had significantly lower odds of receiving intravenous tissue plasminogen activator (in the target population, 229/482 [47.5%] vs 282/467 [60.4%]; OR, 0.59; 95% CI, 0.45-0.76) and significantly higher odds of receiving thrombectomy (in the target population, 235/482 [48.8%] vs 184/467 [39.4%]; OR, 1.46; 95% CI, 1.13-1.89). Mortality at 90 days in the safety population was not significantly different between groups (188/688 [27.3%] vs 194/713 [27.2%]; adjusted hazard ratio, 0.97; 95% CI, 0.79-1.18).

Conclusions and Relevance

In nonurban areas in Catalonia, Spain, there was no significant difference in 90-day neurological outcomes between transportation to a local stroke center vs a thrombectomy-capable referral center in patients with suspected large-vessel occlusion stroke. These findings require replication in other settings.

Trial Registration

ClinicalTrials.gov Identifier: NCT02795962