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 Navarro , Dolores Vilas Rolán , Dolores Espinosa Vivas , Domenech Palau M Carme , Duran Pablo Javier , Duran Marquez Laura , Escoda Martin Pau , Escorcia Juan Antonio , Escudero Maria del Mar , Español Jaime , Español Agusti , Espases Rodriguez Roger , Espert Resa F Xavier , Ester Tio Vilamala , Esteve Casanovas David , Fabregat Sanjuan Joan Pere , Fernandez Perez Patricia , Fernandez Perez Daniel , Fernandez Gomez Carlos , Fernandez Alvarez Joaquin , Fernández Sol Mireia , Ferre Quintero Sergi , Ferreres Yolanda , Figueras Casanova Sylvia , Flores Escobar Sergio , Fontcuberta Anna , Fontquerni Ana , Forés Joan Antoni , Fortes Maria Luisa , Fortes Africa , Franch Espinosa Laura , Franco Romero Maria Teresa , Franco Quesada Sara Maria , Freixes Graells Cristina , Gallego Francisco Rut , Galobardes Vilches Agusti , Galup De Lacanal Carles , Gamiz Gala Alicia , Garcia Tortajada Georgina , Garcia Rodriguez Marina , Garcia Plaza Marta , Garcia Lopez Pascual Luis , Garcia Castañeda Laura , 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Neus , Montejo Carmen , Monterde Ortega Angela , Morales Shyrlei , Mormeneo Claudia , Morón Nicolás , Muchada Marian , Muñoz Lucía , Muñoz Albert , Muñoz Gamito Gemma , Muriana Batiste Desiree , Nieto Clara Gris Ambrós Eloisa , Nogueroles Antonio , Núñez Ana , Nuria López Claverol Matilde , Olaizola Cristina , Olivé Gadea Marta , Orriols María , Ortiz Juan , Mascaró Oscar , Osuna Teresa , Pagola Jorge , Paipa Andrés , Palasi Franco Antonio , Palomeras Soler Ernest , Pardina Oscar , Pardo Albiñana Laura , Paré Martí , Paris Pujol Francesc , Pascual Vanesa , Paula Rodríguez Paula , Pedroza Claudia , Pelaez Roman Hector , Pellisé Guinjoan Anna , Pérez Pilar , Perez de Celis Judit , Pérez de la Ossa Natalia , Pérez Oliveras Marc , Pilar Fossas Felip Maria , Pilar Sanz Cartagena Maria , Pirela Carmen , Pla Xavier , Pla Soler Jaume , Planas Anna , Pons Mellado Pilar , Portell Eduard , Pradas Margarita Feliu , Prats Luís , Presas Silvia , Puig Pastalle Montserrat , Puiggrós Rubiol Elsa , Pujalte Carol , Pujol Lluis , Purroy García Francesc , Quesada García Helena , Quílez Alejandro , Ramon Albert Segui Enric , Ramos Oscar , Ramos Anna , Ramos Alba , Redondo Parejo Laura , Regordosa Carles , Reina Garrido Montserrat , Renú Arturo , Repullo Vilchez Carmen , Requena Manuel , Reverté Silvia , Reverter Anna , Reyes David , Reynaga Esteban , Reynoso Victoria , Riba Yolanda , Ribera Anna , Ribera Tasa Elisenda , Van der Kleyn Richard , Ricol Javier Errando , Robles Augusto , Roca Mireia , Roca Claudia , Roca M  Jesus Millares , Rodriguez Adriana , Rodríguez Puri , Rodríguez Noelia , Rodríguez Luis , Rodríguez Fernando , Rodríguez Alejandro , Rodríguez Campello Ana , Rodriguez-Luna David , Roig Josep , Roldán Elisabet , Romera Cid Primitivo , Romeral Ballester Gemma , Romero Ruth , Romero Lucía , Ros Marta , Rosas Carmen , Rubiera Marta , Rubio Marta , Ruiz María , Ruiz Cristhian , Ruperez Marina Tomas , Rybyeva Maria , Sabartés Guixes Meritxell , Sabaté Ortega Josep , Sala 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

ImportanceIn nonurban areas with limited access to thrombectomy-capable centers, optimal prehospital transport strategies in patients with suspected large-vessel occlusion stroke are unknown.ObjectiveTo 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 ParticipantsMulticenter, 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.InterventionsTransportation to a thrombectomy-capable center (n = 688) or the closest local stroke center (n = 713).Main Outcomes and MeasuresThe 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.ResultsEnrollment 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 RelevanceIn 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 RegistrationClinicalTrials.gov Identifier: NCT02795962