Beyond the Academic Hub: Building a Smarter Stroke System

When it comes to acute ischemic stroke caused by large vessel occlusion (LVO), time is brain. Every minute of delay means the loss of approximately 1.9 million neurons. Mechanical thrombectomy has transformed stroke care, but its success is highly time-dependent. Unfortunately, many health systems still route all interventional stroke patients to academic or quaternary centers, creating unnecessary delays and limiting access to life-saving treatment.

Studies consistently show that direct transport to a thrombectomy-capable center significantly reduces time to treatment and improves functional outcomes compared to interhospital transfer. In the COMPLETE registry, patients taken directly to an endovascular center had a median onset-to-puncture time of 3.18 hours versus 5.65 hours for those transferred from another hospital—a difference of over two hours. This translated into better 90-day functional independence and lower mortality rates for direct-admit patients. Similarly, every 60-minute delay in treatment reduces the odds of independent ambulation by 8–10% and discharge home by 10%. These findings underscore the importance of minimizing delays through direct routing.

One proven strategy is EMS bypass, where suspected LVO patients are taken directly to an endovascular-capable center. Modeling from the STRATIS registry showed that bypass within 20 miles reduced EMS arrival-to-puncture time by up to 94 minutes and improved 3-month disability outcomes, with a 12% increase in patients achieving freedom from disability (mRS 0–1). Other studies confirm that bypass leads to shorter times to both thrombolysis and thrombectomy and better functional independence at 90 days.

The American Heart Association/American Stroke Association recommends regionalization of stroke care and preferential triage of suspected LVO patients to the nearest EVT-capable center. However, implementation varies widely, and many regions lack thrombectomy-capable centers altogether. The national goal for Door-In Door-Out time at transferring hospitals is 90 minutes, but most systems fail to meet this benchmark. Median DIDO times often exceed 120 minutes, and only a small fraction of hospitals achieve the target consistently. These delays compound the time lost during secondary transfers, further reducing the likelihood of good outcomes.

West Virginia illustrates the challenge. The state currently has only three Comprehensive Stroke Centers and no designated thrombectomy-capable centers. Claims data from Definitive Healthcare suggest a much lower-than-expected rate of mechanical thrombectomy procedures, likely reflecting limited access rather than lower incidence of LVO strokes. While rurality makes it impractical to have thrombectomy capability everywhere, there are population centers in WV that could support such services and dramatically improve access.

Southwestern Pennsylvania offers another example. Despite being far more populated than West Virginia, the region has two Comprehensive Stroke Centers and one thrombectomy-capable center clustered in the downtown Pittsburgh area. Beyond that, there is not a single thrombectomy-capable center north of the city until Erie, Pennsylvania. To the south, patients must travel as far as Morgantown, West Virginia; to the west, Akron, Ohio; and to the east, Hershey or Harrisburg. This geographic gap leaves large populations without timely access to thrombectomy, forcing secondary transfers that add hours to treatment time and reduce the chances of good outcomes.

Creating regional thrombectomy-capable centers in strategic locations and strengthening EMS bypass protocols can reduce onset-to-treatment times by hours, increase rates of functional independence and survival, and align care with AHA/ASA guidelines for stroke systems of care. Health systems must move beyond the outdated model of funneling all interventional stroke patients to academic hubs. Instead, they should develop thrombectomy-capable centers in high-population areas, implement EMS bypass protocols for suspected LVO patients, and monitor and improve DIDO performance to meet national benchmarks. The evidence is clear: regionalization saves lives. It’s time to act.

By Michelle Luffey