LAUSR

We live in exciting times for acute stroke care. Mechanical thrombectomy (MT) is a wonderful advancement for the care of patients with stroke with large vessel occlusions (LVOs).1 Treatment decisions can now be based on individualized imaging-based analyses.2,3 But MT is still a time-dependent intervention4 that requires human expertise and infrastructure that are unevenly distributed throughout the country.5 The high-priority goal to treat every patient eligible for MT rapidly needs to be matched with the capabilities and expertise of the stroke systems of care in any given region. The challenge will be to expedite MT for all eligible patients without harming the majority of patients that do not qualify for MT and who need to be managed medically. The fervor to treat patients with MT is understandable. But a reorganization solely based on enthusiasm for the novelty of MT and its extension to selected patients within 24 hours of symptom onset will be potentially detrimental to the stroke system. There have already been calls for emergency medical services to bypass patients with suspected LVO from primary stroke centers (PSCs) to MT-capable hospitals.1 In fact, some areas of the country have already implemented bypass protocols, despite an uncertain risk/benefit ratio. Testing of this hypothesis has been proposed,6 and a trial randomizing direct transfer of patients with suspected LVO to endovascular centers versus the closest nonendovascular PSCs is already being conducted in Catalonia, Spain.7 But how will randomized clinical trials provide data that would be generalizable to various other regional settings, each with their own unique geography, infrastructure, expertise, and transportation challenges? The answer ultimately will depend on multiple local factors, such as distance to the different facilities, mode of transportation, human expertise, neuroimaging capabilities, and process performance. We have seen these issues …