Direct routing to a thrombectomy-capable center shortened every major treatment interval
Nonurban stroke systems are still built around geography, not biology. In this retrospective study from an academic health care system with integrated telestroke and transport services, direct transport to a thrombectomy-capable center consistently compressed the time it took to deliver reperfusion therapy for patients with acute ischemic stroke undergoing mechanical thrombectomy.
The cohort included consecutive nonurban patients with ground transport of at least 15 minutes to the thrombectomy center who were brought in by emergency medical services between January 2021 and October 2024. Investigators compared patients taken directly to the thrombectomy-capable center with those first delivered to one of 12 telestroke-supported local stroke centers and then transferred onward. In the final sample of 304 patients, 174 were transported directly and 130 were routed first through a local stroke center. The median age was 72 years, the median National Institutes of Health Stroke Scale score was 16, and 36.5% of patients arrived by air transport. Those baseline figures reflect a clinically severe population in which minutes translate into neuronal loss, infarct growth, and shrinking salvageable penumbra.
The most important signal was straightforward: direct routing shortened first medical contact-to-intravenous thrombolysis, first medical contact-to-arterial puncture, and door-to-needle time. Median first medical contact-to-intravenous thrombolysis time fell to 75 minutes in the direct-to-center group versus 86 minutes in the group that stopped first at a local stroke center. Door-to-needle time was 40 minutes versus 63 minutes. First medical contact-to-arterial puncture was 117 minutes versus 197 minutes. Those differences are not cosmetic. They represent a narrower window for fibrinolysis, earlier access to endovascular therapy, and less time for clot-driven ischemia to evolve into irreversible infarction.
One interval did move in the opposite direction. Patients sent directly to the thrombectomy center had longer first medical contact-to-arrival time and longer door-to-puncture time. Direct transport required a longer ride, as reflected in first medical contact-to-arrival times of 36 minutes versus 27 minutes and door-to-puncture times of 74 minutes versus 25 minutes. Yet the system-level delay created by the extra stop at a local stroke center overwhelmed any apparent advantage from the shorter initial trip. In stroke care, an extra handoff can cost far more time than a few saved road miles.
The transfer stop added complexity without improving reperfusion speed
The time pattern is clinically revealing because it separates transport distance from treatment efficiency. A local stroke center can be useful for evaluation, but this study suggests that in nonurban patients already suspected of needing mechanical thrombectomy, the intermediate stop often inserted a substantial delay before definitive therapy. Telestroke support did not erase the delay introduced by reassessment, imaging review, repeat triage, arranging transfer, and preparing a second emergency transport. Each step can be justified in isolation. Together, they form a cumulative bottleneck.
The analytical framework used inverse probability of treatment weighting, which strengthens the comparison by balancing measured differences between the two transport strategies. Even with that adjustment, the time advantage remained with direct transport. The finding has practical implications for regional stroke systems that still rely on a “closest hospital first” reflex in nonurban settings. For a patient with a large vessel occlusion, the biological clock is unforgiving: persistent arterial occlusion feeds infarct expansion, while earlier reperfusion preserves penumbral tissue and reduces the volume of permanent injury.
This cohort also helps explain why transport policy cannot be built on a single metric such as initial distance to a hospital. The direct route was slower to arrival, but it was faster to the steps that actually matter—thrombolysis and arterial puncture. In hyperacute stroke, treatment time is the meaningful endpoint because it tracks the window during which salvageable tissue still exists. The data show that the system optimized for the nearest facility did not optimize for the fastest path to reperfusion.
Regional stroke systems will need to favor definitive therapy over first-stop convenience
The most defensible reading of these findings is not that local stroke centers lack value, but that nonurban triage should be tuned to the probability of mechanical thrombectomy. When a patient’s presentation strongly suggests a large vessel occlusion, direct transport to a thrombectomy-capable center may avoid the delays built into a transfer-dependent pathway. The benefit is especially relevant in regions where distances are long, transport resources are limited, and every additional transition slows the chain of care.
The median first medical contact-to-arterial puncture time of 117 minutes in the direct-to-center group still leaves room for improvement. So does the 75-minute median to thrombolysis. But compared with the transfer pathway, the direct strategy clearly moved patients closer to reperfusion sooner. The same pattern held for door-to-needle and first medical contact-to-arterial puncture, reinforcing the idea that the bottleneck was not a single workflow step but the architecture of the regional system itself.
This study was not designed to prove superiority on functional outcomes, and the abstract does not provide those data. Even so, the clinical meaning is hard to miss. In acute ischemic stroke, treatment speed is not an abstract process measure; it is the mechanism by which tissue survives. A regional system that can identify likely thrombectomy candidates early and route them directly to definitive care has a better chance of preserving brain, not just moving patients through doors more quickly.