Comparison between different referral strategies for acute ischemic stroke patients in a hub-spoke emergency stroke network: a real-world experience in south-east Lazio

Aim To describe different referral strategies for acute ischemic stroke (AIS) patients in a Hub-Spoke emergency stroke network with their incidence, time metrics and related outcomes. Methods Referral paradigms were defined as follows: primary transfer to the comprehensive stroke center (CSC) from a remote region, called mothership (MS); secondary transfer to the CSC from a primary stroke center where intravenous thrombolysis was available, called drip and ship (DS); secondary transfer to the CSC from a community hospital where no reperfusion therapy was available, called ship and drip (SD); primary transfer to the CSC from its catchment area, called direct CSC (dCSC). Results Among 517 anterior circulation AIS patients treated with mechanical thrombectomy between 2015 and 2020, 16.6% of them were SD, in addition to the well-known referral paradigms of MS (21.8%) and DS (18.1%). This rate grew to 30% when only patients whose place of onset was outside the CSC catchment area were considered. In the SD group, onset to CSC and onset to groin were significantly longer (178±80 min vs. 102±60 min, p <0.001, and 277±77 min vs. 211±61 min, p <0.001, respectively), and the risk of any intracranial hemorrhage (ICH) was significantly higher (OR: 2.514; 95%CI: 1.18–5.35, p =0.017) compared to MS. Conclusion In this hub-spoke stroke network, a high proportion of SD paradigm was found, which was associated with longer times to treatment and higher rates of any ICH. A closer cooperation between hospital stroke physicians, national health system staff, and paramedics is warranted to identify the most appropriate referral strategy for each patient.