Leaving No Large Vessel Occlusion Stroke Behind: Reorganizing Stroke Systems of Care to Improve Timely Access to Endovascular Therapy

Stroke care was revolutionized in 2015 with the publication of the first randomized control trials showing that endovascular therapy (EVT) is far more effective than intravenous thrombolysis alone for patients with large vessel occlusion (LVO) stroke,1–5 and later trials showed benefit up to 24 hours from last seen well in selected patients.6,7 While EVT is highly efficacious, it is also profoundly time dependent.8,9 Every 4-minute delay to substantial reperfusion results in one more patient out of 100 being more disabled.9 From the patient’s perspective, for every minute faster to recanalization, the average patient gains a week of disability-free life.10 While the upfront costs for EVT are higher than medical treatment alone, cost-effectiveness (economic dominance) has been proven in both industrialized nations and developing countries.11–16 Furthermore, any improvement in time to recanalization or recanalization itself favorably modifies the stroke cost curve.17
Although the clinical trials of EVT have transformed what we do, it is now time to transform how we do it. Too few patients have access to EVT because we are too slow, and our systems of care remain poorly organized.10,18 There is an opportunity to learn from our colleagues in cardiology and trauma surgery who deal with diseases with similar time-dependence as good outcomes depend on transporting patients to most appropriate hospital as quickly as possible. To accomplish this, partnering with regional emergency medical services (EMS) professionals19,20 and establishing formal LVO protocols with non-Comprehensive Stroke Center (CSC) partners is absolutely essential.21
This article will discuss how to improve early access to EVT starting with first medical contact with Emergency Medical Services (EMS) and moving forward to the arrival at a CSC capable of delivering EVT. We will discuss a variety of solutions, acknowledging that the optimal solution for regions will vary based on geography and available resources.