3 Questions About Primary vs Comprehensive Stroke Centers

Minimizing time to stroke care is critical and is strongly associated with outcomes. However, emergency medical service (EMS) professionals are often faced with a decision: should the ambulance bypass primary stroke centers for comprehensive stroke centers?

To give us her view, Neurology Consultant reached out to Johanna T. Fifi, MD, who is an associate professor of Neurosurgery, Neurology, and Radiology; the associate director of the Cerebrovascular Center; director of Endovascular Ischemic Stroke; and codirector of the Neuroendovascular Surgery Fellowship at Mount Sinai Health System in New York, New York.

She also spoke about this topic during a debate at the American Academy of Neurology’s 2019 Fall Conference.¹

NEURO CON: In your opinion, should ambulances bypass primary stroke centers for comprehensive stroke centers? Why/why not?

Johanna Fifi: Yes. I think that there should be protocols developed to allow for first responders to screen stroke calls for large vessel occlusions and triage to the appropriate center. In New York City, a triage/bypass protocol was implemented earlier this year. The details of the protocol should be worked out for each geographic region.

NEURO CON: Does “time to stroke care” play a role in your stance?

JF: Yes. The clinical outcome for large vessel occlusion is highly dependent on time from symptom onset to vessel recanalization. Once patients are taken to a non-thrombectomy capable site, it’s been shown that door-in to door-out (DIDO) times correlate with outcome.  The average DIDO time is often 2 to 3 hours, as shown in various studies. The American Heart Association and American Stroke Association recommend a DIDO time of 60 minutes for most patients.² However, this can’t always be achieved. Therefore, critical time is always lost in having to transfer a large vessel stroke patient.

NEURO CON: Would taking patients directly to a comprehensive stroke center affect the cost of health care? If so, what effect would it have?

JF: I am not certain. Triaging patients correctly, leading to faster treatment times, would lead to less disability from stroke in our health care system. Therefore, long-term costs should outweigh any short-term costs of the actual triage itself. Obviously, this is dependent on many factors such as what technology is used for the triage, ranging from clinical scales done by personnel to devices to mobile stroke units. This is something that should be studied going forward.

References:

1. Fifi J. Controversies in neurology plenary session: “No: Should Ambulances Bypass Primary Stroke Centers for Comprehensive Stroke Centers?” Talk presented at: American Academy of Neurology’s 2019 Fall Conference; October 18-20, 2019; Las Vegas, NV. https://issuu.com/americanacademyofneurology/docs/19fc_programbooklet_full_cx_v810?fr=sMWNhMTE1MjQ0NQ. Accessed November 7, 2019.
2. Powers WJ, Rabinstein AA, Ackerson T, et al; American Heart Association Stroke Council. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46-e99. https://doi.org/10.1161/STR.0000000000000158.