DISCUSSION
PASS, death, ICH, stroke, PSC/telestroke
STROKE
TRIAGE-STROKE randomized patients with clinical signs of LVO eligible for IVT and who had onset of symptoms while located in a PSC catchment area. The trial was carried out in a setting where transport time from the scene to PSC was 27 minutes, transport time from the scene to CSC was 58 minutes, and the transfer time between PSC and CSC was 55 minutes. The study was underpowered and did not have the strength to show an effect on functional outcome at day 90 (OR, 1.42 [95% CI, 0.72–2.82]; The Grotta bars indicated benefit in the CSC group, why a post hoc analysis of mRS score of 0 to 3 was made. When dichotomizing the primary outcome for mRS score of 0 to 3 at day 90, the OR was 2.65 (95% CI, 1.06–7.13, Transport strategy models to predict optimal transport strategies have investigated thresholds for differences in onset to treatment times, with purpose of achieving the best functional outcome.One randomized controlled trial (RACECAT) has been published previously. The trial cluster-randomized 1401 patients to either PSC/telestroke center or a CSC and analyzed 949 patients with AIS. This trial was neutral with respect to shift in mRS (adjusted common OR, 1.03 [95% CI, 0.82–1.29]).TRIAGE-STROKE demonstrated efficient workflows in both arms. The door-in-door-out time at the PSC was 67 minutes and the door-to-groin time was 16 minutes in the PSC arm. Comparing time metrics to RACECAT, patients were delayed approximately half an hour to IVT in both trials when going directly to CSC (30 minutes in TRIAGE-STROKE versus 35 minutes in RACECAT), but delay to EVT was markedly longer in RACECAT (56 minutes versus 35 minutes in TRIAGE-STROKE) for patients going first to PSC. Hence, LVO patients in RACECAT going directly to the CSC were left untreated for a longer time. Time differences in the 2 trials mainly reflect different geographic characteristics (In RACECAT, a trend was observed towards an increased risk of death in patients with ICH (adjusted hazard ratio, 1.21 [95% CI, 0.86–1.70]) if patients were routed directly to CSC. In the present study, no difference in outcome was seen (common OR, 0.94 [95% CI, 0.34–2.63]) for this patient group, however, mortality in patients with ICH in the CSC group was slightly higher compared with the PSC group. This was a nonsignificant difference, but the same trend was seen in RACECAT. This is an issue for further investigation.The strengths of this study are the valid and individual randomization process, the detailed data collection, and accuracy in collection of prehospital time measures. Furthermore, the study was conducted within the 4.5-hour window of IVT (for patients eligible for IVT) and using a simple stroke severity score (PASS). This study confirmed previous findings that PASS is acceptable for LVO detection with a positive predictive value of 42% in this trial. The tool has been validated to have a PPV of 40 in a previous trial.This trial has several limitations. First, the planned number of included patients was not achieved as described in the preplanned power analysis and the results are underpowered. Second, generalizability beyond the local setting and population in which the trial was conducted may be limited although detailed time metrics were collected to enhance generalizability. The fact that only 2 out of the planned 6 PSCs were recruiting could introduce nonrandom imbalances in this setting. Third, we acknowledge that the treatment rates for IVT are non significantly higher in the group randomized to CSC first and this could reflect in-hospital challenges that are not an issue elsewhere. Guidelines at the centers are the same but a more conservative use of IVT at PSCs should be further investigated as annually reports have shown this tendencyWe suggest to collect more randomized data addressing this topic to sort out the best transport options for patients with suspected LVO.