Needed dialog: regionalization of stroke systems of care along the trauma model.

Abstract

The burden of stroke is indisputable. Stroke is the fourth leading cause of death and the leading cause of major disability in the United States, and affects ≈800 000 people every year.1 Of these events, ≈87% are acute ischemic strokes, or ≈700 000 per year. Furthermore, stroke accounts for ≈200 000 deaths and results in an estimated $73 billion cost to the United States healthcare system annually,2 the single highest Medicare reimbursement entity for long-term adult care. Interventions that positively impact the outcome of ischemic stroke would be of tremendous value to both patients and society at large. Although improvements have been made with increased public awareness, enhanced prehospital triage systems, and hospital stroke certification programs, recent studies suggest that acute ischemic stroke reperfusion interventions (both intravenous and intra-arterial) remain significantly underused.3 In most community settings, only 5% of patients with acute stroke actually receive intravenous recombinant tissue-type plasminogen activator (r-tPA) therapy.3,4 Furthermore, advanced stroke care goes beyond acute reperfusion with intravenous or intra-arterial techniques: for patients who develop significant infarcts, subsequent care, such as dedicated neurointensive management, intracranial pressure monitoring and control, decompressive surgery, or hemorrhage evacuation are all potentially critical aspects of managing ischemic or hemorrhagic strokes that can significantly affect patient outcome. These resources are often found only at comprehensive stroke centers (CSCs). Intra-arterial therapies, such as intra-arterial (IA) thrombolysis or mechanical thrombectomy, have emerged as a means of restoring perfusion after large vessel occlusion and have exhibited excellent recanalization and outcome measures in recent prospective trials.5–13 Although 3 randomized trials published in 2013 demonstrated no added benefit to IA intervention compared with intravenous tPA alone,14–16 the randomized controlled trials the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands …