Background and Purpose—Patients with acute ischemic stroke who have large vessel occlusion benefit from direct transport to a comprehensive stroke center (CSC) capable of endovascular therapy. To avoid harm for patients without large vessel occlusion from delayed access to intravenous thrombolysis (IVT), it has been suggested to only redirect patients with high likelihood of large vessel occlusion for whom the additional delay to intravenous thrombolysis (IVT) caused by transport to the CSC is below a certain threshold. However, which threshold achieves the greatest clinical benefit is unknown.Methods—We used mathematical modeling to calculate additional-delay-to-IVT thresholds associated with the greatest reduction in disability-adjusted life years in abstracted 2-stroke center and multiple-stroke center scenarios. Model parameters were extracted from recent meta-analyses or large prospective cohort studies. Uncertainty was quantified in probabilistic and 2-way univariate sensitivity analyses.Results—Assuming ideal treatment time performance metrics, transport to the nearest CSC was the preferred strategy irrespective of additional delay-to-IVT when the transfer time between primary stroke center and CSC was <40 minutes (95% credible interval: 25–66 minutes); otherwise, the optimal additional delay-to-IVT-threshold ranged from 28 to 139 minutes. In multiple-stroke center scenarios, optimal additional-delay-to-IVT thresholds were 30 to 54 minutes in urban and 49 to 141 minutes in rural settings; use of optimal thresholds as compared with a 15 minute-threshold saved 0 to 0.11 and 0 to 0.37 disability-adjusted life years per triage case, respectively. Assuming slower treatment times at primary stroke centers and CSCs yielded longer permissible additional delays.Conclusions—Our results suggest that patients with acute ischemic stroke with suspected large vessel occlusion should be redirected to a CSC if the additional delay to IVT is <30 minutes in urban and 50 minutes in rural settings.

中文翻译：

---

绕过最近的血栓切除术候选者卒中中心：可以接受哪些额外的溶栓延迟？

背景与目的-患有严重缺血性卒中的大血管闭塞患者可从直接转运到能够进行血管内治疗的综合性卒中中心（CSC）中受益。为避免对没有大血管阻塞的患者造成的延迟进入静脉溶栓治疗（IVT）的伤害，建议仅将大血管阻塞的可能性较大的患者改道，因为这些患者由于转运至静脉而导致额外的静脉溶栓治疗（IVT）延迟CSC低于某个阈值。但是，哪种阈值可以实现最大的临床益处尚不明确。方法-我们使用数学模型来计算与抽象2冲程中心和多冲程中心的残疾调整生命年的最大减少相关的IVT附加延迟场景。模型参数是从最近的荟萃分析或大型前瞻性队列研究中提取的。结果通过概率和两因素单因素敏感性分析进行了定量。结果—假设理想的治疗时间性能指标，无论在原发性卒中中心和CSC之间的转移时间为IVT时是否考虑到IVT的额外延迟，均首选向最近的CSC转运。 <40分钟（95％可信区间：25–66分钟）；否则，最佳的IVT延迟附加延迟范围为28至139分钟。在多冲程中心场景中，IVT的最佳附加延迟阈值在城市为30至54分钟，在农村为49至141分钟。与15分钟的阈值相比，使用最佳阈值可将每个分诊案例的残障调整生命年分别节省0至0.11和0至0.37。