Waimei Tai, MD

Grotta JC, Savitz SI, Persse D. Stroke Severity as Well as Time Should Determine Stroke Patient Triage. Stroke. 2013; 44: 555-557.

Recently Grotta et. al. from Baylor proposed a novel scheme of incorporating both time and severity to in the pre-hospital arena in order to more appropriately direct patients to either primary stroke centers (certified for iv thrombolytic therapy access) or to comprehensive stroke centers (certified for ability to provide both iv thrombolytic and higher level interventions).  Analogies are made to acute coronary syndrome in the cardiology arena, and differing levels of trauma centers for acute traumatic injury. Previous observational data shows that larger occlusions (internal carotid artery) are less likely to have re-canalization with iv thrombolytic alone and most need catheter based intervention to attain re-canalization. Data also suggests that higher volume stroke centers (also more likely to be comprehensive stroke centers) have better outcomes for their patients, perhaps from co-localization of multitude of experts and familiarity with stroke treatment process thereby increasing efficiency.

I think the idea of adding a fast EMS level evaluation of severity to help aid fast transport to the appropriate level of care (primary versus comprehensive stroke centers) is useful, but careful consideration of the time to primary stroke versus time to nearest comprehensive stroke center needs to weighed. We know that the earlier iv thrombolytic is used, the more likely it will benefit the patient.  As the authors suggested, evaluating the local systems of care at the county or state level is needed prior to initiating an additional level of triaging to the process.