Interhospital Transfer Delays and Futile EVT: A Transatlantic Perspective on Stroke System Optimization
Stroke is one of the leading neurological disorders worldwide, with acute ischemic stroke (AIS) representing its most common type, making effective management a global priority. While the MDR in AIS project focuses on optimizing stroke care pathways within Europe, similar initiatives exist transatlantically. In Canada, the largest national effort in system-level optimization of AIS care is OPTIMISING ACCESS (https://www.optimisingaccess.ca/)1, which aims to ensure equitable access to endovascular thrombectomy (EVT). By bringing together stroke neurologists, provincial stroke administrators, patient representatives, interventional radiologists, and paramedics, the initiative’s goal, like MDR in AIS, is to improve EVT access and streamline patient transfers from peripheral centers to thrombectomy-capable hospitals.
A study that was performed as part of this initiative analyzed data from the OPTIMISE Registry that provides insight into how interhospital transfers affect EVT delivery in Canada2. Between 2018 and 2021, 6803 patients across 20 Canadian centers received EVT, with roughly half transferred from peripheral stroke centers. Compared with patients presenting directly to EVT-capable centers, transferred patients experienced longer overall times from symptom onset to arterial access (median 322 vs. 181 minutes), reflecting delays incurred before arrival. However, once at the EVT center, they had shorter in-hospital door-to-arterial access times (37 vs. 87 minutes). Procedural success rates and a likelihood for good functional outcome were similar between groups, although transferred patients had a slightly higher risk of 90-day mortality (29% vs. 25%). These findings align with retrospectively collected MDR in AIS data and highlight that pre-hospital and interhospital transfer delays remain key bottlenecks in EVT delivery, underscoring the global importance of ensuring timely access to thrombectomy.
Another recent Canadian study3, published in 2025, showed that a significant proportion of interhospital transfers of patients with LVO AIS end up being futile. In this retrospective analysis of 326 patients transferred from primary stroke centers and community hospitals to a comprehensive stroke center, 26% of transfers did not result in EVT. The main reasons for non-treatment were spontaneous recanalization of the target vessel (44.7%), infarct growth (29.4%), clinical improvement or low NIHSS (17.6%), and hemorrhagic transformation (8.2%). Predictors of transfer futility included lower NIHSS at presentation, intravenous thrombolysis at the referring center, and greater ASPECTS decay (a decrease in the Alberta Stroke Program Early CT Score, reflecting progression of ischemic brain injury during transfer) during transport. These findings are also highly relevant in the MDR in AIS context and emphasize that, while interhospital transfers are important for providing EVT, a significant proportion may be unnecessary or “futile,” highlighting the need for enhanced triage, real-time patient monitoring, and optimized decision-making to ensure transfers are both timely and effective.
Overall, these findings reinforce the need for a telemedical tool that enables all specialists involved in stroke care to monitor patients in real time from stroke onset through treatment on a single platform.
Sources:
- https://www.optimisingaccess.ca/
- https://www.ahajournals.org/doi/10.1161/STROKEAHA.124.046690?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
- https://pmc.ncbi.nlm.nih.gov/articles/PMC12730273/
Author(s): Liva Araka, Riga Stradins University