Abstract Background and aims The optimal prehospital transport strategy for patients eligible for mechanical thrombectomy remains debated. We evaluated how direct versus secondary transfer to a comprehensive stroke centre (CSC) influences outcomes in a large metropolitan stroke network. Methods This prospective registry-based cohort included all patients undergoing thrombectomy between 2015 and 2022 in a city of 1.7 million inhabitants. The network comprised 11 primary stroke centres (PSC) referring to a single CSC, all reachable within 60 minutes. Among 2,017 patients, 242 (12%) were transported directly to the CSC and 1,775 (88%) were secondarily transferred after initial assessment at a PSC. Functional outcome was measured by the modified Rankin Scale (mRS) at 90 days. Multivariable logistic and Cox regression models identified independent predictors of good outcome and survival. Results Median onset-to-CSC-admission time was shorter after direct versus secondary transfer (101 7–1,071 vs. 240 40–1,411 min, p 0.0001). Good functional outcome (mRS 0–2) was more frequent after direct transport (50.3% vs. 40.4%, p = 0.015). After adjustment for age, NIHSS, thrombolysis, posterior circulation, and comorbidities, direct transport independently predicted good outcome (OR 1.74, 95% CI 1.25–2.42; p = 0.001). Among patients receiving combined thrombolysis and thrombectomy (n = 1,015), direct transport was associated with better long-term survival (log-rank p = 0.019; adjusted HR 0.67, 95% CI 0.47–0.95; p = 0.026). Conclusions Even within a one-hour-access metropolitan network, direct transport to a CSC shortens delays, improves functional recovery, and enhances survival among patients undergoing combined reperfusion therapy. Conflict of interest Sándor Nardai: Nothing to Disclose
Orosz et al. (2026) studied this question.