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Bridging therapy made functional independence equally likely for stroke patients transported first to primary stroke centers without endovascular capabilities and peers taken straight to a comprehensive stroke center, a study showed.

That strategy of IV thrombolysis within 4.5 hours of symptom onset at one center followed by transport to another where mechanical thrombectomy can be performed within 6 hours of symptom onset was (modified Rankin scale scores of 2 or below) as transporting patients straight to a thrombectomy-capable center (61.0% versus 50.8%, P=0.26) -- even after multivariable adjustment (P=0.82).

"This study found that patients treated under the drip-and-ship paradigm also benefit from bridging therapy, with no statistically significant difference compared with those treated directly in a comprehensive stroke center," , of Hôpital Saint-Antoine in Paris, and colleagues reported online in JAMA Neurology.

Additionally, the two groups shared similar rates of substantial recanalization (84.0% for drip and ship versus 79.7% for mothership, P=0.49) and symptomatic hemorrhagic transformation (2.0% versus 3.4%, P=0.63).

The prospective registry study included 159 patients who had an acute ischemic stroke with a large vessel occlusion. All got mechanical thrombectomy at the Fondation Rothschild hospital in 2013-2016. Of those, 100 had been transferred from Saint-Antoine and Tenon hospitals where they first received IV thrombolysis with tissue plasminogen activator (tPA).

The two hospitals are 3.2 miles apart, or approximately 25 minutes by ambulance. As a rule, patients were transported to the closer of the two.

"Proponents of direct delivery to a comprehensive stroke center (when it is within reasonable transport time) argue that the data regarding effectiveness of IV tPA is based on the entire stroke population and that effectiveness in patients with large artery occlusions is much lower (partial or complete recanalization in approximately 21% of patients with intracranial large artery occlusions)," according to , of Beth Israel Deaconess Medical Center in Boston.

In an , he suggested that Alamowitch's report wasn't generalizable enough to answer the question of which is more important: faster time to tPA or to thrombectomy?

For now, Caplan recommended several changes to all stroke centers:

• Efforts to upgrade physician personnel and training as well as brain and vascular imaging technology at primary stroke centers
• Training ambulance personnel to recognize strokes and to identify the more serious strokes and those most likely to have large artery occlusions
• Giving distance and travel time information to primary stroke centers and comprehensive stroke centers in their jurisdiction
• Acquisition of enough skilled personnel, technology, and protocols at comprehensive stroke centers
• Ongoing cooperation and teaching between spoke-and-hub and telemedicine-connected centers
• Continued research identifying the patients likely to respond to endovascular thrombectomy without or after IV tPA

"This study involved only two urban centers located not very far apart that had excellent time-honed cooperation. Most spoke-and-hub relationships in the U.S. and Europe involve more centers, and distances between centers are often much longer," Caplan noted.

Other limitations to the retrospective study included the relatively small sample size and the imbalanced groups (the drip-and-ship arm tended to have less severe conditions and took longer from symptom onset to treatment).