Impact of prehospital comprehensive stroke center vs. primary stroke center triage protocol on outcome of patients with spontaneous intracerebral hemorrhage

PURPOSE: While prehospital triage protocols for suspected large vessel occlusion (LVO) improve ischemic stroke outcomes, their impact in spontaneous intracerebral hemorrhage (sICH) remain uncertain. We evaluated whether a regional LVO-focused emergency medical service (EMS) transport protocol affected time-based process outcomes and clinical outcomes in sICH patients. METHOD: We conducted a multicenter pre-post implementation retrospective cohort study using the Get-With-The-Guidelines-Stroke database in Chicago (April 2017-January 2020). Included were EMS-transported sICH patients arriving ≤6 hours from last known normal at 8 comprehensive stroke centers (CSCs) and 15 primary stroke centers (PSCs). In September 2018, EMS implemented the 3-Item Stroke Scale (3I-SS) to triage suspected LVO stroke patients; those scoring ≥4 were routed to a CSC bypassing PSC. Primary outcome was favorable discharge disposition (home/acute rehabilitation). Secondary outcomes included in-hospital mortality, good neurologic outcome (independent ambulation) at discharge and time based process outcomes (door-to-CT, symptom-to-arrival, symptom-to-CT). Interrupted time series (ITS) analysis assessed changes while accounting for temporal trends. FINDINGS: Among 303 sICH patients (111 pre-, 192 post-implementation), there was no difference in favorable discharge disposition (58% vs. 64%, p=0.3), in-hospital mortality (12% vs. 9%, p=0.4) or good neurologic outcomes (13% vs. 19%, p=0.4) between pre-post implementation periods for both unadjusted or ITS analyses. Time based process outcomes showed no significant changes in unadjusted or ITS analyses. The protocol also did not impact CSC admission and inter-hospital transfer rates in ITS analyses. DISCUSSION/CONCLUSION: Implementation of an LVO-focused EMS transport protocol did not improve clinical outcomes or time-based process outcomes among sICH patients, nor did it influence CSC admission or transfer rates. These findings suggest that while beneficial for ischemic stroke care, LVO triage protocols may not confer the same advantages for sICH patients and may require tailored approaches for this population.