RACECAT Trial: Direct CSC Transport vs Local Stroke Center for Suspected LVO
In nonurban patients with suspected large vessel occlusion, does direct transport to a thrombectomy-capable comprehensive stroke center improve 90-day functional outcome compared with initial transport to the nearest local stroke center?
Pérez de la Ossa N, et al. (JAMA 2022) · doi:10.1001/jama.2022.4404 · 1401 patients
Population
Included
- Suspected large vessel occlusion in nonurban ambulance catchment
- Onset within the acute treatment window
- Age 18 or older
- Functionally independent, defined as a modified Rankin Scale (mRS) score between 0 and 2, as evaluated by EMS personnel in the field
- Suspected acute stroke secondary to large-vessel occlusion (LVO), defined as a Rapid Arterial Occlusion Evaluation (RACE) Scale score between 5 and 9
- Evaluation by EMS personnel in a geographical area where the primary referral center was a local stroke center without thrombectomy capabilities, covering a population of 3.85 million
- Estimated arrival at a thrombectomy-capable center less than 7 hours after symptom onset (for witnessed onset) or last time seen well
Excluded
- Direct CSC admission clinically indicated
- Participation in another trial
- Unstable clinical status and/or coma requiring emergent life-support care
- Direct comprehensive-stroke-center admission otherwise clinically indicated
- Participation in another trial
Source: Pérez de la Ossa N et al., JAMA 2022;327(18):1782–1794· Retrieved 2026-06-09
Primary Outcome — mRS Distribution at 90 Days
Ischemic stroke or TIA population (primary endpoint, n=949)
Study Arms
- Agent
- Direct transport to a thrombectomy-capable comprehensive stroke center (mothership strategy)
- Route
- Prehospital transport routing
- Co-interventions
- Standard clinical care and endovascular treatment per institutional protocols, in agreement with European Stroke Organisation guidelines; intravenous thrombolysis and thrombectomy delivered as indicated at the comprehensive stroke center
Time to admission was determined by transport time to the allocated thrombectomy-capable center. Transport time to a thrombectomy-capable center ranged from 20 to 180 minutes. This is a transport-strategy comparison, not a drug comparison.
- Agent
- Transport to the nearest local stroke center first (drip-and-ship strategy)
- Route
- Prehospital transport routing
- Co-interventions
- Intravenous thrombolysis at the local stroke center as indicated; for confirmed LVO (or, if imaging was unavailable, clinical suspicion of LVO with NIHSS score 6 or higher), subsequent interhospital transfer to a thrombectomy-capable referral center
Time to admission to a thrombectomy-capable center was determined by the sum of onset to first hospital arrival, door-in-door-out, and interhospital transfer. Local stroke centers had no thrombectomy capability; telestroke centers could initiate intravenous thrombolysis after telemedicine consultation with a stroke neurologist.
Trial Design
Type
- Population-based, cluster-randomized trial
- Nonurban suspected LVO triage strategy study
- Direct CSC routing vs nearest local stroke center first
Timeline
Catalonia, Spain; March 2017 to June 2020
N
1401
Enrollment
Population-based cluster-randomized trial in Catalonia, Spain. Enrollment March 2017 to June 2020. Stopped early for futility after interim analysis. Nonurban network with real-world ambulance routing.
ClinicalTrials.gov
NCT02795962Bedside Pearl
RACECAT shows that in a real nonurban stroke network, bypassing the nearest center to speed thrombectomy did not improve population-level outcomes. The thrombectomy gains were offset by IVT delays and overtriage of non-LVO patients. This is a strong argument against a universal mothership (CSC-direct) protocol in nonurban systems. Triage algorithms should account for LVO prevalence, transfer times, and IVT eligibility window for your specific system.
See also