TRIAGE-STROKE Trial: PSC-First vs CSC-First Routing in IVT-Eligible Suspected LVO
In IVT-eligible patients with suspected LVO stroke within 4 hours of onset, does direct routing to a thrombectomy-capable comprehensive stroke center improve 90-day functional outcome compared with initial transport to the nearest primary stroke center?
Behrndtz A, et al. (Stroke 2023) · doi:10.1161/STROKEAHA.123.043875 · 171 patients
Population
Included
- Age 18 or older
- Suspected LVO stroke (PASS score 2 or higher)
- Within 4 hours of onset or last known well
- Eligible for IV thrombolysis
- Within catchment area of a primary stroke center
- At least 18 years of age
- Acute focal neurological deficits
- Prehospital Acute Stroke Severity (PASS) score of 2 or higher (suspected large-vessel occlusion at the prehospital level)
- Functionally independent before the stroke, defined as a prestroke modified Rankin Scale score of 0 to 2
- Symptoms occurred while the patient was in a primary-stroke-center catchment area, where drive time to the primary stroke center was shorter than drive time to the comprehensive stroke center
- Candidate for intravenous thrombolysis (no oral anticoagulation, no recent surgery or stroke)
- Able to arrive at both the comprehensive stroke center and the primary stroke center within 4 hours from stroke onset
Excluded
- Pre-morbid mRS greater than 2
- Direct CSC admission clinically indicated
- Enrollment in another trial
- Stroke occurred inside a hospital
- Life expectancy below 1 year
Source: Behrndtz A et al., Stroke 2023;54:2714–2723· Retrieved 2026-06-09
Primary Outcome — mRS Distribution at 90 Days
Acute ischemic stroke population (primary endpoint, n=104)
Study Arms
- Agent
- Direct ambulance transport to a comprehensive stroke center, bypassing the nearer primary stroke center (prioritizing endovascular therapy access)
- Route
- Prehospital transport routing
- Co-interventions
- Intravenous thrombolysis and endovascular therapy delivered as indicated at the comprehensive stroke center. Large-vessel occlusion defined as occlusion of the internal carotid artery, first segment of the middle cerebral artery (M1), proximal part of the first division of the middle cerebral artery, or the basilar artery, assessed initially by CT angiography or MR angiography.
Onset-to-needle time was 30 minutes longer when transported directly to the CSC, but onset-to-groin time was 35 minutes shorter. The shortest distance between the primary and comprehensive stroke centers was about 114 km (roughly 1 hour of ground transport). Transport-strategy comparison, not a drug comparison. Source: Behrndtz Stroke 2023 p.2715–2717.
- Agent
- Ambulance transport to the nearest primary stroke center first (prioritizing intravenous thrombolysis), with secondary transfer to a comprehensive stroke center if needed
- Route
- Prehospital transport routing
- Co-interventions
- Intravenous thrombolysis initiated at the primary stroke center as indicated; subsequent interhospital transfer to the comprehensive stroke center for endovascular therapy in patients with confirmed or clinically suspected large-vessel occlusion.
Intravenous thrombolysis was administered in 67% of the PSC-first group versus 78% of the CSC-first group; endovascular therapy was performed in 53% of the PSC-first group versus 63% of the CSC-first group. During the trial period, one primary stroke center was functionally a comprehensive stroke center during daytime hours, so patients from that center were included only in off-hours (4 PM to 8 AM) and on weekends. Source: Behrndtz Stroke 2023 p.2716–2717.
Trial Design
Type
- National, multicenter, randomized assessor-blinded trial
- IVT-eligible suspected LVO transport strategy study
- Nearest PSC vs direct CSC admission
Timeline
Denmark; September 2018 to May 2022
N
171
Enrollment
Randomized September 2018 to May 2022 across Denmark. National, multicenter, assessor-blinded trial. Stopped early at 171 of 424 planned patients. Ambulance-based randomization.
ClinicalTrials.gov
NCT03542188Bedside Pearl
TRIAGE-STROKE was stopped early (N=171 of planned 600) and cannot provide definitive guidance on bypass strategy. The mechanistic signal is informative: CSC-first shortened onset-to-groin time by 35 minutes; PSC-first shortened onset-to-needle time by 30 minutes. The net clinical effect is system dependent and this underpowered trial should not be used alone to mandate a bypass protocol.
See also