Several international randomized trials have demonstrated the clinical benefit of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) in acute ischemic stroke patients due to a large vessel occlusion (LVO) of the anterior circulation [1], [2], [3], [4], [5] and posterior circulation [6], [7]. Nowadays, telemedicine provides access to acute stroke care, and especially IVT, for stroke patients in underserved areas, improving stroke outcome [8], [9].

Conversely, MT is mainly performed at comprehensive stroke centers (CSCs) with on-site neuro-endovascular capability. To date, there are two prehospital strategies for suspected LVO strokes: (i) drip and ship model – transport to the nearest primary stroke center (PSC) or remote hospitals (spoke center, SC) to receive early IVT, and transfer to the CSC for MT if LVO is confirmed; or (ii) mothership model – transfer the patient directly to a CSC where all treatment options are available. However, patient outcomes are time-dependent, and the time difference between the closest CSC versus PSC, and the transfer time from PSC to CSC may render patients ineligible for MT or might imply delaying IVT [10], [11], [12]. The resulting dilemma created a debate about the optimal management model [13], [14]. Moreover, most of the previous studies evaluated networks with SCs located at short distances from the CSC [15], [16] which do not reflect real-world practice.

Through a retrospective analysis of our prospective observational clinical registry, we compared three-month functional and safety outcomes of all LVO patients managed through our regional telestroke system following first admission to a SC, PSC or CSC before reperfusion by MT at the CSC.