Early transfer of stroke patients to comprehensive stroke centers: David and Goliath.

ore than a thousand years ago on a battlefield in ancient Palestine, a shepherd boy (David) defeated a mighty fully armored warrior (Goliath) with a stone and a sling. Comprehensive Stroke Centers (CSC), the Goliath of stroke care, are typically high-volume, more experienced, and more resourced compared with conventional Stroke Units (SU) at community hospitals—David's. 1 Although the benefits from early evaluation and care of stroke patients not candidates for reperfusion therapy are undisputable, their routines transfer to a giant and busy CSC from a small but skilled SU is controversial. Dr Sheth is the Goliath's manager. He considers that our patient is at high risk for early clinical complications and that triaging such patients to a CSC that has the expertise and resources to manage the anticipated complications is essential. In contrast, Dr Langhorne argues that the best management for our patient is to admit him to a well run SU in the local community, despite the overwhelming superiority of CSC. This SU would need to have adequate number of skilled staff who is able to manage the common problems and complications in an acute stroke patient and the capacity for rapid transfer to a CSC if the patient's condition was to deteriorate. The battle begins and David hits Goliath's face first: There is no evidence that an ambulance transfer improves stroke recovery, and it may be even harmful. Immediate acute stroke care at admitting SU is critical to increased chance of survival and regaining some independence. Goliath responds: This is true if the patient is managed in a properly run, well staffed and skilled SU, such a SU requires the corresponding accredi-tation and auditable quality measures. However, the number of such SU at community hospitals is scarce in many countries and mainly concentrated in urban areas. Let us assume that our patient is initially admitted to a well run SU. Should our patient be immediately transferred to a CSC to be safe in case of future clinical deterioration or should the patient be closely monitored and only transferred to a CSC when complications arise? Goliath grabs David by the neck: Severe stroke patients are at risk of clinical deterioration and developing a malignant MCA infarction. In this setting, clinical deterioration and decreased level of consciousness are ominous and late signs that may require intubation, which further delays the emergent transfer to a CSC and increases the risk of …