In the thrombectomy era, triage in the field improves care

We read with interest the comments by Leira and Savitz1 in the June 2018 issue of Stroke regarding ischemic stroke triage, administration of intravenous tissue plasminogen activator (IV tPA), and mechanical thrombectomy. Although the topic is timely and the authors’ insights clearly expressed, we disagree with both the concluding statements and the supporting arguments that lead to these inferences. Current evidence does not suggest that advances in mechanical thrombectomy are occurring at the expense of IV tPA only treated patients, and primary stroke centers (PSCs) are not at an existential risk. We offer the following thoughts: Endovascular therapy (ET) is now the standard of care for emergent large vessel occlusion (ELVO) acute ischemic stroke following the overwhelmingly positive outcomes from multiple randomized trials that compared ET with IV tPA or best medical management.2–8 It is one of the most effective therapies available in modern medicine.2–8 It was estimated that only 10–15% of patients with acute ischemic stroke were eligible for ET.9–11 In the past year, the number of eligible patients has increased further due to the demonstrated efficacy of treatment for …