Decentralizing acute stroke reperfusion therapies: moving from structural centralization to organizational equity

Abstract

Acute ischemic stroke remains one of the major causes of disability and mortality worldwide (1). The introduction of mechanical thrombectomy has reshaped the management of stroke, establishing endovascular treatment (EVT) as standard care for eligible patients. Despite strong clinical evidence for EVT and its time-dependent benefit (2), access to these therapies continues to vary substantially across regions. Many health systems still concentrate access to EVT in tertiary centers, often requiring interhospital transfers for patients initially presenting to secondary or regional hospitals.

This viewpoint contends that we should no longer consider the current centralization of acute stroke reperfusion therapies, particularly EVT, as a structurally mandatory organization. Instead, it represents a modifiable organizational choice. The purpose is not to argue against centralization itself but to support the selective expansion of qualified thrombectomy-capable centers in specific regions within coordinated hub-and-spoke stroke systems while maintaining referral pathways and quality standards.