Acute Stroke Care for Intracranial Artery Occlusion in an Aging Rural Region: Insights From the Fukushima Large Vessel Occlusion (LVO) Stroke Registry

BACKGROUND: Establishing an effective stroke care system for patients with acute intracranial artery occlusion is particularly challenging in regions affected by aging and depopulation with limited medical resources. We conducted a study, termed the Fukushima Large Vessel Occlusion (LVO) Stroke Registry, to clarify real-world treatment practices and patient pathways in such a setting. METHODS: This prospective multicenter registry enrolled consecutive patients with acute intracranial artery occlusion admitted within 24 h of symptom onset across 12 hospitals in Fukushima Prefecture between July 2020 and June 2022. Patients receiving mechanical thrombectomy or medical treatment were analyzed. Functional independence was defined as a modified Rankin Scale (mRS) score of 0-2 on Day 90. Among patients undergoing mechanical thrombectomy, the treatment pathways were classified as mothership, patient transfer, or physician transfer. RESULTS: A total of 210 patients were enrolled in this study. The median age was 81 years, and the median National Institutes of Health Stroke Scale (NIHSS) score was 18. Functional independence at 90 days was achieved in 68 patients (32.4%), while symptomatic intracranial hemorrhage occurred in 7 (3.3%), and 90-day mortality occurred in 53 (25.2%). Among 147 patients treated with mechanical thrombectomy, successful reperfusion (defined by a modified Thrombolysis in Cerebral Infarction (mTICI) 2b or 3) was achieved in 107 (72.8%). Functional independence was associated with younger age (76.5 vs. 82 years, P = 0.016), premorbid mRS score 0-2 (98.0% vs. 88.7%, P = 0.042), mothership pathway (60.0% vs. 38.1%, P = 0.012), lower NIHSS score (16 vs. 21, P < 0.001), higher Alberta Stroke Program Early CT Score (ASPECTS) (10 vs. 8, P < 0.001), shorter puncture-to-recanalization time (38 vs. 67 minutes, P < 0.001), and higher successful reperfusion rate (92.0% vs. 62.9%, P < 0.001). In multivariate analysis, age (odds ratio (OR) 0.959, 95% confidence interval (CI) 0.925-0.995; P = 0.024), NIHSS score (OR 0.914, 95% CI 0.864-0.968; P = 0.002), ASPECTS (OR 1.519, 95% CI 1.146-2.013; P = 0.004), and mTICI 2b or 3 (OR 8.741, 95% CI 2.581-29.597; P < 0.001) were independently associated with functional independence. Although unadjusted functional independence differed among the pathways, no clear differences in safety outcomes were observed. CONCLUSIONS: In aging and depopulated regions, a hybrid stroke care system integrating mothership, patient transfer, and physician transfer pathways can maintain patients' access to mechanical thrombectomy with acceptable safety. These findings highlight the importance of a flexible region-specific stroke network and the need for workflow optimization to improve clinical outcomes in resource-limited settings.