Endovascular thrombectomy (EVT) in eligible acute ischemic stroke (AIS) treatment is associated with an increased likelihood of excellent functional outcomes in a cost-effective manner. However, EVT is resource-intensive and available only at comprehensive stroke centers or EVT-capable centers. Access to EVT is deficient in high-income countries ^{Reference Kamel, Parikh and Chatterjee1,Reference Eagles, Beall, Ben-Israel, Wong, Hill and Spackman2} and worse in low- and middle-income countries. ^{Reference Asif, Otite and Desai3} One of the key barriers to EVT access is geographical: driving time is defined as the distance between the patient’s residence and the nearest EVT-capable site.

Taghdiri F et al. ^{Reference Taghdiri, Vyas and Kapral4} conducted an interesting retrospective population-based cohort study to explore driving time as a metric to understand EVT access. Over 5 years, they included n = 57,587 adult patients hospitalized with a diagnosis of acute ischemic stroke, 4150 received EVT and 8285 received intravenous thrombolysis (IVT). Driving time to an EVT-capable site was calculated as travel time by a car while accounting for speed limits in Ontario and divided into three groups: <20 (n = 25,180), 20 – 60 (n = 20,029) and >60 (12,478) minutes. The authors observed that the likelihood of receiving EVT was reduced beyond 120 minutes of driving time to the nearest EVT-capable site. This is an important insight into geographic disparities in stroke care access.

Driving time indicates remoteness but may be associated with other socioeconomic disparities. In a study from Alberta, patients living in the most deprived neighborhoods were 50% less likely to receive EVT; these areas had a median driving distance of >74 Km. ^{Reference Eagles, Beall, Ben-Israel, Wong, Hill and Spackman2} A study from Wisconsin noted that long drive distances from advanced-care-capable stroke centers were associated with increased mortality. ^{Reference Halada, Beyer, Zhou and Weston5} These are important factors as many Canadians live more than 120 minutes from an EVT center.

Therefore, traditional strategies of urban areas, such as the drip-and-ship versus bypass model, may not work in remote areas as the driving time increases. ^{Reference Yu, Panagos and Kansagra6} Yet, important system-level improvements are still needed: shortening door-to-neurology contact, decreasing door-in door-out times and improving air transportation may be helpful. Novel solutions are also needed, such as neuro-cytoprotection and detection of large vessel occlusion by non-computed tomography-based tools for better bypass strategies. Mobile stroke units may improve access in some jurisdictions. ^{Reference Kate, Jeerakathil and Buck7,Reference Mac Grory, Sun and Alhanti8}

Reliance on driving time as a metric has some limitations. It is a nonphysiological variable that may be influenced by jurisdictional speed limit laws and real-time challenges (weather and driving conditions). Driving time may also vary based on advanced cardiac life support, ambulance and air transport. Nevertheless, driving time is a viable model for identifying EVT access deserts worldwide.