Across global stroke systems, primary stroke centers (PSCs) serve as the first point of contact for a substantial proportion of patients. These centers deliver thrombolysis but lack endovascular capability and historically have been underrepresented in acute stroke trials. The reasons are familiar: limited research infrastructure, fewer dedicated personnel and the perception that complex trials are better suited for comprehensive stroke centers (CSCs). Yet, this paradigm is beginning to shift.
The Alteplase Compared to Tenecteplase in Patients With Acute Ischemic Stroke (AcT) trialReference Menon, Buck and Singh1 offers an example of what becomes possible when PSCs are integrated into the research ecosystem. Investigators made a deliberate effort to include PSCs, supporting five centers to participate meaningfully in a large, pragmatic national trial. This work lays the groundwork for future PSC engagement and demonstrates that research can be integrated into routine care, even in resource-constrained environments.
In a secondary analysis of AcT, the authors compared outcomes between patients who presented directly to a PSC (n = 99 of 1577) and those who arrived at a CSC.Reference Gutiérrez, Ignacio and Tkach2 Patients treated at PSCs achieved better long-term clinical outcomes despite having longer workflow metrics. This counterintuitive finding invites careful reflection. The authors appropriately caution against overinterpretation, noting that the results are hypothesis-generating rather than definitive.
Several explanations are plausible. Selection bias is a possibility: PSCs may have enrolled patients with less complex presentations or fewer comorbidities. Although the AcT trial did not restrict baseline functioning, the PSC cohort included a notably higher proportion of patients with National Institute of Health Stroke Scale (NIHSS) < 8 and a lower proportion of patients with NIHSS 8–15, a 10% difference that could influence outcomes. Without detailed baseline functional data, the true extent of this imbalance remains uncertain.
Still, these findings underscore the value of expanding research leadership within PSCs, whether through prospective observational studies, quality-improvement initiatives or future randomized trials. The five PSC sites and the AcT investigators deserve recognition for demonstrating that PSC-based research is both feasible and impactful.
Momentum is building. Organizations such as the Canadian Stroke Consortium are now working directly with PSC teams to map workflows, understand local contexts and develop adaptable Research Toolkits to assist with contracts and supervision plans. These efforts signal a broader commitment to democratizing clinical research and ensuring that the centers caring for stroke patients are also shaping the evidence that guides their treatment. If anything, the AcT experience reminds us that PSCs are not peripheral to stroke research – they are essential to its future.
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Across global stroke systems, primary stroke centers (PSCs) serve as the first point of contact for a substantial proportion of patients. These centers deliver thrombolysis but lack endovascular capability and historically have been underrepresented in acute stroke trials. The reasons are familiar: limited research infrastructure, fewer dedicated personnel and the perception that complex trials are better suited for comprehensive stroke centers (CSCs). Yet, this paradigm is beginning to shift.
The Alteplase Compared to Tenecteplase in Patients With Acute Ischemic Stroke (AcT) trialReference Menon, Buck and Singh1 offers an example of what becomes possible when PSCs are integrated into the research ecosystem. Investigators made a deliberate effort to include PSCs, supporting five centers to participate meaningfully in a large, pragmatic national trial. This work lays the groundwork for future PSC engagement and demonstrates that research can be integrated into routine care, even in resource-constrained environments.
In a secondary analysis of AcT, the authors compared outcomes between patients who presented directly to a PSC (n = 99 of 1577) and those who arrived at a CSC.Reference Gutiérrez, Ignacio and Tkach2 Patients treated at PSCs achieved better long-term clinical outcomes despite having longer workflow metrics. This counterintuitive finding invites careful reflection. The authors appropriately caution against overinterpretation, noting that the results are hypothesis-generating rather than definitive.
Several explanations are plausible. Selection bias is a possibility: PSCs may have enrolled patients with less complex presentations or fewer comorbidities. Although the AcT trial did not restrict baseline functioning, the PSC cohort included a notably higher proportion of patients with National Institute of Health Stroke Scale (NIHSS) < 8 and a lower proportion of patients with NIHSS 8–15, a 10% difference that could influence outcomes. Without detailed baseline functional data, the true extent of this imbalance remains uncertain.
Still, these findings underscore the value of expanding research leadership within PSCs, whether through prospective observational studies, quality-improvement initiatives or future randomized trials. The five PSC sites and the AcT investigators deserve recognition for demonstrating that PSC-based research is both feasible and impactful.
Momentum is building. Organizations such as the Canadian Stroke Consortium are now working directly with PSC teams to map workflows, understand local contexts and develop adaptable Research Toolkits to assist with contracts and supervision plans. These efforts signal a broader commitment to democratizing clinical research and ensuring that the centers caring for stroke patients are also shaping the evidence that guides their treatment. If anything, the AcT experience reminds us that PSCs are not peripheral to stroke research – they are essential to its future.
Competing interests
None.