{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T05:23:20Z","timestamp":1787289800273,"version":"build-2736575974"},"reference-count":32,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T00:00:00Z","timestamp":1787270400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:p>Acute ischaemic stroke triage between Drip-and-Ship (DS), Mothership (MS) and Mobile Stroke Unit (MSU) strategies has been formalised over the past decade by conditional-probability decision models. Two recent developments motivate an updated treatment: the shift of the intravenous thrombolysis standard from alteplase to tenecteplase, and the maturation of randomised evidence on DS-versus-MS triage and on MSU effectiveness. A Bayesian conditional-probability simulation framework is presented that combines random-effects synthesis of the modern trial corpus for intravenous thrombolysis (alteplase, tenecteplase) and endovascular thrombectomy with a log-normal decomposition of onset-to-reperfusion into strategy- and pharmacology-specific process-time components. The prehospital large-vessel-occlusion probability is updated from validated screening scales, and the optimal strategy together with a 95% posterior credible interval is computed at every coordinate of the decision space spanned by the inter-facility transit-time differential and the LVO posterior probability. Sobol first-order and total-effect indices decompose outcome variance over the sampled input space, and first- and second-order stochastic dominance between strategies is tested under the same posterior. Under the production calibration the tenecteplase paradigm reallocated 14.1% of the decision plane relative to alteplase, concentrated in the low-probability, long-differential region; the prehospital large-vessel-occlusion posterior accounted for the dominant share of outcome variance (Sobol first-order index 0.84\u20130.93); and no coordinate of the decision plane reached 95% posterior agreement on a single optimal strategy. The framework is open and reproducible and depends only on published trial-level evidence. It is presented as a decision-analytic and hypothesis-generating tool for structuring the tenecteplase-era triage question rather than as a validated operational triage rule, and prospective calibration against region-specific stroke-system data would be required before any deployment.<\/jats:p>","DOI":"10.3389\/fneur.2026.1881451","type":"journal-article","created":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T04:23:14Z","timestamp":1787286194000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["A Bayesian conditional probability simulation framework for pre-hospital stroke transport decisions in the tenecteplase era: decision boundaries, global sensitivity, and stochastic dominance"],"prefix":"10.3389","volume":"17","author":[{"given":"Tu\u01e7ba","family":"\u00c7al\u0131\u015f\u0131r","sequence":"first","affiliation":[{"name":"Department of Neurology, Hatay Mustafa Kemal University","place":["Hatay, T\u00fcrkiye"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,8,21]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"1279","DOI":"10.1001\/jama.2016.13647","article-title":"Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis","volume":"316","author":"Saver","year":"2016","journal-title":"JAMA"},{"key":"B2","doi-asserted-by":"publisher","first-page":"1723","DOI":"10.1016\/S0140-6736(16)00163-X","article-title":"Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials","volume":"387","author":"Goyal","year":"2016","journal-title":"Lancet"},{"key":"B3","doi-asserted-by":"publisher","first-page":"1832","DOI":"10.1016\/j.jacc.2019.10.034","article-title":"Management of acute ischemic stroke due to large-vessel occlusion","volume":"75","author":"Ospel","year":"2020","journal-title":"J Am Coll Cardiol"},{"key":"B4","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1056\/NEJMoa1706442","article-title":"Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct","volume":"378","author":"Nogueira","year":"2018","journal-title":"N Engl J Med"},{"key":"B5","doi-asserted-by":"publisher","first-page":"708","DOI":"10.1056\/NEJMoa1713973","article-title":"Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging","volume":"378","author":"Albers","year":"2018","journal-title":"N Engl J Med"},{"key":"B6","doi-asserted-by":"publisher","first-page":"1477","DOI":"10.1001\/jamaneurol.2018.2424","article-title":"Modeling stroke patient transport for all patients with suspected large-vessel occlusion","volume":"75","author":"Holodinsky","year":"2018","journal-title":"JAMA Neurol"},{"key":"B7","doi-asserted-by":"publisher","first-page":"1805","DOI":"10.1161\/STROKEAHA.119.028474","article-title":"Hill MD. In what scenarios does a mobile stroke unit predict better patient outcomes?: A modeling study","volume":"51","author":"Holodinsky","year":"2020","journal-title":"Stroke"},{"key":"B8","doi-asserted-by":"publisher","first-page":"971","DOI":"10.1056\/NEJMoa2103879","article-title":"Prospective, multicenter, controlled trial of mobile stroke units","volume":"385","author":"Grotta","year":"2021","journal-title":"N Engl J Med"},{"key":"B9","doi-asserted-by":"publisher","first-page":"454","DOI":"10.1001\/jama.2020.26345","article-title":"Association between dispatch of mobile stroke units and functional outcomes among patients with acute ischemic stroke in Berlin","volume":"325","author":"Ebinger","year":"2021","journal-title":"JAMA"},{"key":"B10","doi-asserted-by":"publisher","first-page":"945","DOI":"10.1161\/STROKEAHA.117.019307","article-title":"Ambulance clinical triage for acute stroke treatment: paramedic triage algorithm for large vessel occlusion","volume":"49","author":"Zhao","year":"2018","journal-title":"Stroke"},{"key":"B11","doi-asserted-by":"publisher","first-page":"2184","DOI":"10.1161\/STROKEAHA.117.017281","article-title":"Optimal transport destination for ischemic stroke patients with unknown vessel status: use of prehospital triage scores","volume":"48","author":"Schlemm","year":"2017","journal-title":"Stroke"},{"key":"B12","doi-asserted-by":"publisher","first-page":"126","DOI":"10.1177\/2396987318759362","article-title":"Drip and ship versus direct to endovascular thrombectomy: the impact of treatment times on transport decision-making","volume":"3","author":"Holodinsky","year":"2018","journal-title":"Eur Stroke J"},{"key":"B13","doi-asserted-by":"publisher","first-page":"4010","DOI":"10.1161\/STROKEAHA.120.031633","article-title":"Optimizing emergency stroke transport strategies using physiological models","volume":"52","author":"Paydarfar","year":"2021","journal-title":"Stroke"},{"key":"B14","doi-asserted-by":"publisher","first-page":"135","DOI":"10.1080\/02664763.2024.2360590","article-title":"Bayesian modeling framework for optimizing pre-hospital stroke triage decisions","volume":"52","author":"Nwoke","year":"2025","journal-title":"J Appl Stat"},{"key":"B15","doi-asserted-by":"publisher","first-page":"3440","DOI":"10.1161\/STROKEAHA.120.029749","article-title":"Tenecteplase thrombolysis for acute ischemic stroke","volume":"51","author":"Warach","year":"2020","journal-title":"Stroke"},{"key":"B16","doi-asserted-by":"publisher","first-page":"161","DOI":"10.1016\/S0140-6736(22)01054-6","article-title":"Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial","volume":"400","author":"Menon","year":"2022","journal-title":"Lancet"},{"key":"B17","doi-asserted-by":"publisher","first-page":"e70791","DOI":"10.1002\/brb3.70791","article-title":"Efficacy and safety of tenecteplase in acute ischemic stroke: a meta-analysis of randomized controlled trials","volume":"15","author":"Bacha","year":"2025","journal-title":"Brain Behav"},{"key":"B18","doi-asserted-by":"publisher","first-page":"2491","DOI":"10.1161\/STROKEAHA.123.042691","article-title":"Early recanalization among patients undergoing bridging therapy with tenecteplase or alteplase","volume":"54","author":"Checkouri","year":"2023","journal-title":"Stroke"},{"key":"B19","doi-asserted-by":"publisher","first-page":"261","DOI":"10.1177\/17474930241307098","article-title":"Should we switch to tenecteplase for all ischemic strokes? Evidence and logistics","volume":"20","author":"Muir","year":"2025","journal-title":"Int J Stroke"},{"key":"B20","doi-asserted-by":"publisher","first-page":"1782","DOI":"10.1001\/jama.2022.4404","article-title":"Effect of direct transportation to thrombectomy-capable center vs local stroke center on neurological outcomes in patients with suspected large-vessel occlusion stroke in nonurban areas: the RACECAT randomized clinical trial","volume":"327","author":"P\u00e9rez de la Ossa","year":"2022","journal-title":"JAMA"},{"key":"B21","doi-asserted-by":"publisher","first-page":"3644","DOI":"10.1161\/STROKEAHA.122.039172","article-title":"Quantifying improved outcomes, cost savings, and hospital volume changes from optimized emergency stroke transport","volume":"53","author":"Paydarfar","year":"2022","journal-title":"Stroke"},{"key":"B22","doi-asserted-by":"publisher","first-page":"768381","DOI":"10.3389\/fneur.2021.768381","article-title":"Optimal transport scenario with rotary air transport for access to endovascular therapy considering patient outcomes and cost: a modeling study","volume":"12","author":"Wheaton","year":"2021","journal-title":"Front Neurol"},{"key":"B23","doi-asserted-by":"publisher","first-page":"729","DOI":"10.1007\/s00062-020-00933-y","article-title":"Modeling the optimal transportation for acute stroke treatment: impact of diurnal variations in traffic rate","volume":"31","author":"Ernst","year":"2021","journal-title":"Clin Neuroradiol"},{"key":"B24","doi-asserted-by":"publisher","DOI":"10.1287\/mnsc.2021.4231","article-title":"Improving patient transfer protocols for regional stroke networks","author":"Ardestani-Jaafari","year":"2022","journal-title":"Managem Sci"},{"key":"B25","doi-asserted-by":"publisher","first-page":"177","DOI":"10.1016\/0197-2456(86)90046-2","article-title":"Meta-analysis in clinical trials","volume":"7","author":"DerSimonian","year":"1986","journal-title":"Control Clin Trials"},{"key":"B26","doi-asserted-by":"publisher","first-page":"137","DOI":"10.1111\/j.1467-985X.2008.00552.x","article-title":"A re-evaluation of random-effects meta-analysis","volume":"172","author":"Higgins","year":"2009","journal-title":"J Royal Statist Soc: Series A"},{"key":"B27","doi-asserted-by":"publisher","first-page":"87","DOI":"10.1161\/STROKEAHA.113.003071","article-title":"Design and validation of a prehospital stroke scale to predict large arterial occlusion: the Rapid Arterial oCclusion Evaluation (RACE) scale","volume":"45","author":"P\u00e9rez de la Ossa","year":"2014","journal-title":"Stroke"},{"key":"B28","doi-asserted-by":"publisher","first-page":"1109","DOI":"10.1016\/j.ress.2005.11.014","article-title":"Sensitivity analysis practices: strategies for model-based inference","volume":"91","author":"Saltelli","year":"2006","journal-title":"Reliability Eng Syst Safety"},{"key":"B29","doi-asserted-by":"publisher","first-page":"1212","DOI":"10.1016\/j.ress.2008.03.028","article-title":"Calculating first-order sensitivity measures: a benchmark of some recent methodologies","volume":"94","author":"Gatelli","year":"2009","journal-title":"Reliability Eng Syst Safety"},{"key":"B30","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1016\/j.envsoft.2019.01.012","article-title":"Why so many published sensitivity analyses are false: a systematic review of sensitivity analysis practices","volume":"114","author":"Saltelli","year":"2019","journal-title":"Environm Model Softw"},{"key":"B31","doi-asserted-by":"publisher","first-page":"1435","DOI":"10.1111\/1468-0262.00167","article-title":"Statistical inference for stochastic dominance and for the measurement of poverty and inequality","volume":"68","author":"Davidson","year":"2000","journal-title":"Econometrica"},{"key":"B32","doi-asserted-by":"publisher","first-page":"86","DOI":"10.1186\/s12883-018-1021-8","article-title":"Clinical benefit of improved prehospital stroke scales to detect stroke patients with large vessel occlusions: results from a conditional probabilistic model","volume":"18","author":"Schlemm","year":"2018","journal-title":"BMC Neurol"}],"container-title":["Frontiers in Neurology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2026.1881451\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T04:23:15Z","timestamp":1787286195000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2026.1881451\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,21]]},"references-count":32,"alternative-id":["10.3389\/fneur.2026.1881451"],"URL":"https:\/\/doi.org\/10.3389\/fneur.2026.1881451","relation":{},"ISSN":["1664-2295"],"issn-type":[{"value":"1664-2295","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,21]]},"article-number":"1881451"}}