AI-enhanced pathway reorganization in drip-and-ship stroke management: Italian MDRinAIS experience

Background and Aims

The MDRinAIS project is an EU-funded initiative to optimize acute ischemic stroke (AIS) care through AI-powered telemedicine in the drip-and-ship model. Beyond AI implementation, the pathway was reorganized to enable direct hub admission to the Neuroradiology Unit, bypassing the emergency department. This study evaluates the impact of this integrated reorganization on time metrics and clinical outcomes in South-East Tuscany.

Methods

This cohort study included 277 AIS patients with large vessel occlusion treated via drip-and-ship: pre-reorganization (n = 214, 2018–2021) and post-reorganization (n = 78, 2025–2026). Key time metrics assessed were door-to-groin (DTG) and spoke admission-to-hub puncture (DT). Clinical outcomes included 24h NIHSS and 3-month mRS. Mann-Whitney U test; p < 0.05.

Results

Cohorts were comparable at baseline for age, sex, risk factors and baseline NIHSS. The post-reorganization group showed significantly shorter in-hospital time metrics: DTG (40 vs 58min; p < 0.001), DT (212 vs 240 min; p < 0.001). Pre-hospital intervals, including onset-to-door and door-to-fibrinolysis, were comparable between groups. Early neurological recovery was significantly better in the post-reorganization cohort (24h NIHSS 7 vs 13; p = <0.001), with a trend toward lower discharge NIHSS (3 vs 6; p = 0.015). At 3 months, functional independence improved significantly (mRS 1 vs 3; p = 0.018), with reduced moderate-to-severe disability (mRS 3–6: 42.9% vs 61.7%; p = 0.024). Reperfusion rates and safety profiles, including hemorrhagic complications, were comparable between cohorts.

Conclusions

Integrated pathway reorganization combining AI-powered telemedicine and direct Neuroradiology admission was associated with reduced in-hospital time metrics and improved clinical outcomes. These findings support the value of system-level innovation in stroke network optimization.

Key messages

• Integrating AI-powered telemedicine with direct admission to the Neuroradiology Unit significantly reduces in-hospital treatment times in drip-and-ship stroke care.

• This system-level reorganization, in a rural low density area, translates into improved clinical outcomes, including improved early neurological recovery and higher rates of functional independence.