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Optimising Prehospital Pathways to Improve Acute Stroke Reperfusion Therapy Delivery: Systems-Based Approaches

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Intravenous thrombolysis and endovascular thrombectomy are the only approved reperfusion treatments available for patients with acute ischemic stroke. Despite the advances in reperfusion therapy, time continues to be a critical factor in the delivery of reperfusion treatment in acute stroke settings. In recent years, some systems-based approaches have been pursued with considerable success. However, approaches aimed at optimising and reducing treatment delays specifically in the prehospital settings are limited. A systems-based approach aimed at improving the process of care in the prehospital setting may result in the reduction of treatment delays and potentially improve clinical outcomes. In this article, we present an overview of the current prehospital acute stroke pathway. Areas to reduce treatment delays are identified and optimisations to the prehospital workflow addressing the identified gaps in acute stroke settings are proposed. Improving process and system gaps would translate to improved post-stroke outcomes following reperfusion therapy.

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Availability of Data and Material

All data generated or analysed during this study are included in this published article and Supplementary Information (SI) attached.



Ataxia, Blindness, Consciousness, Dysphagia, Eye 1 (Diplopia), Eye 2 (Pupillary abnormalities)


Ambulance clinical triage for acute stroke treatment


Acute ischemic stroke


Activated partial thromboplastin time


Balance Eyes Face Arms Speech Test


Blood pressure


Culturally and linguistically diverse communities


Confidence interval


Cincinnati Prehospital Stroke Scale


Comprehensive Stroke Centre


Cincinnati Stroke Triage Assessment Tool


Computed tomography scan


Call to needle time


Emergency department


Emergency medical dispatcher


Emergency medical services


Emergency Medical Stroke Assessment


Endovascular thrombectomy


Face Arms Speech Test


Field Assessment Stroke Triage for Emergency Destination


Glial fibrillary acidic protein


Gaze Face Arm Speech Test


General practitioner


Intracerebral haemorrhage


International normalised ratio


Improving Treatment with Rapid Evaluation of Acute Stroke via Mobile Telemedicine




Intravenous thrombolysis


Los Angeles Motor Scale


Los Angeles Prehospital Stroke Scale


Low molecular weight heparin


Large vessel occlusion


Melbourne Ambulance Stroke Scale


Medic Prehospital Assessment for Code Stroke


Medical Priority Dispatch System


Modified Rankin Scale


Mobile Stroke Unit


National Institute of Health


National Institute of Health Stroke Scale


Negative predictive value


Ontario Prehospital Stroke Screening Tool


Odds ratio


On scene time


Prehospital Acute Stroke Severity Scale


Paramedic—Norwegian Acute Stroke Prehospital Project


Posterior circulation stroke


Point of care


Positive predictive value


PreHospital Ambulance Stroke Test


Pre-hospital Triage of Patients with Suspected Stroke Symptoms


Primary Stroke Centre


Rapid Arterial Occlusion Evaluation


Transfer to the Local Stroke Center Versus Direct Transfer to Endovascular Center of Acute Stroke Patients With Suspected Large Vessel Occlusion in the Catalan Territory


Randomised control trial


Recognition of Stroke in the Emergency Room


Stockholm Stroke Triage System


Systematic Evaluation of Patients Treated with Stroke Devices for Acute Ischemic Stroke


Tissue plasminogen activator


Treatment Strategy in Acute Large Vessel Occlusion


Stroke Vision Aphasia Neglect Assessment


Ventura Emergent Large Vessel Occlusion Score


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We would like to acknowledge the support from the administrative staff and our NSW-wide clinician and investigator partners.


Seed funding from the UNSW Medicine Mindgardens CAG funding 2017 for the Thrombolysis and Endovascular FLow Network (TEFLON) trial (Chief Investigator: Dr Sonu Bhaskar) and funding for the NSW Brain Clot Bank (Chief Investigator: Dr Sonu Bhaskar) from the NSW Ministry of Health (2019–2022) is acknowledged. The funding body has no role in the study design, data collection, analysis, interpretation of findings and manuscript preparation.

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SMMB conceived the study, contributed to the planning, draft and revision of the manuscript; supervision of the students and the conduct of the trial; towards ethics submission and statewide leadership and networking development. SMMB and SC wrote the first draft of the manuscript. SC contributed to the literature review, writing and revision of the manuscript. All authors contributed to the revision of the manuscript. All authors approved the final draft of the manuscript.

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Correspondence to Sonu Menachem Maimonides Bhaskar.

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Chowdhury, S.Z., Wardman, D., Cordato, D.J. et al. Optimising Prehospital Pathways to Improve Acute Stroke Reperfusion Therapy Delivery: Systems-Based Approaches. SN Compr. Clin. Med. 3, 2558–2575 (2021).

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