Short cuts make long delays

The approval in 1996 of alteplase for the treatment of acute ischemic stroke (AIS) prompted recognition of the need to organize and implement coordinated stroke systems of care to ensure optimal access to thrombolysis.^1,2 For more than a decade, alteplase remained the sole agent proven effective in acute stroke reperfusion, and thus, the emergency medical services (EMS) system required a straightforward, one-size-fits-all approach of transporting all patients with early-onset suspected stroke to the nearest appropriate thrombolysis-capable center. However, after proven benefit of thrombectomy for stroke due to large vessel occlusion (LVO), evaluation of people with severe stroke and treatment with endovascular thrombectomy (EVT) have become Class 1, Level A recommendations. Recently published data of efficacy up to 24 hours and evidence of harm from interfacility transfer-related delays³ increased exponentially the complexity of prehospital triage for suspected AIS. With many imperfect prehospital stroke screens and severity scales to choose from, the question becomes, not if, but how should we prioritize triage of suspected LVO stroke?