Sage Journals: Discover world-class research

Abstract

Acute stroke treatment has advanced substantially over the last years. Important milestones constitute intravenous thrombolysis, endovascular therapy (EVT), and treatment of stroke patients in dedicated units (stroke units). At present in Switzerland there are 13 certified stroke units and 10 certified EVT-capable stroke centers. Emerging challenges for the prehospital pathways are that (i) acute stroke treatment remains very time sensitive, (ii) the time window for acute stroke treatment has opened up to 24 h in selected cases, and (iii) EVT is only available in stroke centers. The goal of the current guideline is to standardize the prehospital phase of patients with acute stroke for them to receive the optimal treatment without unnecessary delays. Different prehospital models exist. For patients with large vessel occlusion (LVO), the Drip and Ship model is the most commonly used in Switzerland. This model is challenged by the Mothership model where stroke patients with suspected LVO are directly transferred to the stroke center. This latter model is only effective if there is an accurate triage by paramedics, hence the patient may benefit from the right treatment in the right place, without loss of time. Although the Cincinnati Prehospital Stroke Scale is a well-established scale to detect acute stroke in the prehospital setting, it neglects nonmotor symptoms like visual impairment or severe vertigo. Therefore we suggest “acute occurrence of a focal neurological deficit” as the trigger to enter the acute stroke pathway. For the triage whether a patient has a LVO (yes/no), there are a number of scores published. Accuracy of these scores is borderline. Nevertheless, applying the Rapid Arterial Occlusion Evaluation score or a comparable score to recognize patients with LVO may help to speed up and triage prehospital pathways. Ultimately, the decision of which model to use in which stroke network will depend on local (e.g. geographical) characteristics.

Keywords

Stroke prehospital guidelines Swiss large vessel occlusion

Introduction and methodology

Randomized controlled studies of the last two decades have proven the impressive benefit of acute stroke therapy. This is true for both treatment in a stroke unit¹ and for revascularization procedures such as intravenous thrombolysis (IVT) and endovascular therapy (EVT) of proximal vessel occlusion (large vessel occlusion (LVO)).^2

–6

Actually, 70–80% of patients with acute ischemic stroke do not have LVO and are ideal candidates for IVT in the setting of a stroke unit or center. In contrast, the remaining 20–30% of patients with LVO benefit from additional or isolated EVT in a stroke center setting. In the latter category, triage in a non-center hospital can delay the time to open the occluded vessel by up to 100 min.^7,8 Most of the time is lost in the first care hospital for diagnostics and possibly IVT before transfer to the stroke center. For patients without LVO, however, the longer transport to a distant stroke center instead of a nearby stroke unit could delay systemic thrombolysis. Accordingly, both under- and over-triage to a stroke center may be associated with worse outcome.

This knowledge indicates that the emergency medical service plays a crucial role in the appropriate triage of stroke patients. On the one hand, transfer of all stroke patients to a stroke center should be avoided. On the other hand, under-triage to a stroke center of patients with potential indication for EVT should be minimized.

An additional challenge in the prehospital phase is patients with unknown symptom onset, including strokes occurring during sleep (“wake-up stroke” and “siesta stroke”). With advanced imaging available in all stroke units and stroke centers, some of the patients can go on to benefit from IVT up to about 9 h after symptoms onset or last proof of good health (LPGH).^9,10 For EVT in the context of LVO, the time window may be extended to at least 24 h after symptoms onset/LPGH.^11,12

The multidisciplinary working group for “Prehospital phase of stroke” of the Swiss Stroke Society prepared the present recommendations for the prehospital phase of stroke based on the current literature and Swiss conditions. The Swiss Society for Emergency and Rescue Medicine, the Swiss Neurological Society, the Swiss Association of Paramedics, and the Inter Association of Rescue Services coauthored and approved the recommendations. The overall aim is to organize clearly the prehospital phase for stroke in Switzerland so that (i) the vast majority (∼90%) of patients with an acute stroke are treated at a stroke unit/stroke center and (ii) transport to a stroke unit or stroke center happens without unnecessary time delays.

144 emergency calls center: Does the patient have a possible acute stroke?

When the emergency services first come into contact with the patient, the fundamental questions they need to resolve are, does the patient have a stroke at all and if yes, how acute is it. This should first be attempted by the 144 emergency calls center and then again by the paramedics on-site.

The 144 emergency call centers in all regions of Switzerland should have a standard checklist, which they can use to determine the level of emergency by checking a list of predefined stroke symptoms (or special signs). An example of such a checklist is shown in Table 1.

Table 1.

Checklist for emergency call centers (144) to determine the operational level “with special signal.”^a

Symptom onset or Last Seen Well Time < = 24 h	Yes/no
At least one of the following acute neurological deficit(s)
Paralysis of the face and/or arm and/or leg (usually unilateral)	Yes/no
Speech disorder	Yes/no
Visual impairment (loss of vision on one or both sides, double vision)	Yes/no
Acute severe dizziness with inability to walk	Yes/no

^a In cases of complete recovery of symptoms and suspicion of a transient ischemic attack, the patient is immediately taken to the nearest stroke unit or stroke center. A special signal is not mandatory.

Triage 1 on-site: Does the patient have an acute stroke or not?

At first contact with the patient, the paramedics (on-site) should decide quickly if the patient has a stroke or not. At this stage triage with a high sensitivity is important and the Cincinnati Prehospital Stroke Scale (CPSS), for example, is well suited for this purpose. However, this scale only measures motor skills and speech.

We propose for triage 1 therefore, scoring the “acute occurrence of a focal neurological deficit.” In addition to motor function and speech, we also include acute severe dizziness and acute visual impairment.

The emergency service staff should try to discover when the acute neurological deficit started. If the time of onset of symptoms is unclear, it should be taken as the time of last indication of a normal state of health (“Last Seen Well Time”). If the symptoms occurred in sleep, this is considered “acute.”

Recommendations for triage 1

– A patient with an acute focal neurological deficit, that is, with symptom onset within the last 24 h or on waking, should be taken to a hospital with a stroke unit or stroke center as soon as possible (with special signal). These capable hospital facilities have neurovascular multimodal imaging (vessel/mismatch) and IVT offered 24 h/7 days.

– Nearby hospitals without these infrastructures should be bypassed unless cardiorespiratory instability prevents further travel.

– In cases of complete disappearance of all symptoms and clinical signs (transient ischemic attack) or in cases of a clear preexisting severe disability, transport to a stroke unit/stroke center can go ahead in the absence of a special signal.

– Difficult situations for triage decisions for the emergency service can be discussed with stroke specialists at the stroke center (SC)/stoke unit (SU).

Triage 2 on-site: Does the patient have a LVO?

In principle, the more severe the stroke, the more likely is an LVO. Since the paramedics usually treat a stroke patient without medical supervision on scene, a paramedic must be able to carry out triage 2 reliably and quickly. The prehospital LVO triage tool should have sufficient sensitivity/specificity to keep the number of false triages as low as possible. Several scores are under development to determine LVO yes/no as accurately as possible in the prehospital phase. The progress and performance of these scores are discussed in the Online Appendix 1. Although evidence is still lacking concerning triage benefit and the “best” triage score, this working group favors triage using the Rapid Arterial Occlusion Evaluation (RACE) score because of its good discriminatory power and its validation by paramedics already in the prehospital setting.^13

–16 Other tests such as gaze-face-arm-speech-time (G-FAST) may also be used as they are faster and easier, but their discriminatory power seems less good (see Online Annex 1). Of note, it has been described that thrombectomy is also effective for LVO patients with low symptomatology (National Institutes of Health Stroke Scale (NIHSS) ≤ 5) (odds ratio [OR] for 90-day modified Ranking Scale [mRS] 0–2 for all patients: 2.35 versus for patients with low symptomatology: 4.37).^4,17

If an LVO is likely based on the chosen score, there are different prehospital concepts which will briefly be discussed below.

Drip and Ship concept

A patient with a suspected stroke would be taken to the nearest stroke unit by ambulance if it were closer than the stroke center. If LVO is diagnosed in the unit by imaging (computed tomography [CT]/MRI), the patient is immediately transferred to the nearest stroke center (by ground or air) with ongoing systemic thrombolysis. The stroke center would be alerted, the images transmitted electronically, and the patient transferred directly on arrival to the angio-suite without repeating the diagnosis, provided there is no clinical worsening.

Advantages of this concept are:

– Short time to systemic thrombolysis (onset-to-needle) with possible revascularization by IVT alone.

– A higher thrombolysis rate.

– Triage LVO versus no LVO very good as based on imaging.

The disadvantages:

– The potential loss of time (onset-to-groin puncture) in patients with LVO due to the detour via a stroke unit and organization of further transport.

The following critical time variables should be met:

– The time from entry into the first stroke unit to further transport (door-in-to-door-out (DIDO) time) must be kept as short as possible (target: door-to-needle: 30 min, turnaround 20 min = DIDO target < 50 min; max 60 min).

– In addition, appropriate organization of the stroke center is necessary to keep the “door-to-groin-puncture time” as low as possible (target: 30 min; max. 60 min).¹⁸

Mothership concept

The core of this concept is that the emergency service drives (or flies) the patient directly to a stroke center if LVO is suspected, even if there is a stroke unit nearby. In the stroke center, the patient is usually thrombolysed after diagnosis and then transferred to the angio-suite for EVT.

Advantage of this concept:

– The likely time saving of onset-to-groin-puncture time compared to patients who are first screened and (if necessary) thrombolysed in a stroke unit.

The disadvantage:

– The possible time delay of systemic thrombolysis.

The data regarding the abovementioned concepts are still insufficient: Two nonrandomized prospective studies showed worse functional outcome for Drip and Ship compared to the Mothership concept.^19,20 On the other hand, two retrospective studies did not find a difference in clinical outcome between the two prehospital concepts.^21,22 A randomized study comparing the Drip and Ship with the Mothership concept for suspected LVO strokes occurring remotely from and endovascular center showed similar 3 months functional outcomes in both arms.²³

Drip and Drive concept

In this concept, a stroke patient living closer to a stroke unit than to a stroke center is examined in the former for LVO. If there is an indication for EVT, a neuroradiologist drives from a stroke center to the stroke unit to perform EVT there rather than transporting the patient.

Advantage of this concept:

– A small study measured average time intervals and saw that the time to recanalization was about 2 h shorter than the above Drip and Ship concept.⁷

Disadvantage:

– The data regarding this concept are not yet convincing and depend strongly on the local situation.

– The major problems of the Drip and Drive concept are the human resources certainly as well as the availability of trained personnel on-site.

At present, we consider this solution of little use in Switzerland. Nevertheless, this study does indicate that the Drip and Ship concept results in significant time loss.

Mobile thrombolysis on-site

Here, an ambulance incorporating acute imaging (CT) and IVT procedure drives to the patient with a suspected stroke.

Advantage:

This allows rapid IVT to be performed on-site if necessary, screening the patient for LVO and direct transport to a stroke center.²⁴

Disadvantage:

This concept requires significant investments in money and human resources, and seems to be particularly useful for densely populated areas with about a million persons or more.

The authors agree that mobile thrombolysis is of unlikely benefit for Switzerland because of relatively small cities and the high density of stroke units and stroke centers and the geographical conditions.

Recommendations for triage 2: Does the patient have a LVO?

A precise statement on whether Drip and Ship or Mothership should be favored is not possible at present. Preliminary results of a large randomized study in Catalonia indicate that both models lead to similar clinical outcomes within a well-organized stroke care system.²³ Some studies have used models to calculate which concept should be favored over another and when.^18,25 The results depend highly on the distance between the event location, stroke unit, and stroke center but also on the capabilities of the particular stroke unit and stroke center. In principle, the current data allow us to make the following assertions (see Table 2):

– Patients should be transferred directly to the stroke center if the distance from the event to the stroke center is <20 min.

– If the distance to a stroke unit is shorter than to the stroke center, the Drip and Ship concept would make sense with a transport time of >20 min between the two institutions.

– Avoid driving away for more than 10 min from the stroke center toward a stroke unit, as this route would have to be taken again to the stroke center if needed (Figure 1).

With the Drip and Ship concept

– Critical time intervals should be measured and analyzed: DIDO time of the stroke unit: target <50 min; max. 60 min.

– The incoming emergency team should remain on-site until referral (or not) to an SC.

– Imaging should not be repeated at the SC, except in exceptional and justified cases.

– In the SC, the goal is to achieve a “door-to-groin-puncture time” of 30 min (max. 60 min).

Mothership concept

– Door-to-groin puncture of 60 min (max. 90 min) can be achieved.

In the event that there is no prehospital triage for LVO, the Drip and Ship concept critical time-criteria apply (Figure 2).

Table 2.

Advantages/disadvantages of different prehospital models.

	Advantages	Disadvantages
Drip and Ship	– Prompt IVT – Better patient selection – Higher thrombolysis rate – Prompt acute treatment of cerebral hemorrhages	– Delay to reperfusion in LVO
Mothership	– Earlier start with EVT – Shorter time to recanalization – Higher percentage of patients treated with EVT	– Delay or miss systemic thrombolysis – If the EVT is not successful, no, or delayed IVT
Drip and Drive	– Rapid start to EVT	– Need to keep personnel resource available on-site – Quality of treatment—aftercare – Neuroradiologist missing in the center
Mobile thrombolysis	– On-site diagnostics and therapy – Fastest onset-to-treatment time	– Given the density of SCs and SUs in Switzerland, it makes little sense

IVT: intravenous thrombolysis; EVT: endovascular therapy; SU: stroke unit, SC: stroke center.

Figure 1.

Prehospital patient flow in cases of suspected stroke at initial on-site evaluation, including triage for LVO. LPGH: last proof of good health; RACE: Rapid Arterial Occlusion Evaluation or comparable score; LVO: large vessel occlusion; SU: stroke unit; SC: stroke center; DIDO = door-in-to-door-out time.

Figure 2.

Prehospital patient flow in cases of suspected stroke at initial on-site evaluation, without triage for LVO. LVO: large vessel occlusion; LPGH: last proof of good health; SU: stroke unit; SC: stroke center.

Prehospital concepts for specific time windows

If an acute neurological deficit occurs within 24 h, the patient must be triaged for transport to the stroke unit or stroke center. A fast and problem-oriented workup with targeted medication or interventional secondary prophylaxis in a stroke unit/stroke center reduces the probability of long-term disability even without acute revascularization treatment.¹

Time window <8 h after symptom onset/LPGH or since waking up (wake-up stroke)

In this situation, the nearest thrombolysis-capable facility (stroke unit or stroke center) should be reached with special signal.

If the LVO score is positive (e.g. RACE ≥ 5), the above recommendations for triage 2 should be consulted for choosing a stroke unit or stroke center.

Time window 8–24 h after symptom onset/LPGH or since waking up (wake-up stroke)

If the LVO score is positive (e.g. RACE ≥ 5), patients in this time window should be taken to the nearest stroke center (“Mothership”) with special signal. If the LVO score is low (e.g. RACE < 5), patients are transported without special signal to the nearest stroke unit or center for clarification and treatment.

If there is no triage for LVO, transfer should be performed with special signal to the nearest stroke unit/stroke center. The time indications for onwards transport to the SC apply as to the Drip and Ship concept.

Mode of transport and general measures in the prehospital phase

If a stroke is suspected from an acute neurological deficit, the general Swiss emergency number (144) should be called without delay.

If the estimated time by ground transport from the patient’s location to the target hospital is more than 45–60 min, air transport may be faster. The choice of the most appropriate means of transport is the responsibility of the 144 emergency control center and depends on the weather conditions, traffic density, landing possibilities, and availability of transport.

If the patient goes by air (helicopter), the patient should be taken directly to the nearest stroke center, regardless of the severity of the symptoms (RACE score). A stopover in a stroke unit can lead to long delays for LVO, which is counterproductive to the time gained by flying directly to a stroke center.

To improve information flow, the rescue service/air rescue should provide practical preliminary information to the facility, where the patient is being transferred (stroke unit and stroke center) in the form of a “stroke code call.”

This should accelerate onset-to-treatment time, internal “door-to-needle time,” “door-to-groin-puncture time,” and result in a higher thrombolysis rate (Table 3).

Table 3.

Recommended information to forward as “Stroke Code Call” by the rescue service (with or without suspected LVO).

Information	Comment
Name, first name, sex, and date of birth
Preexisting severe disability	Yes/no (Walker? Dementia? Need of assistance?)
Symptom onset	<24 h?
- Known	Date and time
- Unknown/wake up	Last proof of good health
RACE score	Score
Anticoagulation	Phenprocoumon, apixaban, rivaroxaban, edoxaban, and dabigatran
Platelet inhibitors	Aspirin, clopidogrel, ticagrelor, and prasugrel
Contraindication for MRI^a	Claustrophobia, pacemaker, and metal
Next of kin contact	Name and phone number
Estimated time of arrival	Time and mode of transportation

LVO: large vessel occlusion; RACE: Rapid Arterial Occlusion Evaluation.

^a For target hospitals using MRI for acute imaging.

The following measures should be taken by the paramedics/air rescue team in cases of suspected stroke on-site in the shortest possible time, especially if symptom onset is less than 24 h:

– Secure the respiratory tract and circulation.

– Do not give antithrombotics.

– Blood pressure reduction only if systolic pressure over 220 mmHg or organ manifestations according to internal algorithms.

– Advance information to stroke unit/stroke center (Stroke Code Call).

– Travel with special signal for ground transport.

Stroke care in geographically remote regions

Small remote hospitals with specific expertise in acute stroke care

On the one hand, the basic requirement is to move patients as quickly as possible to the nearest capable hospital for acute stroke treatment (i.e. a stroke unit and stroke center). On the other hand, small hospitals in remote regions cannot reach the minimum mandatory number of cases for certification as a stroke unit (minimum of 200 stroke patients and 20 systemic thrombolyses per year). Due to the large distance of remote hospitals from nearest stroke unit/stroke centers (>60 min) and ensuing time delay to specific start of therapy, there is a need for small hospitals to be able to at least start acute stroke treatment including systemic thrombolysis. In principle, acute processes, medical stroke expertise, and infrastructure (CT and laboratory) should be available in these hospitals as in certified stroke units, so they can perform systemic thrombolysis and triage (LVO yes/no).

Virtual stroke expertise (telemedicine) is well suited for these hospitals, as a neurological presence on-site (24/7) cannot usually be guaranteed for hospitals of this size (Table 4).

Table 4.

Criteria for specific expertise in stroke care in geographically remote hospitals.²⁶

Criterion	Quality indicator
Presence of stroke expertise	Within 30 min (physically or virtually via telemedicine)
Protocols for acute stroke care	Regularly reevaluated
Emergency room	Standard operating procedures for stroke
Lab/ECG	24/7 and available within 45 min
Brain-CT (including CT-A, CT-P (or MRI))	Available 24/7
Stroke unit	Not required
Systemic thrombolyses	Within 60 min (door-to-needle) possible
Transfer to stroke unit/stroke center	According to Drip and Ship criteria
Systematic documentation quality indicators	Number of stroke patients, number of systemic thrombolyses (door-to-needle times), and transfers to SC/SUs

ECG: electrocardiogram; SU: stroke unit, SC: stroke center.

After starting acute care in such a hospital, the patient should then be transferred to a stroke unit or stroke center to benefit from specialized treatment (number needed to treat [NNT] of stroke unit 6–8 regarding outcome in independence) in these more capable facilities.¹

Conclusions

Due to the increasing diversification of treatment methods for stroke patients, the organization of the prehospital phase needs to be adapted accordingly. These guidelines describe a prehospital organization that creates efficacious access for all stroke patients to specialized systems (stroke unit/stroke center) allowing for appropriate and rapid treatment. The working group does not provide a conclusive recommendation on the use of the RACE score (LVO yes/no): Ultimately, the decision of which model to use will depend on local (e.g. geographical) characteristics. However, it is important that the critical time intervals of the chosen model are taken into account, measured, and evaluated.

Supplemental material

Supplemental Material, sj-pdf-1-ctn-10.1177_2514183X21999230 - Swiss guidelines for the prehospital phase in suspected acute stroke

Supplemental Material, sj-pdf-1-ctn-10.1177_2514183X21999230 for Swiss guidelines for the prehospital phase in suspected acute stroke by Georg Kägi, David Schurter, Julien Niederhäuser, Gian Marco De Marchis, Stefan Engelter, Patrick Arni, Olivier Nyenhuis, Paul Imboden, Christophe Bonvin, Andreas Luft, Susanne Renaud, Krassen Nedeltchev, Emmanuel Carrera, Carlo Cereda, Urs Fischer, Marcel Arnold and Patrik Michel in Clinical and Translational Neuroscience

Footnotes

Authors’ note

Swiss Stroke Society: The guidelines were co-authored and approved by the Swiss Society for Emergency and Rescue Medicine, the Swiss Neurological Society, the Swiss Association of Paramedics, and the Inter Association of Rescue Services.

Acknowledgment

The authors thank Mrs Melanie Price Hirt, PhD, for English language correction and editing of the text translated by the first author.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was financially supported by the Swiss Stroke Society.

ORCID iD

Christophe Bonvin

Patrik Michel

Supplemental material

Supplemental material for this article is available online.

References

Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2013; 2013(9): Cd000197.

Berkhemer

Fransen

Beumer

, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372(1): 11–20.

Campbell

Mitchell

Kleinig

, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015; 372(11): 1009–1018.

Goyal

Menon

van Zwam

, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387(10029): 1723–1731.

Jovin

Chamorro

Cobo

, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372(24): 2296–2306.

Michel

PDM

Mordasini

Schubert

, et al. Acute revascularisation in ischemic stroke: updated Swiss guidelines. Clin Transl Neurosci 2020; submitted.

Brekenfeld

Goebell

Schmidt

, et al. ‘Drip-and-drive’: shipping the neurointerventionalist to provide mechanical thrombectomy in primary stroke centers. J Neurointerv Surg 2018; 10(10): 932–936.

Goyal

Jadhav

Bonafe

, et al. Analysis of workflow and time to treatment and the effects on outcome in endovascular treatment of acute ischemic stroke: results from the SWIFT PRIME randomized controlled trial. Radiology 2016; 279(3): 888–897.

Campbell

Parsons

, et al. Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke. N Engl J Med 2019; 380(19): 1795–1803.

10.

Thomalla

Simonsen

Boutitie

, et al. MRI-guided thrombolysis for stroke with unknown time of onset. N Engl J Med 2018; 379(7): 611–622.

11.

Albers

Marks

Kemp

, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018; 378(8): 708–718.

12.

Nogueira

Jadhav

Haussen

, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 2018; 378(1): 11–21.

13.

Perez de la Ossa

Carrera

Gorchs

, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke 2014; 45(1): 87–91.

14.

Jumaa

Castonguay

Salahuddin

, et al. Long-term implementation of a prehospital severity scale for EMS triage of acute stroke: a real-world experience. J Neurointerv Surg 2020; 12(1): 19–24.

15.

Hackett

Rahangdale

Protetch

, et al. Rapid arterial occlusion evaluation scale agreement between emergency medical services technicians and neurologists. J Stroke Cerebrovasc Dis 2020; 29(6): 104745.

16.

Carrera

Gorchs

Querol

, et al. Revalidation of the RACE scale after its regional implementation in Catalonia: a triage tool for large vessel occlusion. J Neurointerv Surg 2019; 11(8): 751–756.

17.

Griessenauer

Medin

Maingard

, et al. Endovascular mechanical thrombectomy in large-vessel occlusion ischemic stroke presenting with low national institutes of health stroke scale: systematic review and meta-analysis. World Neurosurg 2018; 110: 263–269.

18.

Holodinsky

Williamson

Demchuk

, et al. Modeling stroke patient transport for all patients with suspected large-vessel occlusion. JAMA Neurol 2018; 75(12): 1477–1486.

19.

Froehler

Saver

Zaidat

, et al. Interhospital transfer before thrombectomy is associated with delayed treatment and worse outcome in the STRATIS registry (systematic evaluation of patients treated with neurothrombectomy devices for acute ischemic stroke). Circulation 2017; 136(24): 2311–2321.

20.

Mohamad

Hastrup

Rasmussen

, et al. Bypassing primary stroke centre reduces delay and improves outcomes for patients with large vessel occlusion. Eur Stroke J 2016; 1(2): 85–92.

21.

Gerschenfeld

Muresan

Blanc

, et al. Two paradigms for endovascular thrombectomy after intravenous thrombolysis for acute ischemic stroke. JAMA Neurol 2017; 74(5): 549–556.

22.

Park

Yoon

Kim

, et al. Drip, ship, and on-demand endovascular therapy for acute ischemic stroke. PLoS One 2016; 11(3): e0150668.

23.

Pérez de la Ossa

Ribo

. Transfer to closest stroke center vs. direct transfer to endovascular stroke center of acute stroke patients with suspected large vessel occlusion in Catalonia (RACECAT): final results. In: ESO-WSO Virtual Conference 2020 (abstract).

24.

Walter

Ragoschke-Schumm

Lesmeister

, et al. Mobile stroke unit use for prehospital stroke treatment—an update. Der Radiologe 2018; 58(Suppl 1): 24–28.

25.

Holodinsky

Williamson

Kamal

, et al. Drip and ship versus direct to comprehensive stroke center: conditional probability modeling. Stroke 2017; 48(1): 233–238.

26.

Alberts

Wechsler

Jensen

, et al. Formation and function of acute stroke-ready hospitals within a stroke system of care recommendations from the brain attack coalition. Stroke 2013; 44(12): 3382–3393.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.17 MB