on behalf of the catalan stroke code and reperfusion consortium (cat-scr) Ischemic Stroke To cite: carrera D, gorchs M, Querol M, et al. J NeuroIntervent Surg epub ahead of print: [please include Day Month Year].AbSTrACT background and purpose Our aim was to revalidate the race scale, a prehospital tool that aims to identify patients with large vessel occlusion (lVO), after its region-wide implementation in catalonia, and to analyze geographical differences in access to endovascular treatment (eVT). Methods We used data from the prospective cicaT registry (stroke code catalan registry) that includes all stroke code activations. The race score evaluated by emergency medical services, time metrics, final diagnosis, presence of lVO, and type of revascularization treatment were registered. sensitivity, specificity, and area under the curve (aUc) for the race cut-off value ≥5 for identification of both lVO and eligibility for eVT were calculated. We compared the rate of eVT and time to eVT of patients transferred from referral centers compared with those directly presenting to comprehensive stroke centers (csc). results The race scale was evaluated in the field in 1822 patients, showing a strong correlation with the subsequent in-hospital evaluation of the national institute of health stroke scale evaluated at hospital (r=0.74, P<0.001). a race score ≥5 detected lVO with a sensitivity 0.79 and specificity 0.62 (aUc 0.76). Patients with race ≥5 harbored a lVO and received eVT more frequently than race <5 patients (lVO 35% vs 6%; eVT 20% vs 6%; all P<0.001). Direct admission at a csc was independently associated with higher odds of receiving eVT compared with admission at a referral center (Or 2.40; 95% ci 1.66 to 3.46), and symtoms onset to groin puncture was 133 min shorter. Conclusions This large validation study confirms race accuracy to identify stroke patients eligible for eVT, and provides evidence of geographical imbalances in the access to eVT to the detriment of patients located in remote areas. MeThodS Study setting

Less than half of our patients participated in the telemedicine study. However, those who completed the study had confidence in the system, a high degree of satisfaction with the tools and positive behavioral changes.

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Purpose of the ReviewThis article reviews prehospital organization in the treatment of acute stroke. Rapid access to an endovascular therapy (EVT) capable center and prehospital assessment of large vessel occlusion (LVO) are 2 important challenges in acute stroke therapy. This article emphasizes the use of transfer protocols to assure the prompt access of patients with an LVO to a comprehensive stroke center where EVT can be offered. Available prehospital clinical tools and novel technologies to identify LVO are also discussed. Moreover, different routing paradigms like first attention at a local stroke center (“drip and ship”), direct transfer of the patient to an endovascular center (“mothership”), transfer of the neurointerventional team to a local primary center (“drip and drive”), mobile stroke units, and prehospital management communication tools all aimed to improve connection and coordination between care levels are reviewed.Recent FindingsLocal observational data and mathematical models suggest that implementing triage tools and bypass protocols may be an efficient solution. Ongoing randomized clinical trials comparing drip and ship vs mothership will elucidate which is the more effective routing protocol.SummaryPrehospital organization is critical in realizing maximum benefit from available therapies in acute stroke. The optimal transfer protocols directed to accelerate EVT are under study, and more accurate prehospital triage tools are needed. To improve care in the prehospital setting, efficient tools based on patient factors, local geography, and hospital capability are needed. These tools would optimally lead to individualized real-time decision-making.

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