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Stroke-CVA-TIA

Date Last Search Run: Mar 03, 2025
Table last updated: Jan 28, 2025
Data last added: Jan 28, 2025

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)  
2 (fair evidence exists)  
3 (weak evidence exists)    


Interventions

12-Lead ECG
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Cardiac Arrhythmia Patient Bobinger T., Kallmünzer B., Kopp M., Kurka N., Arnold M., Heider S., et al. Diagnostic value of prehospital ECG in acute stroke patients. Neurology 2017;88(20):1894-8. Medline
III Supportive (Green) Prevalence of abnormalities and effect on prognosis and outcome Process Munro SF., Cooke D., Kiln-Barfoot V., Quinn T. The use and impact of 12-lead electrocardiograms in acute stroke patients: A systematic review. European heart journal Acute cardiovascular care 2018;7(3):257-63. Medline

ASA/Aspirin
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Death from any cause during the 4-week treatment period Patient In-Patient CAST (Chinese Acute Stroke Trial) Collaborative Group: CAST. Randomised placebo-controlled trial of early aspirin use in 20 000 patients with acute ischaemic stroke. The Lancet 1997; 349:1641-9. Medline
I Neutral (Yellow) Death at 14days Patient ED-MD International Stroke Trial Collaborative Group. The International Stroke Trial (IST): A randomised trial of aspirin, subcutaneous heparin, both, or neither among 19 435 patients with acute ischaemic stroke. The Lancet 1997; 349:1569-81. Medline
III Supportive (Green) Modified Rankin Scale score of 1 or lower on discharge Patient ED-MD Su TH., Chan YL., Lee JD., Lee M., Lin LC., Wen YW., et al. To Load or Not to Load? Aspirin Loading in Acute Ischemic Stroke: A Study of Clinical Outcomes. J Stroke Cerebrovasc Dis 2016; 25(10) 2439-47. Medline
III Neutral (Yellow) Morbidity Patient PH-Paramedic & MD Levri JM, Ocon A, Schunk P, Cunningham CW. Use of Acetylsalicylic Acid in the Prehospital Setting for Suspected Acute Ischemic Stroke. J of Special Operations Medicine 2017; 17(3):21-3. Medline

Blood Glucose Control
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) BGL reduction Process PH-Paramedic Nurmi J., Lindsberg PJ., Happola O., Klemetti E., Westerbacka J., Castren M. Strict glucose control after acute stroke can be provided in the prehospital setting. Acad Emerg Med 2011; 18(4):436-9. Medline
III Neutral (Yellow) Incidence of hypoglycemia Patient PH-Paramedic Abaranell NR. Is prehospital blood glucose measurement necessary in suspected CVA patients? Am J Emerg Med 2005; 23:823-7. Medline

Bypass to EVT capable centre
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Functional improvement at 90 days Patient PH-Paramedic Behrndtz A, Blauenfeldt RA, Johnsen SP, Valentin JB, et al. Transport Strategy in Patients With Suspected Acute Large Vessel Occlusion Stroke: TRIAGE-STROKE, a Randomized Clinical Trial. Stroke October 2023; 54(11):2714-23. Medline
I Neutral (Yellow) Disability at 90 days Patient PH-Paramedic Pérez de la Ossa N, Abilleira S, Jovin TG, García-Tornel Á, Jimenez X, Urra X, et al. Effect of Direct Transportation to Thrombectomy-Capable Center vs Local Stroke Center on Neurological Outcomes in Patients With Suspected Large-Vessel Occlusion Stroke in Nonurban Areas: The RACECAT Randomized Clinical Trial. JAMA 2022; 327(18):1782–94. Medline
I Opposes (Red) Functional independence at 90 days for pts with hemorrhagic stroke Patient PH-Paramedic Ramos-Pachón A, Rodríguez-Luna D, Martí-Fàbregas J, et al. Effect of Bypassing the Closest Stroke Center in Patients with Intracerebral Hemorrhage: A Secondary Analysis of the RACECAT Randomized Clinical Trial. JAMA Neurol August 2023. Medline
II Supportive (Green) Treatment delays Process PH-Paramedic Duvekot MHC, Garcia BL, Dekker L, Nguyen TM, et al. Prehospital stroke triage: a modeling study on the impact of triage tools in different regions. Prehosp Emerg Care 2023; 1-15. Medline
II Supportive (Green) Rates fo EVT Process PH-Paramedic Kass-Hout T, Lee J, Tataris K, Richards CT, Markul E, Weber J, et al. Prehospital Comprehensive Stroke Center vs Primary Stroke Center Triage in Patients With Suspected Large Vessel Occlusion Stroke. JAMA Neurol 2021. Medline
II Supportive (Green) Shift in modified Rnkin Score Patient PH-Paramedic Keselman B, Berglund A, Ahmed N, Bottai M, M von E, Holmin S, et al. The Stockholm Stroke Triage Project: Outcomes of Endovascular Thrombectomy Before and After Triage Implementation. Stroke 2022; 53(2):473–81. Medline
II Supportive (Green) Symptom onset-to-ED time <2 hrs Process PH-Paramedic Park HA., Ahn KO., Shin SD., Cha WC., Ro YS. The Effect of Emergency Medical Service Use and Inter-hospital Transfer on Prehospital Delay among Ischemic Stroke Patients: A Multicenter Observational Study. J Korean Med Sci 2016; 31(1):139-46. Medline
II Supportive (Green) Mortality Patient PH-Paramedic Rinaldo L, Brinjikji W, McCutcheon BA, Bydon M, Cloft H, Kallmes DF, et al. Hospital transfer associated with increased mortality after endovascular revascularization for acute ischemic stroke. J of Neurointerventional Surgery 2017; 9(12):1166-72. Medline
II Supportive (Green) Proportion of pts cared for at a stroke centre Process PH-Paramedic Sanossian N., Liebeskind DS., Eckstein M., Starkman S., Stratton S., Pratt FD., et al. Routing Ambulances to Designated Centers Increases Access to Stroke Center Care and Enrollment in Prehospital Research. Stroke 2015; 46(10):2886-90. Medline

Direct to CT
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Door-to-orderd CT time Process PH-Paramedic Cone DC, Cooley C, Ferguson J, Harrell AJ, Luk JH, Martin-Gill C, et al. Observational Multicenter Study of a Direct-to-CT Protocol for EMS-transported Patients with Suspected Stroke. PEC 2017; 22(1):1-6. Medline
II Supportive (Green) Feasibilty Process PH-Paramedic Glober N, Supples M, Persaud S, Kim D, Liao M, Glidden M, et al. A novel emergency medical services protocol to improve treatment time for large vessel occlusion strokes. PLoS One 2022; 17(2):e0264539. Medline
II Neutral (Yellow) Door-to-needle time Process PH-Paramedic Sloane B, Bosson N, Sanossian N, Saver JL, Perez L, Gausche-Hill M. Is Door-to-Needle Time Reduced for Emergency Medical Services Transported Stroke Patients Routed Directly to the Computed Tomography Scanner on Emergency Department Arrival? J of Stroke and Cerebrovascular Diseases 2019:104477. Medline

Drip and ship
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Safety and time course Process ED-MD Ishihara H, Oka F, Oku T, Shinoyama M, Suehiro E, Sugimoto K, et al. Safety and Time Course of Drip-and-Ship in Treatment of Acute Ischemic Stroke. J of Stroke and Cerebrovascular Diseases 2017; 26(11):2477-81. Medline
II Neutral (Yellow) Time to Tx Process PH-Paramedic Duvekot MHC, Garcia BL, Dekker L, Nguyen TM, et al. Prehospital stroke triage: a modeling study on the impact of triage tools in different regions. Prehosp Emerg Care 2023; 1-15. Medline
III Supportive (Green) Identifying factors that delay EVT in stroke patients Process Other Hädrich K, Krukowski P, Barlinn J, Gawlitza M, Gerber JC, Puetz V, et al. Optimizing Time Management for Drip-and-Ship Stroke Patients Qualifying for Endovascular Therapy-A Single-Network Study. Healthc 2022;10(8). Medline

HEMS
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Mortality and neurological outcomes Patient PH-Paramedic & CCT Florez-Perdomo WA, Garcia-Ballestas E, Konar SK, Ramos-Gomez L, Al-Mufti F, et al. Effect of Helicopter Transportation of Acute Ischemic Stroke Patients on Mortality and Functional Outcomes: A Systematic Review and Meta-Analysis. Air Med J 2022; 41(5):476–83. Medline
II Supportive (Green) Thrombolytic Rate Process PH-Paramedic Reiner-Deitemyer V., Teuschl Y., Matz K., et al. Helicopter transport of stroke patients and its influence on thrombolysis rates: Data from the austrian stroke unit registry. Stroke 2011; 42(5):1295-300. Medline
II Supportive (Green) Access to Stroke Center Process PH-Paramedic & CCT Silliman SL., Quinn B., Huggett V., Merino JG. Use of a field-to-stroke center helicopter transport program to extend thrombolytic therapy to rural patients. Stroke 2003; 34:729-33. Medline
II Supportive (Green) out of hospital time Process ED-Paramedic & MD Stowell A, Bobbia X, Cheret J, Genre Grandpierre R, Moreau A, Pommet S, et al. Out-of-hospital Times Using Helicopters Versus Ground Services for Emergency Patients. Air Med J 2019; 38(2):100-5. Medline
II Supportive (Green) Transport time Process PH-Paramedic Vuorinen P, Setälä P, Ollikainen J, Hoppu S. A hybrid strategy using an ambulance and a helicopter to convey thrombectomy candidates to definite care: a prospective observational study. BMC Emerg Med January 2024; 24(1):17. Medline
II Neutral (Yellow) Accurate triage Process In-Patient Adcock AK, Minardi J, Findley S, Daniels D, Large M, Power M. Value Utilization of Emerg Medical Services Air Transport in Acute Ischemic Stroke. J Emerg Med 2020. Medline
II Neutral (Yellow) Transfer velocity Process PH-Paramedic Kunte SA, Anderson D, Brown-Espaillat K, Froehler MT. Total Transfer Time for Ground vs. Air Transport for Interhospital and Scene Transfers of Acute Stroke Patients. J Stroke Cerebrovasc Dis 2021; 30(6):105704. Medline
II Neutral (Yellow) Time from transfer request to arrival at CCRU Patient PH-Paramedic & CCT Tran QK, Ternovskaia A, Chen N, et al. Air or Ground Transport to the Critical Care Resuscitation Unit: Does It Really Matter? Air Med J. July 2024; 43(4):295-302. Medline
III Supportive (Green) Feasibility Process PH-Paramedic & CCT Conroy MB., Rodriguez SU., Kimmel SE., Kasner SE. Helicopter transfer offers potential benefit to stroke patients. Stroke 1999; 30:2580-4. Medline
III Neutral (Yellow) Mortality rate. Patient PH-Paramedic & CCT Tal S, Mor S. The impact of helicopter emergency medical service on acute ischemic stroke patients: A systematic review. Am J Emerg Med 2021; 42:178-87. Medline

Hypertension Control
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Scalar functional outcome of stroke mimics. Patient PH-Paramedic Tunnage B, Woodhouse LJ, Dixon M, Anderson C, Ankolekar S, et al. Pre-hospital transdermal glyceryl trinitrate in patients with stroke mimics: data from the RIGHT-2 randomised-controlled ambulance trial. BMC Emerg Med 2022; 22(1):2. Medline
I Neutral (Yellow) Disability Patient PH-Paramedic Appleton JP, Woodhouse LJ, Anderson CS, et al. Prehospital transdermal glyceryl trinitrate for ultra-acute ischaemic stroke: data from the RIGHT-2 randomised sham-controlled ambulance trial. Stroke Vasc Neurol 2023. Medline
I Neutral (Yellow) Functional status. Patient PH-Paramedic Li G, Lin Y, Yang J, et al. Intensive Ambulance-Delivered Blood-Pressure Reduction in Hyperacute Stroke. N Engl J Med May 2024; 390(20):1862-72. Medline
I Neutral (Yellow) Mortality Patient PH-Paramedic Lim BL, Lee WF, Ng WM, Situ W, Loo KV, Man Goh CJ, Chan WL. Benefits and safety of transdermal glyceryl trinitrate in acute stroke: A systematic review and meta-analysis of randomized trials. Acad Emerg Med 2022; 29(6):772–88. Medline
I Opposes (Red) Functional outcome at 90 days. Patient PH-Paramedic van den Berg SA, Uniken Venema SM, Reinink H, Hofmeijer J, Schonewille WJ, et al. Prehospital transdermal glyceryl trinitrate in patients with presumed acute stroke (MR ASAP): an ambulance-based, multicentre, randomised, open-label, blinded endpoint, phase 3 trial. Lancet Neurol 2022; 21(11):971–81. Medline
II Neutral (Yellow) modified Ranking scale Patient PH-Paramedic Bath PM, Woodhouse LJ, Krishnan K, Appleton JP, Anderson CS, Berge E, et al. Prehospital Transdermal Glyceryl Trinitrate for Ultra-Acute Intracerebral Hemorrhage: Data From the RIGHT-2 Trial. Stroke 2019; 50(11):3064-71. Medline
II Neutral (Yellow) Functional recovery at day 7 Patient ED-MD Chamorro A., Vila N., Ascaso C., et al. Blood pressure and functional recovery in acute ischemic stroke. Stroke 1998; 29:1850-3. Medline
III Supportive (Green) Systolic BP Patient PH-Paramedic Ankolekar S., Fuller M., Cross I., Renton C., Cox P., Sprigg N., Bath PM. Feasibility of an ambulance-based stroke trial, and safety of glyceryl trinitrate in ultra-acute stroke: The rapid intervention with glyceryl trinitrate in hypertensive stroke trial (RIGHT, ISRCTN66434824). Stroke; a Journal of Cerebral Circulation 2013; 44(11):3120-8. Medline
III Supportive (Green) Feasibility Process PH-Paramedic Shaw L., Price C., McLure S., et al. Paramedic initiated lisinopril for acute stroke treatment (PIL-FAST): Results from the pilot randomised controlled trial. Emerg Med J 2014; 31(12):994-999. Medline
III Neutral (Yellow) Mortality rates, unfavorable outcomes, hematoma expansion, neurologic deterioration, severe hypotension, rate of renal adverse event Patient ED-MD Gong S, Lin C, Zhang D, Kong X, Chen J, Wang C, et al. Effects of Intensive Blood Pressure Reduction on Acute Intracerebral Hemorrhage: A Systematic Review and Meta-analysis. Scientific reports 2017; 7(1):10694. Medline
X Not Yet Graded (White) - Appleton JP, Dixon M, Woodhouse LJ, Anderson CS, et al. Pre-hospital transdermal glyceryl trinitrate for transient ischaemic attack: Data from the RIGHT-2 trial. Eur J Neurol 2024; 31(12):e16502. Medline
X Not Yet Graded (White) - Ibrahim AA, Khlidj Y, Amin AM, Rakab MS, et al. Pre-hospital blood pressure lowering in presumed hyperacute stroke: A systematic review and meta-analysis of randomized controlled trials. J Stroke Cerebrovasc Dis Nov 2024; 34(2):108158. Medline
X Not Yet Graded (White) - Yuan X, Gan Q, Zhang Y, Wang P, Chong W, Hai Y, Fang F. Prehospital Blood Pressure Lowering in Patients with Ischemic Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Int J Stroke 2024; 17474930241298444. Medline

Hypotension Control
Level Direction Primary Outcome Patient/Process Setting Reference

Magnesium
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Brain under protection time Process PH-Paramedic Matossian V, Starkman S, Sanossian N, Stratton S, Eckstein M, Conwit R, et al. Quantifying the amount of greater brain ischemia protection time with pre-hospital vs. in-hospital neuroprotective agent start. Front Neurol 2022; 13:990339. Medline
I Neutral (Yellow) Feasibility Process PH-Paramedic Saver JL., Kidwell C., Eckstein M., Starkman S. Prehospital neuroprotective therapy for acute stroke. Field administration of magnesium. Stroke 2004; 35:e10-8. Medline
I Neutral (Yellow) Target serum level Patient PH-Paramedic Shkirkova K., Starkman S., Sanossian N., Eckstein M., Stratton S., Pratt F., et al. Paramedic Initiation of Neuroprotective Agent Infusions Successful Achievement of Target Blood Levels and Attained Level Effect on Clinical Outcomes in the FAST-MAG Pivotal Trial (Field Administration of Stroke Therapy - Magnesium). Stroke 2017; 48(7) 1901-07. Medline
II Neutral (Yellow) Cardiac adverse events in stroke Patient PH-Paramedic Bechler K, Shkirkova K, Saver JL, Starkman S, Hamilton S, Liebeskind DS, et al. The Effect of Early Treatment with Intravenous Magnesium Sulfate on the Incidence of Cardiac Comorbidities in Hospitalized Stroke Patients. Cardiovascular Therapeutics 2020. Medline
II Neutral (Yellow) Hematoma Expansion Patient PH-Paramedic Naidech AM, Shkirkova K, Villablanca JP, Sanossian N, Liebeskind DS, Sharma L, Eckstein M, Stratton S, Conwit R, Hamilton S, Saver JL. Magnesium Sulfate and Hematoma Expansion: An Ancillary Analysis of the FAST-MAG Randomized Trial. Stroke 2022; 53(5):1516–9. Medline

Mobile Stroke unit
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Rates of TPA Process PH-Paramedic Ellens NR, Schartz D, Rahmani R, Akkipeddi SMK, Kelly AG, et al. Mobile Stroke Unit Operational Metrics: Institutional Experience, Systematic Review and Meta-Analysis. Front Neurol 2022; 13:868051. Medline
I Supportive (Green) Accurate triage decision Process PH-Paramedic & MD Helwig SA, Ragoschke-Schumm A, Schwindling L, Kettner M, Roumia S, Kulikovski J, et al. Prehospital Stroke Management Optimized by Use of Clinical Scoring vs Mobile Stroke Unit for Triage of Patients With Stroke: A Randomized Clinical Trial. JAMA neurology 2019. Medline
I Supportive (Green) Alarm to Decision Time Process PH-Paramedic Walter S., Kostopoulos P., Haass A., et al. Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: A randomised controlled trial. Lancet Neurol 2012; 11(5):397-404. Medline
II Supportive (Green) Door to needle time. Process PH-Paramedic Andrew BY, Stack CM, Yang JP, Dodds JA. mStroke: "Mobile Stroke"-Improving Acute Stroke Care with Smartphone Technology. J of Stroke and Cerebrovascular Diseases 2017; 26(7):1449-56. Medline
II Supportive (Green) Transfer times to intra arterial treatment Process Cerejo R., John S., Buletko AB., Taqui A., Itrat A., Organek N., et al. A Mobile Stroke Treatment Unit for Field Triage of Patients for Intraarterial Revascularization Therapy. J Neuroimaging 2015; 25(6):940-5. Medline
II Supportive (Green) Modified Rankin Scale score at 3 months Patient PH-Paramedic & MD Ebinger M, Siegerink B, Kunz A, Wendt M, Weber JE, Schwabauer E, et al. Association Between Dispatch of Mobile Stroke Units and Functional Outcomes Among Patients With Acute Ischemic Stroke in Berlin. JAMA 2021; 325(5):454-66. Medline
II Supportive (Green) Feasibility Process PH-Paramedic Itrat A., Taqui A., Cerejo R., Briggs F., Cho SM., Organek N., et al. Telemedicine in Prehospital Stroke Evaluation and Thrombolysis: Taking Stroke Treatment to the Doorstep. JAMA Neurol 2016; 73(2):162-8. Medline
II Supportive (Green) Modified Rankin Scale Patient PH-Paramedic & MD Nolte CH., Ebinger M., Scheitz JF., Kunz A., Erdur H., Geisler F., et al. Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency. Stroke 2018; 49(3) 646-51. Medline
II Supportive (Green) Mobile Stroke Unit Patient Other Ramanathan RS, Wisco D, Vela-Duarte D, Zafar A, Taqui A, Winners S, et al. Pre-Hospital Diagnosis in Mobile Stroke Unit. J Stroke Cerebrovasc Dis 2021; 30(7):105801. Medline
II Supportive (Green) Neurological outcomes at 90 days Patient PH-Paramedic & MD Turc G, Hadziahmetovic M, Walter S, Churilov L, Larsen K, Grotta JC, et al. Comparison of Mobile Stroke Unit With Usual Care for Acute Ischemic Stroke Management: A Systematic Review and Meta-analysis. JAMA Neurol 2022. Medline
II Supportive (Green) Supportive of mobile stroke unit Patient PH-Paramedic & MD Zheng B, Li Y, Gu G, et al. Comparing 5G mobile stroke unit and emergency medical service in patients acute ischemic stroke eligible for t-PA treatment: A prospective, single-center clinical trial in Ya’an, China. Brain Behav August 2023; e3231. Medline
III Supportive (Green) Feasibility Process Bowry R., Parker S., Rajan SS., Yamal JM., Wu TC., Richardson L., et al. Benefits of Stroke Treatment Using a Mobile Stroke Unit Compared With Standard Management: The BEST-MSU Study Run-In Phase. Stroke 2015; 46(12) 3370-4. Medline
III Supportive (Green) Feasibility Process PH-Paramedic & MD Hov MR, Ryen A, Finsnes K, Storflor J, Lindner T, Gleditsch J, et al. Pre-hospital ct diagnosis of subarachnoid hemorrhage. Scand J T R Emerg Med 2017; 25(1):21. Medline
III Supportive (Green) Diagnostic accuracy of prehospital MD interpretation of CT Process Other Hov MR, Zakariassen E, Lindner T, Nome T, Bache KG, Røislien J, et al. Interpretation of Brain CT Scans in the Field by Critical Care Physicians in a Mobile Stroke Unit. J of neuroimaging 2018; 28(1):106-11. Medline
III Supportive (Green) Feasibility Process PH-MD & CCT Kettner M, Helwig SA, Ragoschke-Schumm A, Schwindling L, Roumia S, Keller I, et al. Prehospital Computed Tomography Angiography in Acute Stroke Management. Cerebrovasc Dis 2017; 44(5-6):338-43. Medline
III Supportive (Green) Treatment decision Process Kostopoulos P., Walter S., Haass A., et al. Mobile stroke unit for diagnosis-based triage of persons with suspected stroke. Neurology 2012; 78(23):1849-52. Medline
III Supportive (Green) Favourable outcome Patient PH-Paramedic & MD Lorenz MW, Lauer A, Foerch C. Quantifying the Benefit of Prehospital Rapid Treatment in Acute Stroke: Benchmark for Future Innovative Clinical Trials. Stroke 2015 Nov;46(11) 3168-76. Medline
III Neutral (Yellow) Reduction of patient-contact to diagnosis & stroke reperfusion time. Process PH-MD & CCT Kate MP, Jeerakathil T, Buck BH, Khan K, Nomani AZ, Butt A, et al. Pre-hospital triage of suspected acute stroke patients in a mobile stroke unit in the rural Alberta. Sci Rep 2021; 11(1):4988. Medline
III Neutral (Yellow) Time to Dx & Tx Process PH-Paramedic & MD Larsen K, Bache KG, Franer E, Tveit LH, Hov MR, Lund CG, et al. Pre-hospital thrombolysis of ischemic stroke in the emergency service system-A case report from the Treat-NASPP trial. Acta Anaesthesiol Scand 2019; 63(3):410-3. Medline
X Not Yet Graded (White) - Hagrass AI, Elsayed SM, Doheim MF, Mostafa MA, et al. Mobile Stroke Units in Acute Ischemic Stroke: A Comprehensive Systematic Review and Meta-Analysis of 5 “T Letter” Domains. Cardiol Rev. July 2024; 32(4):297-313. Medline
X Not Yet Graded (White) - Ibsen J, Hov MR, Tokerud GE, et al. Prehospital computed tomography in a rural district for rapid diagnosis and treatment of stroke. Eur Stroke J Sept 2024; 23969873241267084. Medline
X Not Yet Graded (White) - Mac Grory B, Sun JL, Alhanti B, Lusk J, Li F, et al. Mobile Stroke Unit Management in Patients With Acute Ischemic Stroke Eligible for Intravenous Thrombolysis. JAMA Neurol 2024. Medline

Oxygen
Level Direction Primary Outcome Patient/Process Setting Reference

Pre-arrival notification/plan
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Thrombolysis frequency Process PH-Paramedic Berglund A., Svensson L., Sjostrand C., et al. Higher prehospital priority level of stroke improves thrombolysis frequency and time to stroke unit: The hyper acute Stroke alarm (HASTA) study. Stroke 2012; 43(10):2666-70. Medline
II Supportive (Green) ED arrival to CT time Process PH-Paramedic Abdullah A, Smith E, Biddinger PD, Kalendarien D, Schwamm LD. Advance hospital notification by EMS in acute stroke is associated with shorted door to CT time and increased likelihood of administration of TPA. Prehosp Emerg Care 2008; 12:426-31. Medline
II Supportive (Green) Rates of TPA Process PH-Paramedic Baldereschi M., Piccardi B., Di Carlo A., Lucente G., Guidetti D., Consoli D., et al. Relevance of prehospital stroke code activation for acute treatment measures in stroke care: a review. Cerebrovasc Dis 2012; 34(3):182-90. Medline
II Supportive (Green) Door-to-needle time Process Other Cheng KY, Yu ELM, Yamamoto T, et al. Impact of a novel pre-hospital stroke notification programme on acute stroke care key performance indicators in Hong Kong: a multicentre prospective cohort study with historical controls. Hong Kong Med J April 2024; 30(2):94-101. Medline
II Supportive (Green) Final diagnosis of CVA Patient PH-Paramedic Ebker-White A, Dinh M, Paver I, Bein K, Tastula K, Gattellari M, et al. Evaluating Stroke Code Activation Pathway in Emergency Departments study. Emerg Med Australas 2022. Medline
II Supportive (Green) Neurological outcome at 90 days Patient PH-Paramedic Fujiwara S, Kuroda T, Matsuoka Y, Ohara N, Imamura H, Yamamoto Y, et al. Prehospital stroke notification and endovascular therapy for large vessel occlusion: a retrospective cohort study. Sci Rep 2022; 12(1):10107. Medline
II Supportive (Green) Rates of TPA Process PH-Paramedic Gladstone D., Rodan L., Sahlas D., et al. A Citywide Prehospital Protocol Increases Access to Stroke Thrombolysis in Toronto. Stroke 2008; 40(12):3841-4. Medline
II Supportive (Green) Door-to-CT Process PH-Paramedic Hsieh MJ, Tang SC., Chiang WC., Tsai LK., Jeng JS., Ma MH., et al. Effect of prehospital notification on acute stroke care: a multicenter study. Scand J Trauma Resusc Emerg Med 2016; 24:57-016-0251-2. Medline
II Supportive (Green) Door-to-puncture time Process PH-Paramedic Lee H, Kim SH, Baek JW, Jin SC. Clinical Significance of Prehospital Telecommunication Defined as the Critical Stroke Call Pathway in Acute Ischemic Stroke Requiring Intra-Arterial Recanalization Therapy. AJNR Am J Neuroradiol 2022; 43(6):899–904. Medline
II Supportive (Green) Predictive value of CVA diagnosis Process PH-Paramedic Medoro I, Cone DC. An Analysis of EMS and ED Detection of Stroke. PEC 2017; 21(4):476-80. Medline
II Supportive (Green) In-hospital mortality Patient PH-Paramedic Nielsen VM, Song G, DeJoie-Stanton C, Zachrison KS. Emergency Medical Services Prenotification is Associated with Reduced Odds of In-Hospital Mortality in Stroke Patients. Prehosp Emerg Care 2022; 1–7. Medline
II Supportive (Green) Time to thromobolysis Process PH-Paramedic O'Brien W., Crimmins D., Donaldson W., Risti R., Clarke TA., Whyte S., Sturm J. FASTER (face, arm, speech, time, emergency response): Experience of central coast stroke services implementation of a pre-hospital notification system for expedient management of acute stroke. Journal of Clinical Neuroscience 2012; 19(2):241-5. Medline
II Supportive (Green) Door-to-CT time Process PH-Paramedic Oostema JA, Nickles A, Allen J, Ibrahim G, Luo Z, Reeves M. Emergency Medical Services Compliance With Prehospital Stroke Quality Metrics Is Associated With Faster Stroke Evaluation and Treatment. Stroke 2024; 55(1):101-9. Medline
II Supportive (Green) Rate of TPA Process PH-Paramedic Quain DA., Parsons MW., Loudfoot AR., Spratt NJ., Evans MK., Russell ML., Levi CR. Improving access to acute stroke therapies: A controlled trial of organised pre-hospital and emergency care. The Medical Journal of Australia 2008; 189(8):429-33. Medline
II Supportive (Green) Onset to needle time Process PH-Paramedic Sangari A, Akhoundzadeh K, Vahedian M, Sharifipour E. Effect of pre-hospital notification on delays and neurological outcomes in acute ischemic stroke. Australas Emerg Care 2021. Medline
II Neutral (Yellow) Scene time for phone vs radio consult Process PH-Paramedic Gunn J. Do methods of hospital pre-alerts influence the on-scene times for acute pre-hospital stroke patients? A retrospective observational study. Br Paramed J 2021; 6(2):19–25. Medline
III Supportive (Green) Door-to-needle time Process PH-Paramedic Flores A, Seró L, Otto C, Mernes R, Gonzalez S, Diaz-Escobar L, et al. Impact of prehospital stroke code in a public center in Paraguay: A pilot study. International J of Stroke 2019; 14(6):646-9. Medline
III Supportive (Green) Time to assessment Process PH-Paramedic Mosley I., Nicol M., Donnan G., Patrick I., Kerr F., Dewey H. The impact of ambulance practice on acute stroke care: a Journal of Cerebral Circulation. Stroke 2007; 38(10):2765-70. Medline
III Neutral (Yellow) Feasibility Process PH-Paramedic Bergrath S., Reich A., Rossaint R., Rortgen D., Gerber J., Fischermann H., et al. Feasibility of prehospital teleconsultation in acute stroke-a pilot study in clinical routine. PLoS One 2012; 7(5):e36796. Medline

RIC (remote ischemic conditioning)
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Modified Rankin Scale (mRS) score at 90 days Patient PH-Paramedic & CCT Blauenfeldt RA, Hjort N, Valentin JB, Homburg AM, et al. Remote Ischemic Conditioning for Acute Stroke: The RESIST Randomized Clinical Trial. JAMA October 2023; 330(13):1236-46. Medline
II Neutral (Yellow) modified Rankin Scale at 90 days Patient PH-Paramedic & MD Blauenfeldt RA, Mortensen JK, Hjort N, Valentin JB, et al. Effect of Remote Ischemic Conditioning in Ischemic Stroke Subtypes: A Post Hoc Subgroup Analysis From the RESIST Trial. Stroke February 2024. Medline

Screening for Large Vessel Occlusion
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Validity for prediction of LVO Process ED-Paramedic & MD Chiu YC, Hsieh MJ, Lin YH, Tang SC, Sun JT, Chiang WC, et al. External validation of prehospital stroke scales for emergent large vessel occlusion. Am J Emerg Med 2021; 41:35-9. Medline
II Supportive (Green) Stroke detection Patient PH-Paramedic Dowbiggin PL, Infinger AE, Purick GT, Swanson DR, Asimos A, et al. Prehospital Evaluation of the FAST-ED as a Secondary Stroke Screen to Identify Large Vessel Occlusion Strokes. Prehosp Emerg Care 2022; 26(3):333–8. Medline
II Supportive (Green) Sensitivity and specificity Patient PH-Paramedic & MD Dowbiggin PL, Inginger AE, Purick GT, Swanson DR, Asimos A, Rhoten JB, et al. Prehospital Evaluation of the FAST-ED as a Secondary Stroke Screen to Identify Large Vessel Occlusion Strokes. Prehosp Emerg Care 2021:1–8. Medline
II Supportive (Green) Clinical diagnosis Process PH-Paramedic Duvekot MHC, Venema E, Rozeman AD, Moudrous W, Vermeij FH, Biekart M, et al. Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study. Lancet Neurol 2021; 20(3):213-21. Medline
II Supportive (Green) Stroke scale accuracy Process PH-Paramedic & MD English SW, Chhabra N, Hanus AE, et al. Prehospital stroke scales outperform National Institutes of Health Stroke Scale in predicting large vessel occlusion in a large academic telestroke network. J Telemed Telecare October 2023; 1357633X231204066. Medline
II Supportive (Green) Prediction of LVO Process PH-Paramedic Ganesh A, van de Wijdeven RM, Ospel JM, Duvekot MHC, Venema E, Rozeman AD, Moudrous W, Dorresteijn KRIS, Hensen JH, van Es ACGM, van der Lugt A, Kerkhoff H, Dippel DWJ, Goyal M, Roozenbeek B; PRESTO Investigators. Evaluating the Diagnostic Performance of Prehospital Stroke Scales Across the Range of Deficit Severity: Analysis of the Prehospital Triage of Patients With Suspected Stroke Study. Stroke 2022. Medline
II Supportive (Green) Predictive value for LVO Patient Other Johannes B, Habib P, Schürmann K, Nikoubashman O, Wiesmann M, Schulz JB, et al. Gaze Deviation and Paresis Score (GPS) Sufficiently Predicts Emergent Large Vessel Occluding Strokes. J Stroke Cerebrovasc Dis 2021; 30(3):105518. Medline
II Supportive (Green) Predictive value for LVO Process ED-MD Keenan KJ, Smith WS. The Speech Arm Vision Eyes (SAVE) scale predicts large vessel occlusion stroke as well as more complicated scales. J of Neurointerventional Surgery 2019; 11(7):659-63 Medline
II Supportive (Green) Predictive value for LVO Process PH-Paramedic Lima FO., Silva GS., Furie KL., Frankel MR., Lev MH., Camargo EC., et al. Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes. Stroke 2016; 47(8)1997-2002. Medline
II Supportive (Green) Predictive value Process Nazliel B., Starkman S., Liebeskind D., et al. A Brief Prehospital Stroke Severity Scale Identifies Ischemic Stroke Patients Harboring Persisting Large Arterial Occlusions. Stroke 2007; 39(8):2264-7. Medline
II Supportive (Green) Decreased time to EVT Process PH-Paramedic Nehme A, Deschaintre Y, Labrie M, Daneault N, Odier C, Poppe AY, et al. Cincinnati Prehospital Stroke Scale for EMS Redirection of Large Vessel Occlusion Stroke. The Canadian J of Neurological Sciences 2019; 46(6):684-90. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Nguyen TTM, van den Wijngaard IR, Bosch J, van Belle E, van Zwet EW, Dofferhoff-Vermeulen T, et al. Comparison of Prehospital Scales for Predicting Large Anterior Vessel Occlusion in the Ambulance Setting. JAMA Neurol 2021; 78(2):157-64. Medline
II Supportive (Green) Predictive value for LVO Process ED-Paramedic & MD Noorian AR, Sanossian N, Shkirkova K, Liebeskind DS, Eckstein M, Stratton SJ, et al. Los Angeles Motor Scale to Identify Large Vessel Occlusion: Prehospital Validation and Comparison With Other Screens. Stroke 2018; 49(3):565-72. Medline
II Supportive (Green) Prehospital identification of large vessel occlusion Patient PH-Paramedic Puolakka T, Virtanen P, Kuisma M, Strbian D. Comparison of large vessel occlusion scales using prehospital patient reports. Acta Neurol Scand 2022; 145(3):265–72. Medline
II Supportive (Green) Predictive value for LVO Process PH-Paramedic Richards CT, Huebinger R, Tataris KL, Weber JM, Eggers L, Markul E, et al. Cincinnati Prehospital Stroke Scale Can Identify Large Vessel Occlusion Stroke. PEC 2018; 22(3):312-8. Medline
II Supportive (Green) Predicative value Process PH-Paramedic Suzuki K, Nakajima N, Kunimoto K, Hatake S, Sakamoto Y, Hokama H, et al. Emergent Large Vessel Occlusion Screen Is an Ideal Prehospital Scale to Avoid Missing Endovascular Therapy in Acute Stroke. Stroke 2018; 49(9):2096-101. Medline
II Supportive (Green) Predictive value for LVO Process ED-Paramedic & MD Taqi MA, Sodhi A, Suriya SS, Quadri SA, Farooqui M, Salvucci AA, et al. Design, Application and Infield Validation of a Pre-Hospital Emergent Large Vessel Occlusion Screening Tool: Ventura Emergent Large Vessel Occlusion Score. J of Stroke and Cerebrovascular Diseases 2019; 28(3):728-34. Medline
II Supportive (Green) Predictive value Patient PH-Paramedic Uchida K, Yoshimura S, Sakakibara F, Kinjo N, Araki H, Saito S, et al. Simplified Prehospital Prediction Rule to Estimate the Likelihood of 4 Types of Stroke: The 7-Item Japan Urgent Stroke Triage (JUST-7) Score. Prehosp Emerg Care 2021; 25(4):465–74. Medline
II Supportive (Green) Predictive value Process PH-Paramedic & MD Uchida K., Yoshimura S., Hiyama N., Oki Y., Matsumoto T., Tokuda R., et al. Clinical Prediction Rules to Classify Types of Stroke at Prehospital Stage. Stroke 2018; 49(8) 1820-7. Medline
II Supportive (Green) Predictive value Process PH-Paramedic & MD Vidale S, Agostoni E. Prehospital stroke scales and large vessel occlusion: A systematic review. Acta Neurol Scand 2018; 138(1):24-31. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Zhao H, Pesavento L, Coote S, Rodrigues E, Salvaris P, Smith K, et al. Ambulance Clinical Triage for Acute Stroke Treatment: Paramedic Triage Algorithm for Large Vessel Occlusion. Stroke 2018; 49(4):945-51. Medline
II Neutral (Yellow) Predictive value for LVO Process PH-Paramedic Krebs W, Sharkey-Toppen TP, Cheek F, Cortez E, Larrimore A, Keseg D, et al. Prehospital Stroke Assessment for Large Vessel Occlusions: A Systematic Review. PEC 2017; 22(2):180-8. Medline
II Neutral (Yellow) Predictive value for LVO Patient PH-Paramedic Leto N, Bjørshol CA, Kurz M, Østerås Ø, Fromm A, Lindner TW. Prehospital identification of acute ischaemic stroke with large vessel occlusion: a retrospective study from western Norway. Emerg Med J Nov 2023 2. Medline
II Neutral (Yellow) Predictive value Process ED-MD Si X, Ruan J, Li L, Lu S, Huang H, Xia W, et al. Modified Prehospital Acute Stroke Severity (mPASS) Scale to Predict Emergent Large Arterial Occlusion. Biomed Res Int 2021; 2021:5568696. Medline
III Supportive (Green) Predicative value Process ED-MD Carrera D, Gorchs M, Querol M, Abilleira S, Ribó M, Millán M, et al. Revalidation of the RACE scale after its regional implementation in Catalonia: a triage tool for large vessel occlusion. J of Neurointerventional Surgery 2019; 11(8):751-6. Medline
III Supportive (Green) Predictive value for LVO Process PH-Paramedic Demeestere J, Garcia-Esperon C, Lin L, Bivard A, Ang T, Smoll NR, et al. Validation of the National Institutes of Health Stroke Scale-8 to Detect Large Vessel Occlusion in Ischemic Stroke. J of Stroke and Cerebrovascular Diseases 2017; 26(7):1419-26. Medline
III Supportive (Green) Optimal trip destination Process SIM Schlemm L, Ebinger M, Nolte CH, Endres M. Impact of Prehospital Triage Scales to Detect Large Vessel Occlusion on Resource Utilization and Time to Treatment. Stroke 2018; 49(2):439-46. Medline
III Supportive (Green) Predictive value for LVO Process PH-Paramedic Václaví¬k D, Bar M, Klečka L, Holeš D, Ĉábal M, Mikulí¬k R. Prehospital stroke scale (FAST PLUS Test) predicts patients with intracranial large vessel occlusion. Brain and Behavior 2018; 8(9):e01087. Medline
III Supportive (Green) Feasibility Process PH-Paramedic WD M, Spokoyny I, JT F, Lima B, MD C, MJR N, Niknam K, IP B, MA K, Govindarajan P. Prehospital Identification of Large Vessel Occlusions Using Modified National Institutes of Health Stroke Scale: A Pilot Study. Front Neurol 2021; 12:643356. Medline
III Neutral (Yellow) Predictive value for LVO Process PH-Paramedic Dickson RL., Crowe RP., Patrick C., Crocker K., Aiken M., Adams A., et al. Performance of the RACE Score for the Prehospital Identification of Large Vessel Occlusion Stroke in a Suburban/Rural EMS Service. PEC 2019 1-7. Medline
III Neutral (Yellow) Predicative value Process ED-Paramedic & MD Purrucker JC, Härtig F, Richter H, Engelbrecht A, Hartmann J, Auer J, et al. Design and validation of a clinical scale for prehospital stroke recognition, severity grading and prediction of large vessel occlusion: the shortened NIH Stroke Scale for emergency medical services. BMJ Open 2017; 7(9):e016893. Medline
III Neutral (Yellow) Predictive value Process SIM Schlemm L, Schlemm E. Clinical benefit of improved Prehospital stroke scales to detect stroke patients with large vessel occlusions: results from a conditional probabilistic model. BMC Neurology 2018; 18(1):16. Medline

Stroke Diagnosis Scales (any)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Predictive value Process PH-Paramedic Gude MF, Blauenfeldt RA, Behrndtz AB, Nielsen CN, Speiser L, et al. The Prehospital Stroke Score and telephone conference: A prospective validation. Acta Neurol Scand 2022; 145(5):541–50. Medline
I Supportive (Green) Diagnostic accuracy Patient ED-Paramedic & MD Han F, Zuo C, Zheng G. A systematic review and meta-analysis to evaluate the diagnostic accuracy of recognition of stroke in the Emerg department (ROSIER) scale. BMC Neurology 2020; 20(1). Medline
I Supportive (Green) Diagnostic accuracy Process Other Zarei H, Ebrahimzade M, Hajiqasemi M, et al. Diagnostic accuracy of 3-item stroke scale for detection of cerebral large vessel occlusion: A systematic review and meta-analysis. Am J Emerg Med. July 2024; 83:114-25. Medline
I Neutral (Yellow) Predictive value Process PH-Paramedic & MD Guterud M, Fagerheim Bugge H, Røislien J, et al. Prehospital screening of acute stroke with the National Institutes of Health Stroke Scale (ParaNASPP): a stepped-wedge, cluster-randomised controlled trial. Lancet Neurol Sept 2023; 22(9):800-11. Medline
II Supportive (Green) stroke detection Process Other Alijanpour S, Mostafazdeh-Bora M, Ahmadi Ahangar A. Different Stroke Scales; Which Scale or Scales Should Be Used? Caspian J Intern Med 2021; 12(1):1-21. Medline
II Supportive (Green) Predictive value for LVO Patient Other Almqvist T, Berglund A, Sjöstrand C, Eriksson E, Mazya MV. Prehospital Triage Accuracy in Patients With Stroke Symptoms Assessed Within 6 to 24 Hours or With an Unknown Time of Onset. Stroke 2021; 52(4):1441-5. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Araki H, Uchida K, Yoshimura S, Kurisu K, Shime N, Sakamoto S, et al. Effect of region-wide use of prehospital stroke triage scale on management of patients with acute stroke. J Neurointerv Surg 2021. Medline
II Supportive (Green) Success of hospital acceptance Process PH-Paramedic Araki H, Uchida K, Yoshimura S, Kurisu K, Shime N, Sakamoto S, et al. Effect of region-wide use of prehospital stroke triage scale on management of patients with acute stroke. J Neurointerv Surg 2021. Medline
II Supportive (Green) Door-to-puncture time Process PH-Paramedic Bhatt NR, Martin-Gill C, Al-Qudah A, et al. Acquisition of Prehospital Stroke Severity Scale is associated with shorter door-to-puncture times in patients with prehospital notifications transported directly to a thrombectomy center. J Neurointerv Surg Sept 2024. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Bray JE., Coughlan K., Barger B., Bladin C. Paramedic diagnosis of stroke: Examining long-term use of the melbourne ambulance stroke screen (MASS) in the field. Stroke; a Journal of Cerebral Circulation 2010; 41(7):1363-6. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Bray JE., Martin J., Cooper G., Barger B., Bernard S., Bladin C. Paramedic identification of stroke: Community validation of the melbourne ambulance stroke screen. Cerebrovascular Diseases (Basel, Switzerland) 2005; 20(1): 28-33. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Chaudhary D, Diaz J, Lu Y, Li J, Abedi V, Zand R. An updated review and meta-analysis of screening tools for stroke in the emergency room and prehospital setting. J Neurol Sci Nov 2022; 442:120423. Medline
II Supportive (Green) Validity for prediction of LVO Process ED-Paramedic & MD Chiu YC, Hsieh MJ, Lin YH, Tang SC, Sun JT, Chiang WC, et al. External validation of prehospital stroke scales for emergent large vessel occlusion. Am J Emerg Med 2021; 41:35-9. Medline
II Supportive (Green) Accuracy by paramedic Process PH-Paramedic Daly M, Cummings C, Kittell M, Dubuque A, Plante L, Linares G, et al. Validation of field assessment stroke triage for emergency destination for prehospital use in a rural EMS system. Am J Emerg Med 2021; 50:178–82. Medline
II Supportive (Green) Predictive value Process PH-Paramedic De Luca A, Mariani M, Riccardi MT, Damiani G. The role of the Cincinnati Prehospital Stroke Scale in the emergency department: evidence from a systematic review and meta-analysis. OAEM 2019; 11:147-59. Medline
II Supportive (Green) Predictive value Process ED-Paramedic & MD Dekker L, Daems JD, Duvekot MHC, Nguyen TTM, et al. Comparison of Prehospital Assessment by Paramedics and In-Hospital Assessment by Physicians in Suspected Stroke Patients: Results From 2 Prospective Cohort Studies. Stroke July 2023. Medline
II Supportive (Green) Stroke detection Patient PH-Paramedic Dowbiggin PL, Infinger AE, Purick GT, Swanson DR, Asimos A, et al. Prehospital Evaluation of the FAST-ED as a Secondary Stroke Screen to Identify Large Vessel Occlusion Strokes. Prehosp Emerg Care 2022; 26(3):333–8. Medline
II Supportive (Green) Sensitivity and specificity Patient PH-Paramedic & MD Dowbiggin PL, Inginger AE, Purick GT, Swanson DR, Asimos A, Rhoten JB, et al. Prehospital Evaluation of the FAST-ED as a Secondary Stroke Screen to Identify Large Vessel Occlusion Strokes. Prehosp Emerg Care 2021:1–8. Medline
II Supportive (Green) Clinical diagnosis Process PH-Paramedic Duvekot MHC, Venema E, Rozeman AD, Moudrous W, Vermeij FH, Biekart M, et al. Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study. Lancet Neurol 2021; 20(3):213-21. Medline
II Supportive (Green) accuracy Process PH-Paramedic & MD English SW, Chhabra N, Hanus AE, et al. Prehospital stroke scales outperform National Institutes of Health Stroke Scale in predicting large vessel occlusion in a large academic telestroke network. J Telemed Telecare October 2023; 1357633X231204066. Medline
II Supportive (Green) Predicative value Process PH-Paramedic English SW, Rabinstein AA, Mandrekar J, Klaas JP. Rethinking Prehospital Stroke Notification: Assessing Utility of Emergency Medical Services Impression and Cincinnati Prehospital Stroke Scale. J of Stroke and Cerebrovascular Diseases 2018; 27(4):919-25. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Ganesh A, van de Wijdeven RM, Ospel JM, Duvekot MHC, Venema E, Rozeman AD, Moudrous W, Dorresteijn KRIS, Hensen JH, van Es ACGM, van der Lugt A, Kerkhoff H, Dippel DWJ, Goyal M, Roozenbeek B; PRESTO Investigators. Evaluating the Diagnostic Performance of Prehospital Stroke Scales Across the Range of Deficit Severity: Analysis of the Prehospital Triage of Patients With Suspected Stroke Study. Stroke 2022. Medline
II Supportive (Green) Correlation with NIHSS Process PH-Paramedic Iguchi Y., Kimura K., Watanabe M., Shibazaki K., Aoki J. Utility of the kurashiki prehospital stroke scale for hyperacute stroke. Cerebrovasc Dis 2011; 31(1):51-6. Medline
II Supportive (Green) Predictive value for LVO Patient Other Johannes B, Habib P, Schürmann K, Nikoubashman O, Wiesmann M, Schulz JB, et al. Gaze Deviation and Paresis Score (GPS) Sufficiently Predicts Emergent Large Vessel Occluding Strokes. J Stroke Cerebrovasc Dis 2021; 30(3):105518. Medline
II Supportive (Green) Predictive value for LVO Process ED-MD Keenan KJ, Smith WS. The Speech Arm Vision Eyes (SAVE) scale predicts large vessel occlusion stroke as well as more complicated scales. J of Neurointerventional Surgery 2019; 11(7):659-63 Medline
II Supportive (Green) Predictive value Process PH-Paramedic Kidwell CS., Saver JL., Schubert GB., Eckstein M., Starkman S. Design and retrospective analysis of the Los Angeles Prehospital Stroke Screen (LAPSS). Prehosp Emerg Care 1998; 2:267-73. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Kidwell CS., Starkman S., Eckstein M., Weems K., Saver JL. Identifying stroke in the field. Prospective validation of the LA Prehospital Stroke Screen. Stroke 2000; 31:71-6. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Kim JT., Chung PW., Starkman S., Sanossian N., Stratton SJ., Eckstein M., et al. Field Validation of the Los Angeles Motor Scale as a Tool for Paramedic Assessment of Stroke Severity. Stroke 2017; 48(2):298-306. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Kothari R., Hall K., Brott T., Broderick J. Early stroke recognition: Developing an out-of-hospital NIH Stroke Scale. Acad Emerg Med 1997; 4(10):986-90. Medline
II Supportive (Green) Correlation of diagnosis between EMS providers and physicians Process PH-Paramedic Kothari RU., Pancioli A., Lui T., Brott T., Broderick J. Cincinnati prehospital stroke scale: Reproducibility and validity. Ann Emerg Med 1999; 33:373-8. Medline
II Supportive (Green) Diagnostic accuracy Process PH-Paramedic Krebs S, Sykora M, Krammel M, Girsa M, Auer A, Greisenegger S, et al. Prehospital triage optimization of patients with large vessel occlusion by Austrian Prehospital Stroke Scale. Acta Neurol Scand 2022; 146(3):246–51. Medline
II Supportive (Green) Predictive value Process ED-MD Kuroda R, Nakada T, Ojima T, Serizawa M, Imai N, Yagi N, et al. The TriAGe+ Score for Vertigo or Dizziness: A Diagnostic Model for Stroke in the Emergency Department. J of Stroke and Cerebrovascular Diseases 2017; 26(5):1144-53. Medline
II Supportive (Green) Predictive value for LVO Process PH-Paramedic Lima FO., Silva GS., Furie KL., Frankel MR., Lev MH., Camargo EC., et al. Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes. Stroke 2016; 47(8)1997-2002. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Llanes JN., et al. The LA Motor Scale: A new measure to characterize stroke severity in the field. Prehosp Emerg Care 2004; 8:46-50. Medline
II Supportive (Green) Predictive value Process Other Maddali A, Razack FA, Cattamanchi S, Ramakrishnan TV. Validation of the Cincinnati Prehospital Stroke Scale. J of Emergencies, Trauma, and Shock 2018; 11(2):111-4. Medline
II Supportive (Green) Predictive value Process PH-Paramedic McMullan JT, Katz B, Broderick J, Schmit P, Sucharew H, Adeoye O. Prospective Prehospital Evaluation of the Cincinnati Stroke Triage Assessment Tool. PEC 2017; 21(4):481-8. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Mingfeng H., Zhixin W., Qihong G., Lianda L., Yanbin Y., Jinfang F. Validation of the use of the ROSIER scale in prehospital assessment of stroke. Annals of Indian Academy of Neurology 2012; 15(3):191-5. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Mould-Millman NK, Meese H, Alattas I, Ido M, Yi I, Oyewumi T, et al. Accuracy of Prehospital Identification of Stroke in a Large Stroke Belt Municipality. PEC 2018; 22(6):734-42. Medline
II Supportive (Green) Predictive value Process Nazliel B., Starkman S., Liebeskind D., et al. A Brief Prehospital Stroke Severity Scale Identifies Ischemic Stroke Patients Harboring Persisting Large Arterial Occlusions. Stroke 2007; 39(8):2264-7. Medline
II Supportive (Green) Decreased time to EVT Process PH-Paramedic Nehme A, Deschaintre Y, Labrie M, Daneault N, Odier C, Poppe AY, et al. Cincinnati Prehospital Stroke Scale for EMS Redirection of Large Vessel Occlusion Stroke. The Canadian J of Neurological Sciences 2019; 46(6):684-90. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Nguyen TTM, van den Wijngaard IR, Bosch J, van Belle E, van Zwet EW, Dofferhoff-Vermeulen T, et al. Comparison of Prehospital Scales for Predicting Large Anterior Vessel Occlusion in the Ambulance Setting. JAMA Neurol 2021; 78(2):157-64. Medline
II Supportive (Green) Predictive value for LVO Process ED-Paramedic & MD Noorian AR, Sanossian N, Shkirkova K, Liebeskind DS, Eckstein M, Stratton SJ, et al. Los Angeles Motor Scale to Identify Large Vessel Occlusion: Prehospital Validation and Comparison With Other Screens. Stroke 2018; 49(3):565-72. Medline
II Supportive (Green) Sensitivity and specificity Process ED-Paramedic & CCP Ollikainen J, Jolma P, Pienimäki JP, Vuorinen P, et al. Less is more - The Finnish Prehospital Stroke Scale prospective validation. J Stroke Cerebrovasc Dis April 2023; 32(4):106996. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Ollikainen JP, Janhunen HV, Tynkkynen JA, Mattila KM, Hälinen MM, Oksala NK, et al. The Finnish Prehospital Stroke Scale Detects Thrombectomy and Thrombolysis Candidates-A Propensity Score-Matched Study. J of Stroke and Cerebrovascular Diseases 2018; 27(3):771-7. Medline
II Supportive (Green) Time to stroke diagnosis Process PH-Paramedic Oostema JA, Nickles A, Allen J, Ibrahim G, Luo Z, Reeves M. Emergency Medical Services Compliance With Prehospital Stroke Quality Metrics Is Associated With Faster Stroke Evaluation and Treatment. Stroke 2024; 55(1):101-9. Medline
II Supportive (Green) Predicative value Process PH-Paramedic Pickham D, Valdez A, Demeestere J, Lemmens R, Diaz L, Hopper S, et al. Prognostic Value of BEFAST vs. FAST to Identify Stroke in a Prehospital Setting. PEC 2018; 23(2):195-200. Medline
II Supportive (Green) Prehospital identification of large vessel occlusion Patient PH-Paramedic Puolakka T, Virtanen P, Kuisma M, Strbian D. Comparison of large vessel occlusion scales using prehospital patient reports. Acta Neurol Scand 2022; 145(3):265–72. Medline
II Supportive (Green) Predictive value for LVO Process PH-Paramedic Richards CT, Huebinger R, Tataris KL, Weber JM, Eggers L, Markul E, et al. Cincinnati Prehospital Stroke Scale Can Identify Large Vessel Occlusion Stroke. PEC 2018; 22(3):312-8. Medline
II Supportive (Green) Accuracy of predicting reperfusion candidates Process PH-Paramedic & MD Scott IM, Manoczki C, Swain AH, Ranjan A, McGovern MG, et al. Prehospital Telestroke vs Paramedic Scores to Accurately Identify Stroke Reperfusion Candidates: A Cluster Randomized Controlled Trial. Neurology Nov 2022; 99(19):e2125–36. Medline
II Supportive (Green) Detection of intracranial lesion Process PH-Paramedic & MD Sepponen R, Saviluoto A, Jäntti H, Harve-Rytsälä H, Lääperi M, Nurmi J. Validation of Score to Detect Intracranial Lesions in Unconscious Patients in Prehospital Setting. J Stroke Cerebrovasc Dis 2022; 31(4):106319. Medline
II Supportive (Green) Predicative value Process PH-Paramedic Suzuki K, Nakajima N, Kunimoto K, Hatake S, Sakamoto Y, Hokama H, et al. Emergent Large Vessel Occlusion Screen Is an Ideal Prehospital Scale to Avoid Missing Endovascular Therapy in Acute Stroke. Stroke 2018; 49(9):2096-101. Medline
II Supportive (Green) Predictive value for LVO Process ED-Paramedic & MD Taqi MA, Sodhi A, Suriya SS, Quadri SA, Farooqui M, Salvucci AA, et al. Design, Application and Infield Validation of a Pre-Hospital Emergent Large Vessel Occlusion Screening Tool: Ventura Emergent Large Vessel Occlusion Score. J of Stroke and Cerebrovascular Diseases 2019; 28(3):728-34. Medline
II Supportive (Green) Predictive value Process ED-MD Terzoni S, Destrebecq A, Modaffari F, Prendin F, Ferrara P. Validation of the Italian version of the ROSIER scale for stroke patients at triage. Australas Emerg Care 2022; 25(2):167–71. Medline
II Supportive (Green) Predictive value Patient PH-Paramedic Uchida K, Yoshimura S, Sakakibara F, Kinjo N, Araki H, Saito S, et al. Simplified Prehospital Prediction Rule to Estimate the Likelihood of 4 Types of Stroke: The 7-Item Japan Urgent Stroke Triage (JUST-7) Score. Prehosp Emerg Care 2021; 25(4):465–74. Medline
II Supportive (Green) Predictive value Process PH-Paramedic & MD Uchida K., Yoshimura S., Hiyama N., Oki Y., Matsumoto T., Tokuda R., et al. Clinical Prediction Rules to Classify Types of Stroke at Prehospital Stage. Stroke 2018; 49(8) 1820-7. Medline
II Supportive (Green) Predictive value Process PH-Paramedic & MD Vidale S, Agostoni E. Prehospital stroke scales and large vessel occlusion: A systematic review. Acta Neurol Scand 2018; 138(1):24-31. Medline
II Supportive (Green) Predictive value for TPA use Process ED-MD You JS., Chung SP., Chung HS., Lee HS., Park JW., Kim HJ., Lee HS. Predictive value of the cincinnati prehospital stroke scale for identifying thrombolytic candidates in acute ischemic stroke. The American Journal of Emergency Medicine 2013; 31(12):1699-1702. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Zhao H, Pesavento L, Coote S, Rodrigues E, Salvaris P, Smith K, et al. Ambulance Clinical Triage for Acute Stroke Treatment: Paramedic Triage Algorithm for Large Vessel Occlusion. Stroke 2018; 49(4):945-51. Medline
II Neutral (Yellow) Predictive value Process PH-Paramedic Berglund A., Svensson L., Wahlgren N., von Euler M., HASTA collaborators. Face arm speech time test use in the prehospital setting, better in the ambulance than in the emergency medical communication center. Cerebrovasc Dis 2014; 37(3):212-6. Medline
II Neutral (Yellow) Stroke identification Process PH-Paramedic Eliakundu AL, Cadilhac DA, Kim J, Kilkenny MF, Bagot KL, et al. Determining the sensitivity of emergency dispatcher and paramedic diagnosis of stroke: statewide registry linkage study. J Am Coll Emerg Physicians Open 2022; 3(4):e12750. Medline
II Neutral (Yellow) Predictive value Process PH-Paramedic Frendl DM., Strauss DG., Underhill BK., Goldstein LB. Lack of impact of paramedic training and use of the cincinnati prehospital stroke scale on stroke patient identification and on-scene time. Stroke; a Journal of Cerebral Circulation 2009; 40(3):754-6. Medline
II Neutral (Yellow) Predictive value Process PH-Paramedic Gropen TI., Gokaldas R., Poleshuck R., et al. Factors related to the sensitivity of emergency medical service impression of stroke. Prehosp Emerg Care 2014; 18(3):387-92. Medline
II Neutral (Yellow) Predictive value for LVO Process PH-Paramedic Krebs W, Sharkey-Toppen TP, Cheek F, Cortez E, Larrimore A, Keseg D, et al. Prehospital Stroke Assessment for Large Vessel Occlusions: A Systematic Review. PEC 2017; 22(2):180-8. Medline
II Neutral (Yellow) Sensitivity and NPV of Screening Tool Patient PH-Paramedic Leto N, Bjørshol CA, Kurz M, Østerås Ø, Fromm A, Lindner TW. Prehospital identification of acute ischaemic stroke with large vessel occlusion: a retrospective study from western Norway. Emerg Med J Nov 2023 2. Medline
II Neutral (Yellow) Predictive value Process ED-MD Si X, Ruan J, Li L, Lu S, Huang H, Xia W, et al. Modified Prehospital Acute Stroke Severity (mPASS) Scale to Predict Emergent Large Arterial Occlusion. Biomed Res Int 2021; 2021:5568696. Medline
II Neutral (Yellow) Predictive value Process PH-Paramedic Studnek JR., Asimos A., Dodds J., Swanson D. (2013). Assessing the validity of the cincinnati prehospital stroke scale and the medic prehospital assessment for code stroke in an urban emergency medical services agency. Prehosp Emerg Care 2013; 17(3):348-53. Medline
II Neutral (Yellow) Predictive value for ischemic stroke Process PH-Paramedic Suzuki J, Nakai N, Kondo N, Tsuji H, Inagaki R, Furukawa S, et al. Ten-Year Evaluation of the TOYOTA Prehospital Stroke Scale for Tissue Plasminogen Activator Intravenous Therapy in the Real World. Cerebrovasc Dis 2018; 46(3-4):184-92. Medline
II Neutral (Yellow) Supportive of Intervention Process Other Ye S, Pan H, Li W, Wang J, Zhang H. Development and validation of a clinical nomogram for differentiating hemorrhagic and ischemic stroke prehospital. BMC Neurol March 2023; 23(1):95. Medline
III Supportive (Green) Predicative value Process ED-MD Carrera D, Gorchs M, Querol M, Abilleira S, Ribó M, Millán M, et al. Revalidation of the RACE scale after its regional implementation in Catalonia: a triage tool for large vessel occlusion. J of Neurointerventional Surgery 2019; 11(8):751-6. Medline
III Supportive (Green) Predictive value Process PH-Paramedic Chenkin J., et al. Predictive value of the Ontario prehospital stroke scale screening tool for the identification of patients with acute stroke. Prehosp Emerg Care 2009; 13:153-9. Medline
III Supportive (Green) Predictive value for LVO Process PH-Paramedic Demeestere J, Garcia-Esperon C, Lin L, Bivard A, Ang T, Smoll NR, et al. Validation of the National Institutes of Health Stroke Scale-8 to Detect Large Vessel Occlusion in Ischemic Stroke. J of Stroke and Cerebrovascular Diseases 2017; 26(7):1419-26. Medline
III Supportive (Green) Time to EVT Process PH-Paramedic Duvekot MHC, Garcia BL, Dekker L, Nguyen TM, et al. Prehospital stroke triage: a modeling study on the impact of triage tools in different regions. Prehosp Emerg Care 2023; 1-15. Medline
III Supportive (Green) Predictive value for thrombolytic therapy Process PH-Paramedic Hasegawa Y., Sasaki N., Yamada K., Ono H., Kumai J., Tsumura K., Shigeno T. Prediction of thrombolytic therapy after stroke-bypass transportation: The maria prehospital stroke scale score. Journal of Stroke and Cerebrovascular Diseases : The Official Journal of National Stroke Association 2013; 22(4):514-9. Medline
III Supportive (Green) Accuracy of triage decision Process PH-Paramedic & MD Helwig SA, Ragoschke-Schumm A, Schwindling L, Kettner M, Roumia S, Kulikovski J, et al. Prehospital Stroke Management Optimized by Use of Clinical Scoring vs Mobile Stroke Unit for Triage of Patients With Stroke: A Randomized Clinical Trial. JAMA neurology 2019. Medline
III Supportive (Green) Diagnostic accuracy for stroke detection Process ED-MD Rafiemanesh H, Barikro N, Karimi S, Sotoodehnia M, Jalali A, Baratloo A. The Rapid Arterial oCclusion Evaluation (RACE) scale accuracy for diagnosis of acute ischemic stroke in emergency department - A multicenter study. BMC Emerg Med 2023; 23(1):51. Medline
III Supportive (Green) Optimal trip destination Process SIM Schlemm L, Ebinger M, Nolte CH, Endres M. Impact of Prehospital Triage Scales to Detect Large Vessel Occlusion on Resource Utilization and Time to Treatment. Stroke 2018; 49(2):439-46. Medline
III Supportive (Green) Predictive value for LVO Process PH-Paramedic Václaví¬k D, Bar M, Klečka L, Holeš D, Ĉábal M, Mikulí¬k R. Prehospital stroke scale (FAST PLUS Test) predicts patients with intracranial large vessel occlusion. Brain and Behavior 2018; 8(9):e01087. Medline
III Supportive (Green) Sensitivity Process PH-Paramedic Wasyliw S, Whelan R, Davy K, et al. The FAST VAN for Field Identification of Large Vessel Occlusion in Acute Stroke. Can J Neurol Sci 2023; 50(3):389-92. Medline
III Supportive (Green) Feasibility Process PH-Paramedic WD M, Spokoyny I, JT F, Lima B, MD C, MJR N, Niknam K, IP B, MA K, Govindarajan P. Prehospital Identification of Large Vessel Occlusions Using Modified National Institutes of Health Stroke Scale: A Pilot Study. Front Neurol 2021; 12:643356. Medline
III Supportive (Green) Predictive value Process Other Zhelev Z, Walker G, Henschke N, Fridhandler J, Yip S. Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack. The Cochrane Database of Systematic Reviews 2019; 4:CD011427. Medline
III Neutral (Yellow) Predictive value for LVO Process PH-Paramedic Dickson RL., Crowe RP., Patrick C., Crocker K., Aiken M., Adams A., et al. Performance of the RACE Score for the Prehospital Identification of Large Vessel Occlusion Stroke in a Suburban/Rural EMS Service. PEC 2019 1-7. Medline
III Neutral (Yellow) Diagnostic accuracy Process PH-Paramedic Hunt B, Zhao H, Cassidy A, Peart S, Olaussen A. Diagnostic Accuracy of Posterior Circulation Stroke by Paramedics: A Systematic Review. Prehosp Emerg Care October 2023; 1-9. Medline
III Neutral (Yellow) Predicative value Process ED-Paramedic & MD Purrucker JC, Härtig F, Richter H, Engelbrecht A, Hartmann J, Auer J, et al. Design and validation of a clinical scale for prehospital stroke recognition, severity grading and prediction of large vessel occlusion: the shortened NIH Stroke Scale for emergency medical services. BMJ Open 2017; 7(9):e016893. Medline
III Neutral (Yellow) Predictive value Process SIM Schlemm L, Schlemm E. Clinical benefit of improved Prehospital stroke scales to detect stroke patients with large vessel occlusions: results from a conditional probabilistic model. BMC Neurology 2018; 18(1):16. Medline
X Not Yet Graded (White) - Barrett KM., Pizzi MA., Kesari V., TerKonda SP., Mauricio EA., Silvers SM., et al. Ambulance-based assessment of NIH Stroke Scale with telemedicine: A feasibility pilot study. J Telemed Telecare 2017; 23(4):476-83. Medline
X Not Yet Graded (White) - Claudi C, Worm A, Schmohl D, et al. FAST4D-A New Score to Reduce Missed Strokes in Emergency Medical Service: A Prospective, Multicentric Observational Proof-of-Concept Trial. J Clin Med Aug 2024; 13(17). Medline
X Not Yet Graded (White) - Dekker L, Moudrous W, Daems JD, et al. Prehospital stroke detection scales: A head-to-head comparison of 7 scales in patients with suspected stroke. Int J Stroke Sept 2024; 17474930241275124. Medline
X Not Yet Graded (White) - Illian H, Grimm C, Haller A, et al. Stroke triage using the FAST-ED score shortens process times in large vessel occlusion strokes in a physician staffed pre-hospital emergency medical (PHEM) system. Eur Stroke J Nov 2024; 23969873241301884. Medline
X Not Yet Graded (White) - Kothari SA, Morsi RZ, Kozel OA, Baskaran A, et al. Comparing validated stroke screening scales for identifying large and medium vessel occlusions: a prospective observational cohort study. J Neurointerv Surg Nov 2024. Medline
X Not Yet Graded (White) - Stuby L, Suppan M, Desmettre T, Carrera E, Genoud M, Suppan L. A Two-Step Approach Using the National Health Institutes of Health Stroke Scale Assessed by Paramedics to Enhance Prehospital Stroke Detection: A Case Report and Concept Proposal. J Clin Med Sept 2024; 13(17). Medline

Stroke scale: CPSS
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Predictive value Process PH-Paramedic Bray JE., Coughlan K., Barger B., Bladin C. Paramedic diagnosis of stroke: Examining long-term use of the melbourne ambulance stroke screen (MASS) in the field. Stroke; a Journal of Cerebral Circulation 2010; 41(7):1363-6. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Bray JE., Martin J., Cooper G., Barger B., Bernard S., Bladin C. Paramedic identification of stroke: Community validation of the melbourne ambulance stroke screen. Cerebrovascular Diseases (Basel, Switzerland) 2005; 20(1): 28-33. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Chaudhary D, Diaz J, Lu Y, Li J, Abedi V, Zand R. An updated review and meta-analysis of screening tools for stroke in the emergency room and prehospital setting. J Neurol Sci Nov 2022; 442:120423. Medline
II Supportive (Green) Validity for LVO prediction Process ED-Paramedic & MD Chiu YC, Hsieh MJ, Lin YH, Tang SC, Sun JT, Chiang WC, et al. External validation of prehospital stroke scales for emergent large vessel occlusion. Am J Emerg Med 2021; 41:35-9. Medline
II Supportive (Green) Predictive value Process PH-Paramedic De Luca A, Mariani M, Riccardi MT, Damiani G. The role of the Cincinnati Prehospital Stroke Scale in the emergency department: evidence from a systematic review and meta-analysis. OAEM 2019; 11:147-59. Medline
II Supportive (Green) Detection of LVO Process PH-Paramedic Duvekot MHC, Venema E, Rozeman AD, Moudrous W, Vermeij FH, Biekart M, et al. Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study. Lancet Neurol 2021; 20(3):213-21. Medline
II Supportive (Green) Predicative value Process PH-Paramedic English SW, Rabinstein AA, Mandrekar J, Klaas JP. Rethinking Prehospital Stroke Notification: Assessing Utility of Emergency Medical Services Impression and Cincinnati Prehospital Stroke Scale. J of Stroke and Cerebrovascular Diseases 2018; 27(4):919-25. Medline
II Supportive (Green) Clinical Diagnosis of Ischemic Stroke Process PH-Paramedic Ganesh A, van de Wijdeven RM, Ospel JM, Duvekot MHC, Venema E, Rozeman AD, Moudrous W, Dorresteijn KRIS, Hensen JH, van Es ACGM, van der Lugt A, Kerkhoff H, Dippel DWJ, Goyal M, Roozenbeek B; PRESTO Investigators. Evaluating the Diagnostic Performance of Prehospital Stroke Scales Across the Range of Deficit Severity: Analysis of the Prehospital Triage of Patients With Suspected Stroke Study. Stroke 2022. Medline
II Supportive (Green) Alarm-to-hospital time or Pre-hospital time Process PH-Paramedic Heemskerk JL, Ricardo A, Domingo RA, Tawk RG, Vivas-Buitrago TG, Huang JF, Rogers A, et al. Time Is Brain: Prehospital Emergency Medical Services Response Times for Suspected Stroke and Effects of Prehospital Interventions. Mayo Clin Proc 2021; 96(6):1446–57. Medline
II Supportive (Green) Correlation of diagnosis between EMS providers and physicians Process PH-Paramedic Kothari RU., Pancioli A., Lui T., Brott T., Broderick J. Cincinnati prehospital stroke scale: Reproducibility and validity. Ann Emerg Med 1999; 33:373-8. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Krebs W, Sharkey-Toppen TP, Cheek F, Cortez E, Larrimore A, Keseg D, et al. Prehospital Stroke Assessment for Large Vessel Occlusions: A Systematic Review. PEC 2017; 22(2):180-8. Medline
II Supportive (Green) Predictive value for LVO Process PH-Paramedic Lima FO., Silva GS., Furie KL., Frankel MR., Lev MH., Camargo EC., et al. Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes. Stroke 2016; 47(8)1997-2002. Medline
II Supportive (Green) Predictive value Process Other Maddali A, Razack FA, Cattamanchi S, Ramakrishnan TV. Validation of the Cincinnati Prehospital Stroke Scale. J of Emergencies, Trauma, and Shock 2018; 11(2):111-4. Medline
II Supportive (Green) Predictive value Process PH-Paramedic McMullan JT, Katz B, Broderick J, Schmit P, Sucharew H, Adeoye O. Prospective Prehospital Evaluation of the Cincinnati Stroke Triage Assessment Tool. PEC 2017; 21(4):481-8. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Mingfeng H., Zhixin W., Qihong G., Lianda L., Yanbin Y., Jinfang F. Validation of the use of the ROSIER scale in prehospital assessment of stroke. Annals of Indian Academy of Neurology 2012; 15(3):191-5. Medline
II Supportive (Green) Decreased time to EVT Process PH-Paramedic Nehme A, Deschaintre Y, Labrie M, Daneault N, Odier C, Poppe AY, et al. Cincinnati Prehospital Stroke Scale for EMS Redirection of Large Vessel Occlusion Stroke. The Canadian J of Neurological Sciences 2019; 46(6):684-90. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Richards CT, Huebinger R, Tataris KL, Weber JM, Eggers L, Markul E, et al. Cincinnati Prehospital Stroke Scale Can Identify Large Vessel Occlusion Stroke. PEC 2018; 22(3):312-8. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Studnek JR., Asimos A., Dodds J., Swanson D. (2013). Assessing the validity of the cincinnati prehospital stroke scale and the medic prehospital assessment for code stroke in an urban emergency medical services agency. Prehosp Emerg Care 2013; 17(3):348-53. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Vidale S, Agostoni E. Prehospital stroke scales and large vessel occlusion: A systematic review. Acta Neurol Scand 2018; 138(1):24-31. Medline
II Supportive (Green) Predictive value for TPA use Process ED-MD You JS., Chung SP., Chung HS., Lee HS., Park JW., Kim HJ., Lee HS. Predictive value of the cincinnati prehospital stroke scale for identifying thrombolytic candidates in acute ischemic stroke. The American Journal of Emergency Medicine 2013; 31(12):1699-1702. Medline
II Neutral (Yellow) Predictive value Process PH-Paramedic Alijanpour S, Mostafazdeh-Bora M, Ahmadi Ahangar A. Different Stroke Scales; Which Scale or Scales Should Be Used? Caspian J Intern Med 2021; 12(1):1-21. Medline
II Neutral (Yellow) Predictive value Process PH-Paramedic Frendl DM., Strauss DG., Underhill BK., Goldstein LB. Lack of impact of paramedic training and use of the cincinnati prehospital stroke scale on stroke patient identification and on-scene time. Stroke; a Journal of Cerebral Circulation 2009; 40(3):754-6. Medline
II Neutral (Yellow) Detection of large vessel occlusion Patient PH-Paramedic Puolakka T, Virtanen P, Kuisma M, Strbian D. Comparison of large vessel occlusion scales using prehospital patient reports. Acta Neurol Scand 2022; 145(3):265–72. Medline
III Supportive (Green) Predictive value Process PH-Paramedic Zhelev Z, Walker G, Henschke N, Fridhandler J, Yip S. Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack. The Cochrane Database of Systematic Reviews 2019; 4:CD011427. Medline

Stroke scale: LAMS
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Performance (AUROC) of prehospital stroke scales for LVO Process Other Duvekot MHC, Venema E, Rozeman AD, Moudrous W, Vermeij FH, Biekart M, et al. Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study. Lancet Neurol 2021; 20(3):213-21. Medline
II Supportive (Green) Sensitivity of scale(s) to detect arterial large vessel occlusion in stroke. Process PH-Paramedic Ganesh A, van de Wijdeven RM, Ospel JM, Duvekot MHC, Venema E, Rozeman AD, Moudrous W, Dorresteijn KRIS, Hensen JH, van Es ACGM, van der Lugt A, Kerkhoff H, Dippel DWJ, Goyal M, Roozenbeek B; PRESTO Investigators. Evaluating the Diagnostic Performance of Prehospital Stroke Scales Across the Range of Deficit Severity: Analysis of the Prehospital Triage of Patients With Suspected Stroke Study. Stroke 2022. Medline
II Supportive (Green) Predictive validity Process PH-Paramedic Kim JT., Chung PW., Starkman S., Sanossian N., Stratton SJ., Eckstein M., et al. Field Validation of the Los Angeles Motor Scale as a Tool for Paramedic Assessment of Stroke Severity. Stroke 2017; 48(2):298-306. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Krebs W, Sharkey-Toppen TP, Cheek F, Cortez E, Larrimore A, Keseg D, et al. Prehospital Stroke Assessment for Large Vessel Occlusions: A Systematic Review. PEC 2017; 22(2):180-8. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Llanes JN., et al. The LA Motor Scale: A new measure to characterize stroke severity in the field. Prehosp Emerg Care 2004; 8:46-50. Medline
II Supportive (Green) Predictive value Process ED-MD Nazliel B., Starkman S., Liebeskind D., et al. A Brief Prehospital Stroke Severity Scale Identifies Ischemic Stroke Patients Harboring Persisting Large Arterial Occlusions. Stroke 2007; 39(8):2264-7. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Nguyen TTM, van den Wijngaard IR, Bosch J, van Belle E, van Zwet EW, Dofferhoff-Vermeulen T, et al. Comparison of Prehospital Scales for Predicting Large Anterior Vessel Occlusion in the Ambulance Setting. JAMA Neurol 2021; 78(2):157-64. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Noorian AR, Sanossian N, Shkirkova K, Liebeskind DS, Eckstein M, Stratton SJ, et al. Los Angeles Motor Scale to Identify Large Vessel Occlusion: Prehospital Validation and Comparison With Other Screens. Stroke 2018; 49(3):565-72. Medline
II Supportive (Green) Accuracy Process PH-Paramedic Puolakka T, Virtanen P, Kuisma M, Strbian D. Comparison of large vessel occlusion scales using prehospital patient reports. Acta Neurol Scand 2022; 145(3):265–72. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Vidale S, Agostoni E. Prehospital stroke scales and large vessel occlusion: A systematic review. Acta Neurol Scand 2018; 138(1):24-31. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Zhao H, Pesavento L, Coote S, Rodrigues E, Salvaris P, Smith K, et al. Ambulance Clinical Triage for Acute Stroke Treatment: Paramedic Triage Algorithm for Large Vessel Occlusion. Stroke 2018; 49(4):945-51. Medline
III Supportive (Green) Accuracy of triage decision Process PH-Paramedic Helwig SA, Ragoschke-Schumm A, Schwindling L, Kettner M, Roumia S, Kulikovski J, et al. Prehospital Stroke Management Optimized by Use of Clinical Scoring vs Mobile Stroke Unit for Triage of Patients With Stroke: A Randomized Clinical Trial. JAMA neurology 2019. Medline
III Supportive (Green) Predictive value Process PH-Paramedic Zhelev Z, Walker G, Henschke N, Fridhandler J, Yip S. Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack. The Cochrane Database of Systematic Reviews 2019; 4:CD011427. Medline
X Not Yet Graded (White) - Kothari SA, Morsi RZ, Kozel OA, Baskaran A, et al. Comparing validated stroke screening scales for identifying large and medium vessel occlusions: a prospective observational cohort study. J Neurointerv Surg Nov 2024. Medline

Stroke scale: RACE
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Predictive value Process Other Alijanpour S, Mostafazdeh-Bora M, Ahmadi Ahangar A. Different Stroke Scales; Which Scale or Scales Should Be Used? Caspian J Intern Med 2021; 12(1):1-21. Medline
II Supportive (Green) Validity for LVO prediction Process ED-Paramedic & MD Chiu YC, Hsieh MJ, Lin YH, Tang SC, Sun JT, Chiang WC, et al. External validation of prehospital stroke scales for emergent large vessel occlusion. Am J Emerg Med 2021; 41:35-9. Medline
II Supportive (Green) Time to EVT Process PH-Paramedic Duvekot MHC, Garcia BL, Dekker L, Nguyen TM, et al. Prehospital stroke triage: a modeling study on the impact of triage tools in different regions. Prehosp Emerg Care 2023; 1-15. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Duvekot MHC, Venema E, Rozeman AD, Moudrous W, Vermeij FH, Biekart M, et al. Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study. Lancet Neurol 2021; 20(3):213-21. Medline
II Supportive (Green) Diagnostic performance Process PH-Paramedic & MD English SW, Chhabra N, Hanus AE, et al. Prehospital stroke scales outperform National Institutes of Health Stroke Scale in predicting large vessel occlusion in a large academic telestroke network. J Telemed Telecare October 2023; 1357633X231204066. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Krebs W, Sharkey-Toppen TP, Cheek F, Cortez E, Larrimore A, Keseg D, et al. Prehospital Stroke Assessment for Large Vessel Occlusions: A Systematic Review. PEC 2017; 22(2):180-8. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Lima FO., Silva GS., Furie KL., Frankel MR., Lev MH., Camargo EC., et al. Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes. Stroke 2016; 47(8)1997-2002. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Nguyen TTM, van den Wijngaard IR, Bosch J, van Belle E, van Zwet EW, Dofferhoff-Vermeulen T, et al. Comparison of Prehospital Scales for Predicting Large Anterior Vessel Occlusion in the Ambulance Setting. JAMA Neurol 2021; 78(2):157-64. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Vidale S, Agostoni E. Prehospital stroke scales and large vessel occlusion: A systematic review. Acta Neurol Scand 2018; 138(1):24-31. Medline
II Supportive (Green) Predictive value Process PH-Paramedic Zhao H, Pesavento L, Coote S, Rodrigues E, Salvaris P, Smith K, et al. Ambulance Clinical Triage for Acute Stroke Treatment: Paramedic Triage Algorithm for Large Vessel Occlusion. Stroke 2018; 49(4):945-51. Medline
II Opposes (Red) Effectiveness in detecting LVO Process ED-Paramedic & MD Chehregani Rad , Azimi A. Rapid Arterial Occlusion Evaluation (RACE) Tool in Detecting Large Cerebral Vessel Occlusions; a Systematic Review and Meta-Analysis. Arch Acad Emerg Med January 2024; 12(1):e10. Medline
III Supportive (Green) Predictive value Process PH-Paramedic Carrera D, Gorchs M, Querol M, Abilleira S, Ribó M, Millán M, et al. Revalidation of the RACE scale after its regional implementation in Catalonia: a triage tool for large vessel occlusion. J of Neurointerventional Surgery 2019; 11(8):751-6. Medline
III Supportive (Green) Positive stroke diagnosis. Process ED-MD Rafiemanesh H, Barikro N, Karimi S, Sotoodehnia M, Jalali A, Baratloo A. The Rapid Arterial oCclusion Evaluation (RACE) scale accuracy for diagnosis of acute ischemic stroke in emergency department - A multicenter study. BMC Emerg Med 2023; 23(1):51. Medline
III Supportive (Green) Predictive value Process SIM Schlemm L, Ebinger M, Nolte CH, Endres M. Impact of Prehospital Triage Scales to Detect Large Vessel Occlusion on Resource Utilization and Time to Treatment. Stroke 2018; 49(2):439-46. Medline
III Supportive (Green) Predictive value Process PH-Paramedic Zhelev Z, Walker G, Henschke N, Fridhandler J, Yip S. Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack. The Cochrane Database of Systematic Reviews 2019; 4:CD011427. Medline
III Neutral (Yellow) Predictive value Process PH-Paramedic Dickson RL., Crowe RP., Patrick C., Crocker K., Aiken M., Adams A., et al. Performance of the RACE Score for the Prehospital Identification of Large Vessel Occlusion Stroke in a Suburban/Rural EMS Service. PEC 2019 1-7. Medline
III Neutral (Yellow) Predictive value Process SIM Schlemm L, Schlemm E. Clinical benefit of improved Prehospital stroke scales to detect stroke patients with large vessel occlusions: results from a conditional probabilistic model. BMC Neurology 2018; 18(1):16. Medline
X Not Yet Graded (White) - Krebs W, Alexander M, Fujita A, et al. The RACE Scale for Large Vessel Stroke Diversion to a Comprehensive Stroke Center by Helicopter Air Ambulance: A Retrospective Cohort Study. Air Med J Nov 2024; 43(6):508-511. Medline
X Not Yet Graded (White) - Puolakka T, Virtanen P, Kuisma M, Strbian D. Comparison of large vessel occlusion scales using prehospital patient reports. Acta Neurol Scand 2022; 145(3):265–72. Medline

Telestroke consult
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Composite score of quality indicators Process ED-Paramedic & MD Goh R, Hillier S, Kelly TL, Worley A, Dixon K, Kurunawai C, Tan A, Mahadevan J, Willcourt M, Jannes J, Kleinig T. Implementation of the South Australian Regional Telestroke service is associated with improved care quality and lower stroke mortality: A retrospective cohort study. Aust J Rural Health. 2023 Oct;31(5):878-885. doi: 10.1111/ajr.13012. Epub 2023 Jun 23. PMID: 37350539. Medline
II Neutral (Yellow) Feasibility Patient PH-Paramedic Sarpourian F, Ahmadi Marzaleh M, Fatemi Aghda SA, Zare Z. Application of Telemedicine in the Ambulance for Stroke Patients: A Systematic Review. Prehosp Disaster Med. 2023 Dec;38(6):774-779. doi: 10.1017/S1049023X23006519. Epub 2023 Oct 25. PMID: 37877359. Medline

TIA Score
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Diagnostic accuracy Process PH-Paramedic & MD Chehregani Rad I, Azimi A. Recognition of Stroke in the Emergency Room (ROSIER) Scale in Identifying Strokes and Transient Ischemic Attacks (TIAs); a Systematic Review and Meta-Analysis. Arch Acad Emerg Med October 2023; 11(1):e67. Medline
III Supportive (Green) Prediction of stroke within 7 days Process ED-MD Perry JJ, Sivilotti MLA, Émond M, Stiell IG, Stotts G, Lee J, et al. Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: Multicentre prospective cohort study. BMJ 2021; 372:n49. Medline


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