BACKGROUND: Disparities in the availability of reperfusion services for acute ischemic stroke are considerable globally and require urgent attention. Contemporary data on the availability of reperfusion services in different countries are used to provide the necessary evidence to prioritize where access to acute stroke treatment is needed. AIMS: To provide a snapshot of published literature on the provision of reperfusion services globally, including when facilitated by telemedicine or mobile stroke unit services. METHODS: We searched PubMed to identify original articles, published up to January 2023 for the most recent, representative, and relevant patient-level data for each country. Keywords included thrombolysis, endovascular thrombectomy and telemedicine. We also screened reference lists of review articles, citation history of articles, and the gray literature. The information is provided as a narrative summary. RESULTS: Of 11,222 potentially eligible articles retrieved, 148 were included for review following de-duplications and full-text review. Data were also obtained from national stroke clinical registry reports, Registry of Stroke Care Quality (RES-Q) and PRE-hospital Stroke Treatment Organization (PRESTO) repositories, and other national sources. Overall, we found evidence of the provision of intravenous thrombolysis services in 70 countries (63% high-income countries (HICs)) and endovascular thrombectomy services in 33 countries (68% HICs), corresponding to far less than half of the countries in the world. Recent data (from 2019 or later) were lacking for 35 of 67 countries with known year of data (52%). We found published data on 74 different stroke telemedicine programs (93% in HICs) and 14 active mobile stroke unit pre-hospital ambulance services (80% in HICs) around the world. CONCLUSION: Despite remarkable advancements in reperfusion therapies for stroke, it is evident from available patient-level data that their availability remains unevenly distributed globally. Contemporary published data on availability of reperfusion services remain scarce, even in HICs, thereby making it difficult to reliably ascertain current gaps in the provision of this vital acute stroke treatment around the world.

Center for Genomic and Precision Medicine University of Ibadan Ibadan Nigeria

Department of Biostatistics School of Public Health The University of Alabama at Birmingham Birmingham AL USA

Department of Clinical Sciences Section of Neurology Lund University Skåne University Hospital Lund Sweden

Department of Medicine University of Otago Wellington Wellington New Zealand

Department of Neurology Christian Medical College and Hospital Ludhiana India

Department of Neurology Singapore General Hospital Campus National Neuroscience Institute Singapore

Department of Neurology University of Copenhagen and Bispebjerg Hospital Copenhagen Denmark

Department of Neurosciences Hospital de Santa Maria University of Lisbon Lisbon Portugal

Health Management Institute Brno Czech Republic

Melbourne Brain Centre The University of Melbourne Royal Melbourne Hospital Parkville VIC Australia

National Institute for Stroke and Applied Neurosciences Auckland University of Technology Auckland New Zealand

Neurology Department Bata Hospital Zlin Czech Republic

Neurology Department Hospital Moinhos de Vento Porto Alegre Brazil

School of Rehabilitation Science Population Health Research Institute McMaster University Hamilton ON Canada

Stroke and Ageing Research Department of Medicine School of Clinical Sciences at Monash Health Monash University Clayton VIC Australia

Stroke Research Centre Department of Brain Repair and Rehabilitation UCL Queen Square Institute of Neurology London UK

Stroke Theme The Florey Institute of Neuroscience and Mental Health Heidelberg VIC Australia

Yale School of Medicine New Haven CT USA

Zobrazit více v PubMed

Langhorne P, Audebert HJ, Cadilhac DA, Kim J, Lindsay P. Stroke systems of care in high-income countries: what is optimal? Lancet 2020; 396: 1433–1442. PubMed

Norrving B, Barrick J, Davalos A, et al.. Action plan for stroke in Europe 2018-2030. Eur Stroke J 2018; 3: 309–336. PubMed PMC

Kim J, Thayabaranathan T, Donnan GA, et al.. Global stroke statistics 2019. Int J Stroke 2020; 15: 819–838. PubMed

Thayabaranathan T, Kim J, Cadilhac DA, et al.. Global stroke statistics 2022. Int J Stroke 2022; 17: 946–956. PubMed PMC

Thrift AG, Cadilhac DA, Thayabaranathan T, et al.. Global stroke statistics. Int J Stroke 2014; 9: 6–18. PubMed

Thrift AG, Thayabaranathan T, Howard G, et al.. Global stroke statistics. Int J Stroke 2017; 12: 13–32. PubMed

The PRE-hospital Stroke Treatment Organization (PRESTO), https://www.prestomsu.org/i4a/pages/index.cfm?pageid=1 (accessed January 2023). PubMed

Cadilhac DA, Dalli LL, Morrison JL, et al.. The Australian stroke clinical registry annual report 2021. Report no. 14, 22 December 2022, 66 pp. Heidelberg, VIC, Australia: The Florey Institute of Neuroscience and Mental Health.

Cardiovascular Disease in Barbados. Annual report 2022, http://www.bnr.org.bb/cms/home/37-home/91-bnr-annual-reports

Tsalta-Mladenov M, Andonova S. Health-related quality of life after ischemic stroke: impact of sociodemographic and clinical factors. Neurol Res 2021; 43: 553–561. PubMed

Vuletić V, Dikanović M, Lezaić Z, Sapina L, Kadojić D. Are we ready for intravenous thrombolysis in acute stroke treatment in our region. Acta Clin Croat 2011; 50: 145–148. PubMed

Sedova P, Brown RD, Jr, Bryndziar T, et al.. Treat COVID-19, but not only COVID-19: stroke matters as well. Cerebrovasc Dis 2022; 51: 52–59. PubMed PMC

Folyovich A, Biczó D, Jarecsny T, et al.. Daylight saving time and the incidence of thrombolysis to treat acute ischemic stroke. Rev Neurol 2020; 176: 361–365. PubMed

Maluchnik M, Ryglewicz D, Sienkiewicz-Jarosz H, et al.. Differences in acute ischaemic stroke care in Poland: analysis of claims database of National Health Fund in 2017. Neurol Neurochir Pol 2020; 54: 449–455. PubMed

Uivarosan D, Bungau S, Tit DM, et al.. Financial burden of stroke reflected in a pilot center for the implementation of thrombolysis. Medicina 2020; 56: 54. PubMed PMC

Ždraljević M, Pekmezović T, Stanarčević P, et al.. Influence of thrombocytopenia on the outcome of mechanical thrombectomy in patients with acute ischemic stroke. J Stroke Cerebrovasc Dis 2022; 31: 106240. PubMed

Gdovinová Z, Vitková M, Baráková A, Cvopová A. The impact of the COVID-19 outbreak on acute stroke care in Slovakia: data from across the country. Eur J Neurol 2021; 28: 3263–3266. PubMed

Jeromel M, Miloševicˇ Z, Zaletel M, Žvan B, Švigelj V, Oblak JP. Endovascular therapy for acute stroke is a safe and efficient evolving method: a single-center retrospective analysis. J Vasc Interv Radiol 2015; 26: 1025–1030. PubMed

Zhao J, Li H, Kung D, Fisher M, Shen Y, Liu R. Impact of the COVID-19 epidemic on stroke care and potential solutions. Stroke 2020; 51: 1996–2001. PubMed PMC

Hsieh CY, Chen CH, Chen YC, Kao Yang Y-H. National survey of thrombolytic therapy for acute ischemic stroke in Taiwan 2003-2010. J Stroke Cerebrovasc Dis 2013; 22: e620–e627. PubMed

Smajlović D, Salihović D, Avdić L, Dostović Z, Ibrahimagić OĆ, Vidović M. Intravenous thrombolytic therapy for acute ischemic stroke in Tuzla Canton, Bosnia and Herzegovina. Int J Stroke 2013; 8: E48. PubMed

Gross-Paju K, Thomson U, Adlas R, et al.. Implementation of the Helsinki model at West Tallinn Central Hospital. Medicina 2022; 58: 1173. PubMed PMC

Katsarava Z, Akhvlediani T, Janelidze T, et al.. Establishing stroke services in the Republic of Georgia. Eur Neurol 2022; 85: 56–64. PubMed

Karelis G, Micule M, Klavina E, et al.. The Riga East University Hospital stroke registry—an analysis of 4915 consecutive patients with acute stroke. Medicina 2021; 57: 632. PubMed PMC

Jucevičiūtė N, Mikužis P, Balnytė R. Absolute blood eosinophil count could be a potential biomarker for predicting haemorrhagic transformation after intravenous thrombolysis for acute ischaemic stroke. BMC Neurol 2019; 19: 127. PubMed PMC

Toyoda K, Yoshimura S, Nakai M, et al.. Twenty-year change in severity and outcome of ischemic and hemorrhagic strokes. JAMA Neurol 2022; 79: 61–69. PubMed PMC

Kim JY, Kang K, Kang J, et al.. Stroke statistics in Korea 2018: a report from the epidemiology research council of the Korean Stroke Society. Korean Stroke Society, https://www.stroke.or.kr/bbs/skin/notice_popup/download.php?code=epidemic1&number=5305 (2018, accessed April 2023). PubMed PMC

Pardhan A, Sharp S, Yearwood K, et al.. Ontario and Local Health Integration Network (LHIN) 2017/18 stroke report cards and progress reports. CorHealth, 2019, https://www.corhealthontario.ca/Ontario-&-LHIN-2017-18-Stroke-Report-Cards-&-Progress-Reports.pdf

Asaithambi G, Tong X, Lakshminarayan K, Coleman King SM, George MG. Current trends in the acute treatment of ischemic stroke: analysis from the Paul Coverdell National Acute Stroke Program. J Neurointerv Surg 2020; 12: 574–578. PubMed PMC

Alet M, Lucci FR, Ameriso S. Mechanical thrombectomy for reperfusion of acute ischemic stroke in a Stroke Unit in Argentina. Arq Neuropsiquiatr 2020; 78: 39–43. PubMed

Do Rosário CF, Fernandes Neto WG, Pessotti AL, et al.. Epidemiological analysis of stroke patients with emphasis on access to acute-phase therapies. Arq Neuropsiquiatr 2022; 80: 117–124. PubMed PMC

Brunser AM, Mazzon E, Cavada G, et al.. Low dosis of alteplase, for ischemic stroke after Enchanted and its determinants, a single center experience. Arq Neuropsiquiatr 2020; 78: 681–686. PubMed

Gil-Rojas Y, Lasalvia P. Budgetary impact analysis of alteplase—recombinant tissue plasminogen activator (rtPA)—as a thrombolytic treatment for acute ischemic stroke in Colombia. Expert Rev Pharmacoecon Outcomes Res 2022; 22: 1095–1102. PubMed

Gonzalez-Aquines A, Cordero-Pérez AC, Cristobal-Niño M, Pérez-Vázquez G, Góngora-Rivera F; GECEN Investigators. Contribution of onset-to-alarm time to prehospital delay in patients with ischemic stroke. J Stroke Cerebrovasc Dis 2019; 28: 104331. PubMed

Abanto C, Valencia A, Calle P, et al.. Challenges of thrombolysis in a developing country: characteristics and outcomes in Peru. J Stroke Cerebrovasc Dis 2020; 29: 104819. PubMed

Aref H, Zakaria M, Shokri H, Roushdy T, El Basiouny A, El Nahas N. Changing the landscape of stroke in Egypt. Cerebrovasc Dis Extra 2021; 11: 155–159. PubMed PMC

Khazaei M, Davoodian A, Taheri M, Ghafouri-Fard S. Former antiplatelet drug administration and consequences of intravenous thrombolysis in acute ischemic stroke. Hum Antibodies 2020; 28: 53–56. PubMed

Acherqui M, Khattab H, Habtany Y, et al.. Assessment of eligibility for thrombolysis in acute ischaemic stroke patients in Morocco. Pan Afr Med J 2020; 36: 351. PubMed PMC

Al Harthi HA, Al Kashmiri A, Zakaryia LM, et al.. Clinical profile of stroke patients presenting to the Emergency Department of a Major Stroke Centre in Oman. Sultan Qaboos Univ Med J 2022; 22: 91–97. PubMed PMC

Ibrahim F, Deleu D, Akhtar N, et al.. Burden of stroke in qatar. J Stroke Cerebrovasc Dis 2015; 24(12): 2875–2879. PubMed

Al Khathaami AM, Al Bdah B, Tarawneh M, et al.. Utilization of intravenous tissue plasminogen activator and reasons for nonuse in acute ischemic stroke in Saudi Arabia. J Stroke Cerebrovasc Dis 2020; 29: 104761. PubMed

Kömürcü HF, Gözke E, Doğan Ak P, Aslan IK, Salt I, Bi Er ÇİÖ. Changes in neutrophil, lymphocyte, platelet ratios and their relationship with NIHSS after rtPA and/or thrombectomy in ischemic stroke. J Stroke Cerebrovasc Dis 2020; 29: 105004. PubMed

Hasan ATMH, Das SC, Islam MS, et al.. Impact of COVID-19 on hospital admission of acute stroke patients in Bangladesh. PLoS One 2021; 16: e0240385. PubMed PMC

Mathew T, John SK, Sarma G, et al.. COVID-19-related strokes are associated with increased mortality and morbidity: a multicenter comparative study from Bengaluru, South India. Int J Stroke 2021; 16: 429–436. PubMed PMC

Nepal G, Yadav JK, Basnet B, Shrestha TM, Kharel G, Ojha R. Status of prehospital delay and intravenous thrombolysis in the management of acute ischemic stroke in Nepal. BMC Neurol 2019; 19: 155. PubMed PMC

Zaman Babar MU, Khan AZ, Hakim H, Gilani J, Wasay M. Utilization and outcomes with low dose tissue plasminogen activator as intravenous thrombolytic therapy for ischaemic stroke at Aga Khan University Hospital, Karachi: a retrospective analysis. J Pak Med Assoc 2019; 69: 1705–1710. PubMed

Mesiano T, Kurniawan M, Saputri KM, et al.. Endovascular treatment in acute ischemic stroke adoption and practice: a single-center Indonesian experience. Cerebrovasc Dis Extra 2021; 11: 72–76. PubMed PMC

Aziz ZA, Sidek NN. Annual report of the Malaysian stroke registry 2009-2016. Kuala Terengganu, Malaysia: Clinical Research Centre, 2017.

Navarro JC, San Jose MC, Collantes E, et al.. Stroke thrombolysis in the Philippines. Neurol Asia 2018; 23: 115–120.

Herath HMM, Rodrigo C, Alahakoon A, et al.. Outcomes of stroke patients undergoing thrombolysis in Sri Lanka; an observational prospective study from a low-middle income country. BMC Neurol 2021; 21: 434. PubMed PMC

Tiamkao S, Ienghong K, Cheung LW, Celebi I, Suzuki T, Apiratwarakul K. Stroke incidence, rate of thrombolytic therapy, mortality in Thailand from 2009 to 2021. Open Access Maced J Med Sci 2022; 9: 110–115.

Mai DT, Dao XC, Luong NK, Nguyen TK, Nguyen HT, Nguyen TN. Current state of stroke care in Vietnam. Stroke: Vasc Interv Neurol 2022; 2: e000331.

Ohnmar Kyaw M, Shew ZM, et al.. The pattern and burden of neurological disorders: a systemic review of Neurology Department, Yangon General Hospital, Myanmar. Neurol Asia 2020; 25: 555–561.

Venketasubramanian N, Khine YM, Ohnmar O, Khin MPPK, Win MT. Burden of stroke in Myanmar. Cerebrovasc Dis Extra 2021; 11: 49–51. PubMed PMC

Arabambi B, Oshinaike O, Ogun SA, et al.. Stroke units in Nigeria: a report from a nationwide organizational cross-sectional survey. Pan Afr Med J 2022; 42: 140. PubMed PMC

Mandizvidza V, London L, Bryer A. Shortfall in stroke care: a study of ischaemic stroke care practices in a South African metropole. S Afr Med J 2021; 111: 215–219. PubMed

Marko M, Posekany A, Szabo S, et al.. Trends of r-tPA (Recombinant Tissue-Type Plasminogen Activator) treatment and treatment-influencing factors in acute ischemic stroke. Stroke 2020; 51: 1240–1247. PubMed

Vanhoucke J, Hemelsoet D, Achten E, et al.. Impact of a code stroke protocol on the door-to-needle time for IV thrombolysis: a feasibility study. Acta Clin Belg 2020; 75: 267–274. PubMed

Varjoranta T, Raatiniemi L, Majamaa K, Martikainen M, Liisanantti JH. Prehospital and hospital delays for stroke patients treated with thrombolysis: a retrospective study from mixed rural-urban area in Northern Finland. Australas Emerg Care 2019; 22: 76–80. PubMed

Olié V, Grave C, Tuppin P, Duloquin G, Béjot Y, Gabet A. Patients hospitalized for ischemic stroke and intracerebral hemorrhage in France: time trends (2008-2019), in-hospital outcomes, age and sex differences. J Clin Med 2022; 11: 1669. PubMed PMC

Weber R, Krogias C, Eyding J, et al.. Age and sex differences in ischemic stroke treatment in a nationwide analysis of 1.11 million hospitalized cases. Stroke 2019; 50: 3494–3502. PubMed

Siskou O, Korompoki E, Ntaios G, et al.. Access of stroke patients’ to optimal healthcare technology in Greece: messages to policy makers. Stud Health Technol Inform 2020; 272: 421–424. PubMed

Griffin E, Murphy S, Sheehan M, et al.. Early repatriation post-thrombectomy: a model of care which maximises the capacity of a stroke network to treat patients with large vessel ischaemic stroke. J Neurointerv Surg 2020; 12: 1166–1171. PubMed

Gur AY, Shopin L, Bornstein NM. Lessons learned from 2 years experience in intravenous thrombolysis for acute ischemic stroke in a single tertiary medical center. Isr Med Assoc J 2009; 11: 714–716, 718. PubMed

Manganotti P, Naccarato M, Scali I, et al.. Stroke management during the coronavirus disease 2019 (COVID-19) pandemic: experience from three regions of the north east of Italy (Veneto, Friuli-Venezia-Giulia, Trentino-Alto-Adige). Neurol Sci 2021; 42: 4599–4606. PubMed PMC

Kuhrij LS, Wouters MW, Van den Berg-Vos RM, De Leeuw FE, Nederkoorn PJ. The Dutch Acute Stroke Audit: benchmarking acute stroke care in the Netherlands. Eur Stroke J 2018; 3: 361–368. PubMed PMC

Varmdal T, Indredavik B, Phan A, Fjærtoft H. Hjerneslag i Norge 2015-16 - behandling og resultater [Stroke in Norway 2015-16 - treatment and outcomes]. Tidsskr Nor Laegeforen 2020; 140(2). Doi: 10.4045/tidsskr.19.0246. PubMed

Sobral S, Taveira I, Seixas R, et al.. Late hospital arrival for thrombolysis after stroke in Southern Portugal: who is at risk? J Stroke Cerebrovasc Dis 2019; 28: 900–905. PubMed

Rosa JL, Alves M, Ferreira P, Papoila AL, Nunes AP. Previous disability and benefit of acute phase therapy in functional prognosis of selected patients with ischemic stroke. J Stroke Cerebrovasc Dis 2022; 31: 106183. PubMed

Scottish Stroke Improvement Programme 2022: national report. A management information release for Scotland, 2022, https://www.publichealthscotland.scot/publications/scottish-stroke-improvement-programme/scottish-stroke-improvement-programme-2022-national-report/

Tejada Meza H, Lambea Gil Á, Saldaña AS, et al.. Impact of COVID-19 outbreak on ischemic stroke admissions and in-hospital mortality in North-West Spain. Int J Stroke 2020; 15: 755–762. PubMed PMC

De Marchis GM, Wright PR, Michel P, et al.. Association of the COVID-19 outbreak with acute stroke care in Switzerland. Eur J Neurol 2022; 29: 724–731. PubMed PMC

The road to recovery: sentinel Stroke National Audit Programme annual report 2022, https://www.pslhub.org/learn/patient-safety-in-health-and-care/the-road-to-recovery-sentinel-stroke-national-audit-programme-annual-report-2022-10-november-2022-r8164/ (accessed 10 November 2022).

Demeestere J, Sewell C, Rudd J, et al.. The establishment of a telestroke service using multimodal CT imaging decision assistance: “Turning on the fog lights.” J Clin Neurosci 2017; 37: 1–5. PubMed

Bladin CF, Kim J, Bagot KL, et al.. Improving acute stroke care in regional hospitals: clinical evaluation of the Victorian Stroke Telemedicine program. Med J Aust 2020; 212: 371–377. PubMed

Nagao KJ, Koschel A, Haines HM, Bolitho LE, Yan B. Rural Victorian Telestroke project. Intern Med J 2012; 42: 1088–1095. PubMed

Mahawish K, Gommans J, Kleinig T, Lallu B, Tyson A, Ranta A. Switching to Tenecteplase for stroke thrombolysis: real-world experience and outcomes in a regional stroke network. Stroke 2021; 52: e590–e593. PubMed

Lin CH, Lee KW, Chen TC, et al.. Quality and safety of Telemedicine in acute ischemic stroke: early experience in Taiwan. J Formos Med Assoc 2022; 121: 314–318. PubMed

Fong WC, Ismail M, Lo JW, et al.. Telephone and teleradiology-guided thrombolysis can achieve similar outcome as thrombolysis by neurologist on-site. J Stroke Cerebrovasc Dis 2015; 24: 1223–1228. PubMed

Mong R, Tiah L, Wong M, Tan C. Improving telestroke treatment times through a quality improvement initiative in a Singapore emergency department. Singapore Med J 2019; 60: 69–74. PubMed PMC

Khan K, Shuaib A, Whittaker T, et al.. Telestroke in Northern Alberta: a two year experience with remote hospitals. Can J Neurol Sci 2010; 37: 808–813. PubMed

Porter J, Hall RE, Kapral MK, Fang J, Khan F, Silver FL. Outcomes following telestroke-assisted thrombolysis for stroke in Ontario, Canada. J Telemed Telecare 2018; 24: 492–499. PubMed

Huang JF, Greenway MRF, Nasr DM, et al.. Telestroke in the time of COVID-19: the Mayo Clinic experience. Mayo Clin Proc 2020; 95: 1704–1708. PubMed PMC

Nalleballe K, Sharma R, Kovvuru S, et al.. Why are acute ischemic stroke patients not receiving thrombolysis in a telestroke network? J Telemed Telecare 2020; 26: 317–321. PubMed

Agrawal K, Raman R, Ernstrom K, et al.. Accuracy of stroke diagnosis in telestroke-guided tissue plasminogen activator patients. J Stroke Cerebrovasc Dis 2016; 25: 2942–2946. PubMed

Zanaty M, Chalouhi N, Starke RM, et al.. Epidemiology of a large telestroke cohort in the Delaware valley. Clin Neurol Neurosurg 2014; 125: 143–147. PubMed

Cheshire WP, Barrett KM, Eidelman BH, et al.. Patient perception of physician empathy in stroke telemedicine. J Telemed Telecare 2021; 27: 572–581. PubMed

Demaerschalk BM, Boyd EL, Barrett KM, et al.. Comparison of stroke outcomes of hub and spoke hospital treated patients in Mayo Clinic telestroke program. J Stroke Cerebrovasc Dis 2018; 27: 2940–2942. PubMed

Bruno A, Lanning KM, Gross H, Hess DC, Nichols FT, Switzer JA. Timeliness of intravenous thrombolysis via telestroke in Georgia. Stroke 2013; 44: 2620–2622. PubMed

Switzer JA, Singh R, Mathiassen L, Waller JL, Adams RJ, Hess DC. Telestroke: variations in intravenous thrombolysis by spoke hospitals. J Stroke Cerebrovasc Dis 2015; 24: 739–744. PubMed

Sanders KA, Figiel C, Kiely JM, Gwynn MW, Johnston LH. Expanding access to intravenous tissue-type plasminogen activator treatment with a practice-based telestroke system. J Stroke Cerebrovasc Dis 2013; 22: e546–e548. PubMed

Chaffin HM, Nakagawa K, Koenig MA. Impact of statewide telestroke network on acute stroke treatment in Hawai’i. Hawaii J Health Soc Welf 2019; 78: 280–286. PubMed PMC

Lee VH, Cutting S, Song SY, et al.. Participation in a tele-stroke program improves timeliness of intravenous thrombolysis delivery. Telemed e-Health 2016; 23: 60–62. PubMed

LaMonte MP, Bahouth MN, Hu P, et al.. Telemedicine for acute stroke. Stroke 2003; 34: 725–728. PubMed

Pervez MA, Silva G, Masrur S, et al.. Remote supervision of IV-tPA for acute ischemic stroke by telemedicine or telephone before transfer to a regional stroke center is feasible and safe. Stroke 2010; 41: e18–e24. PubMed PMC

Moreno A, Schwamm LH, Siddiqui KA, et al.. Frequent hub-spoke contact is associated with improved spoke hospital performance: results from the Massachusetts General Hospital telestroke network. Telemed J E Health 2018; 24: 678–683. PubMed PMC

Sharma R, Zachrison KS, Viswanathan A, et al.. Trends in telestroke care delivery: a 15-year experience of an academic hub and its network of spokes. Circ Cardiovasc Qual Outcomes 2020; 13: e005903. PubMed PMC

Belt GH, Felberg RA, Rubin J, Halperin JJ. In-transit telemedicine speeds ischemic stroke treatment. Stroke 2016; 47: 2413–2415. PubMed

Gadhia R, Schwamm LH, Viswanathan A, Whitney C, Moreno A, Zachrison KS. Evaluation of the experience of spoke hospitals in an academic telestroke network. Telemed J E Health 2019; 25: 584–590. PubMed

Yu AT, Regenhardt RW, Whitney C, et al.. CTA protocols in a telestroke network improve efficiency for both spoke and hub hospitals. AJNR Am J Neuroradiol 2021; 42: 435–440. PubMed PMC

Nguyen-Huynh MN, Klingman JG, Avins AL, et al.. Novel telestroke program improves thrombolysis for acute stroke across 21 hospitals of an integrated healthcare system. Stroke 2018; 49: 133–139. PubMed PMC

Sinha K, Bettermann K. Clinical outcomes of moderate to severe acute ischemic stroke in a telemedicine network. J Clin Neurosci 2019; 69: 160–165. PubMed

Sobhani F, Desai S, Madill E, et al.. Remote longitudinal inpatient acute stroke care via telestroke. J Stroke Cerebrovasc Dis 2021; 30: 105749. PubMed

Sweid A, Atallah E, Saad H, et al.. Correlation between pre-admission blood pressure and outcome in a large telestroke cohort. J Clin Neurosci 2019; 62: 33–37. PubMed

Chalouhi N, Dressler JA, Kunkel ES, et al.. Intravenous tissue plasminogen activator administration in community hospitals facilitated by telestroke service. Neurosurgery 2013; 73: 667–671; discussion 671–672. PubMed

Zaidi SF, Jumma MA, Urra XN, et al.. Telestroke-guided intravenous tissue-type plasminogen activator treatment achieves a similar clinical outcome as thrombolysis at a comprehensive stroke center. Stroke 2011; 42: 3291–3293. PubMed

Poupore N, Edrissi C, Sowah M, et al.. Stroke severity among men and women acute ischemic stroke patients in the telestroke network. Cerebrovasc Dis Extra 2022; 12: 93–101. PubMed PMC

Simpson AN, Harvey JB, DiLembo SM, et al.. Population health indicators associated with a statewide telestroke program. Telemed J E Health 2020; 26: 1126–1133. PubMed PMC

Hsiao J, Sayles E, Antzoulatos E, et al.. Effect of COVID-19 on emergent stroke care: a regional experience. Stroke 2020; 51: e2111–e2114. PubMed PMC

Reddy ST, Savitz SI, Friedman E, et al.. Patients transferred within a telestroke network for large-vessel occlusion. J Telemed Telecare 2022; 28: 595–602. PubMed

Adcock AK, Choi J, Alvi M, et al.. Expanding acute stroke care in rural America: a model for statewide success. Telemed J E Health 2020; 26: 865–871. PubMed PMC

Ionita CC, Sharma J, Janicke DM, et al.. Acute ischemic stroke and thrombolysis location: comparing telemedicine and stroke center treatment outcomes. Hosp Pract 2009; 37: 33–39. PubMed

Lee VH, Howell R, Yadav R, Heaton S, Wiles KL, Lakhani S. Thrombolysis of stroke mimics via telestroke. Stroke Vasc Neurol 2022; 7: 267–270. PubMed PMC

Mohr NM, Young T, Harland KK, et al.. Telemedicine is associated with faster diagnostic imaging in stroke patients: a cohort study. Telemed J E Health 2019; 25: 93–100. PubMed

Gutovitz S, Leggett J, Hart L, Leaman SM, James H, Stillinger T. The impact of teleneurologists on acute stroke care at an advanced primary stroke centre. J Telemed Telecare 2022; 28: 115–121. PubMed

Lyerly MJ, Daggy J, LaPradd M, et al.. Impact of telestroke implementation on emergency department transfer rate. Neurology 2022; 98: e1617–e1625. PubMed

Zachrison KS, Sharma R, Wang Y, Mehrotra A, Schwamm LH. National trends in telestroke utilization in a US commercial platform prior to the COVID-19 pandemic. J Stroke Cerebrovasc Dis 2021; 30: 106035. PubMed PMC

Sevilis T, McDonald M, Avila A, et al.. Telestroke: maintaining quality acute stroke care during the COVID-19 pandemic. Telemed J E Health 2022; 28: 481–485. PubMed PMC

Carvalho VS, Jr, Picanço MR, Volschan A, Bezerra DC. Impact of simulation training on a telestroke network. Int J Stroke 2019; 14: 500–507. PubMed

Martins SO, Mont’Alverne F, Rebello LC, et al.. Thrombectomy for stroke in the public health care system of Brazil. N Engl J Med 2020; 382: 2316–2326. PubMed

Kushwaha S, Talwar P, Chandel N, Anthony A, Maheshwari S, Khurana S. Saving the brain initiative—developing an effective hub-and-spoke model to improve the acute stroke management pathways in urban India. J Neurol Sci 2018; 393: 83–87. PubMed

Srivastava PV, Sudhan P, Khurana D, et al.. Telestroke a viable option to improve stroke care in India. Int J Stroke 2014; 9: 133–134. PubMed

Chutinet A, Keosodsay S, Vorasayan P, et al.. The first 10 thrombolysis for acute ischemic stroke in Lao People’s Democratic Republic under teleconsultation from Thailand. J Stroke Cerebrovasc Dis 2019; 28: 104327. PubMed

Muengtaweepongsa S, Dharmasaroja PA, Maungboon P, Wattanaruangkowit P. Feasibility and safety of remote radiology interpretation with telephone consultation for acute stroke in Thailand. Neurol India 2010; 58: 740–742. PubMed

Legris N, Hervieu-Bègue M, Daubail B, et al.. Telemedicine for the acute management of stroke in Burgundy, France: an evaluation of effectiveness and safety. Eur J Neurol 2016; 23: 1433–1440. PubMed

Richard S, Lavandier K, Zioueche Y, Pelletier S, Vezain A, Ducrocq X. Use of telemedicine to manage severe ischaemic strokes in a rural area with an elderly population. Neurol Sci 2014; 35: 683–685. PubMed

Kaminsky AL, Mione G, Omorou Y, et al.. Outcome of patients with large vessel occlusion stroke after first admission in telestroke spoke versus comprehensive stroke center. J Neurointerv Surg 2020; 12: 753–757. PubMed

Vollmuth C, Miljukov O, Abu-Mugheisib M, et al.. Impact of the coronavirus disease 2019 pandemic on stroke teleconsultations in Germany in the first half of 2020. Eur J Neurol 2021; 28: 3267–3278. PubMed PMC

Hubert GJ, Kraus F, Maegerlein C, et al.. The “Flying intervention team”: a novel stroke care concept for rural areas. Cerebrovasc Dis 2021; 50: 375–382. PubMed

Gabriel KMA, Jírů-Hillmann S, Kraft P, et al.. Two years’ experience of implementing a comprehensive telemedical stroke network comprising in mainly rural region: the Transregional Network for Stroke Intervention with Telemedicine (TRANSIT-Stroke). BMC Neurol 2020; 20: 104. PubMed PMC

Zerna C, Siepmann T, Barlinn K, et al.. Association of time on outcome after intravenous thrombolysis in the elderly in a telestroke network. J Telemed Telecare 2016; 22: 18–24. PubMed

Busetto L, Sert M, Herzog F, et al.. “But it’s a nice compromise”—qualitative multi-centre study of barriers and facilitators to acute telestroke cooperation in a regional stroke network. Eur J Neurol 2022; 29: 208–216. PubMed

Wiborg A, Widder B; Telemedicine in Stroke in Swabia Project. Teleneurology to improve stroke care in rural areas. Stroke 2003; 34: 2951–2956. PubMed

Quadflieg LTM, Beckers SK, Bergrath S, et al.. Comparing the diagnostic concordance of tele-EMS and on-site-EMS physicians in emergency medical services: a retrospective cohort study. Sci Rep 2020; 10: 17982. PubMed PMC

Klingner C, Tinschert P, Brodoehl S, et al.. The effect of endovascular thrombectomy studies on the decision to transfer patients in a telestroke network. Telemed J E Health 2020; 26: 388–394. PubMed

Gallerini S, Marsili L, Groccia V, et al.. Appropriateness, safety, and effectiveness of “drip and ship” teleconsultation model in Southeastern Tuscany: a feasibility study. Neurol Sci 2020; 41: 2961–2965. PubMed

Brunetti V, Broccolini A, Caliandro P, et al.. Effect of the COVID-19 pandemic and the lockdown measures on the local stroke network. Neurol Sci 2021; 42: 1237–1245. PubMed PMC

Nardetto L, Dario C, Tonello S, et al.. A one-to-one telestroke network: the first Italian study of a web-based telemedicine system for thrombolysis delivery and patient monitoring. Neurol Sci 2016; 37: 725–730. PubMed

Kjelle E, Myklebust AM. Telemedicine remote controlled stroke evaluation and treatment, the experience of radiographers, paramedics and junior doctors in a novel rural stroke management team. BMC Health Serv Res 2021; 21: 554. PubMed PMC

Kerr E, Dennis M, Keir S. Thrombolysis: attempting to reduce postcode prescribing in Scotland? Int J Stroke 2010; 5: 486–488. PubMed

Pedragosa A, Alvarez-Sabín J, Rubiera M, et al.. Impact of telemedicine on acute management of stroke patients undergoing endovascular procedures. Cerebrovasc Dis 2012; 34: 436–442. PubMed

Martínez-Sánchez P, Miralles A, Sanz de Barros R, et al.. The effect of telestroke systems among neighboring hospitals: more and better? The Madrid Telestroke Project. J Neurol 2014; 261: 1768–1773. PubMed

Montaner J, Barragán-Prieto A, Pérez-Sánchez S, et al.. Break in the stroke chain of survival due to COVID-19. Stroke 2020; 51: 2307–2314. PubMed PMC

Evans NR, Sibson L, Day DJ, Agarwal S, Shekhar R, Warburton EA. Hyperacute stroke thrombolysis via telemedicine: a multicentre study of performance, safety and clinical efficacy. BMJ Open 2022; 12: e057372. PubMed PMC

Alexandrov AW, Arthur AS, Bryndziar T, et al.. High-resolution CT with arch/neck/head CT angiography on a mobile stroke unit. J Neurointerv Surg 2022; 14: 623–627. PubMed

Ohannessian R, Schott AM, Colin C, Nighoghossian N, Medeiros de Bustos E, Moulin T. Acute telestroke in France: a systematic review. Rev Neurol 2020; 176: 316–324. PubMed

Fassbender K, Merzou F, Lesmeister M, et al.. Impact of mobile stroke units. J Neurol Neurosurg Psychiatry 2021; 92: 815–822. PubMed PMC

Walter S, Zhao H, Easton D, et al.. Air-Mobile Stroke Unit for access to stroke treatment in rural regions. Int J Stroke 2018; 13: 568–575. PubMed

Zachrison KS, Cash RE, Adeoye O, et al.. Estimated population access to acute stroke and telestroke centers in the US, 2019. JAMA Netw Open 2022; 5: e2145824. PubMed PMC

Chen J, Lin X, Cai Y, Huang R, Yang S, Zhang G. A systematic review of mobile stroke unit among acute stroke patients: time metrics, adverse events, functional result and cost-effectiveness. Front Neurol 2022; 13: 803162. PubMed PMC

Stroke Service Tracker (SST), https://actionplan.eso-stroke.org/stroke-service-tracker-2 (accessed July 2023).

Aguiar de Sousa D, Wilkie A, Norrving B, et al.. Delivery of acute ischaemic stroke treatments in the European region in 2019 and 2020. Eur Stroke J 2023; 8: 618–628. PubMed PMC

Ouriques Martins SC, Sacks C, Hacke W, et al.. Priorities to reduce the burden of stroke in Latin American countries. Lancet Neurol 2019; 18: 674–683. PubMed

Martins SCO, Lavados P, Secchi TL, et al.. Fighting against stroke in Latin America: a joint effort of medical professional societies and governments. Front Neurol 2021; 12: 743732. PubMed PMC

Ranta A, Whitehead M, Gunawardana C, et al.. International telestroke: the first five cases. J Stroke Cerebrovasc Dis 2016; 25: e44–e45. PubMed