Optimizing Acute Ischemic Stroke Systems of Care: Current State and Future Directions

Despite significant progress in hospital quality initiatives and the organization of regional stroke systems of care, a significant gap persists between the number of patients eligible for acute ischemic stroke reperfusion therapies and those who receive them in a timely manner. This gap reflects persistent delays and variability across the prehospital and interhospital phases of care, from prehospital dispatch and field assessment to destination selection and interhospital transfer workflows. This expert narrative review synthesizes current evidence on acute stroke systems of care, with a particular focus on prehospital identification of stroke, destination decision-making for suspected large-vessel occlusion, and interhospital transfer for patients requiring endovascular thrombectomy. Key processes, including prehospital response and scene times, destination decision-making, and door-in-door-out metrics, are examined to illustrate how system-level bottlenecks affect access to and outcomes of reperfusion therapies. Emerging and novel technologies are also described, including mobile stroke units, blood-based biomarkers for prehospital stroke diagnosis, portable neuroimaging modalities, physiological and device-based detection systems, and cross-cutting tools such as telestroke, all aimed at shifting accurate diagnosis and treatment decisions earlier in the stroke care pathway.