title: The Direct Referral to Endovascular Center criteria: a proposal for pre-hospital evaluation of acute stroke in the Madrid Stroke Network.
abstract: For patients with acute ischaemic stroke due to large-vessel occlusion, it has recently been shown that mechanical thrombectomy (MT) with stent retrievers is better than medical treatment alone. However, few hospitals can provide MT 24 h/day 365 days/year, and it remains unclear whether selected patients with acute stroke should be directly transferred to the nearest MT-providing hospital to prevent treatment delays. Clinical scales such as Rapid Arterial Occlusion Evaluation (RACE) have been developed to predict large-vessel occlusion at a pre-hospital level, but their predictive value for MT is low. We propose new criteria to identify patients eligible for MT, with higher accuracy.
  
  
  
  The Direct Referral to Endovascular Center criteria were defined based on a retrospective cohort of 317 patients admitted to a stroke center. The association of age, sex, RACE scale score and blood pressure with the likelihood of receiving MT were analyzed. Cut-off points with the highest association were thereafter evaluated in a prospective cohort of 153 patients from nine stroke units comprising the Madrid Stroke Network.
  
  
  
  Patients with a RACE scale score ≥ 5, systolic blood pressure <190 mmHg and age <81 years showed a significantly higher probability of undergoing MT (odds ratio, 33.38; 95% confidence interval, 12-92.9). This outcome was confirmed in the prospective cohort, with 68% sensitivity, 84% specificity, 42% positive and 94% negative predictive values for MT, ruling out 83% of hemorrhagic strokes.
  
  
  
  The Direct Referral to Endovascular Center criteria could be useful for identifying patients suitable for MT.
authors.affiliation: Department of Neurology, La Paz University Hospital, Madrid, Spain.
authors.forename: J
authors.identifier: 0000-0002-8926-1287
authors.initials: J
authors.lastname: Rodríguez-Pardo
authors.affiliation: Department of Neurology, La Paz University Hospital, Madrid, Spain.
authors.forename: B
authors.initials: B
authors.lastname: Fuentes
authors.affiliation: Department of Neurology, La Paz University Hospital, Madrid, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Alonso de Leciñana
authors.affiliation: Department of Neurology, La Princesa University Hospital, Madrid, Spain.
authors.forename: Á
authors.initials: Á
authors.lastname: Ximénez-Carrillo
authors.affiliation: Department of Neurology, La Princesa University Hospital, Madrid, Spain.
authors.forename: G
authors.initials: G
authors.lastname: Zapata-Wainberg
authors.affiliation: Department of Neurology, La Paz University Hospital, Madrid, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Álvarez-Fraga
authors.affiliation: Department of Neurology, Alcorcon University Hospital Foundation, Madrid, Spain.
authors.forename: F J
authors.initials: FJ
authors.lastname: Barriga
authors.affiliation: Department of Neurology, Alcorcon University Hospital Foundation, Madrid, Spain.
authors.forename: L
authors.initials: L
authors.lastname: Castillo
authors.affiliation: Department of Neurology, Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Carneado-Ruiz
authors.affiliation: Department of Neurology, 12 de Octubre University Hospital, Madrid, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Díaz-Guzman
authors.affiliation: Department of Neurology, San Carlos University Hospital, Madrid, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Egido-Herrero
authors.affiliation: Department of Neurology, Ramón y Cajal University Hospital, Madrid, Spain.
authors.forename: A
authors.initials: A
authors.lastname: de Felipe
authors.affiliation: Department of Neurology, Rey Juan Carlos University Hospital, Madrid, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Fernández-Ferro
authors.affiliation: Department of Neurology, La Paz University Hospital, Madrid, Spain.
authors.forename: L
authors.initials: L
authors.lastname: Frade-Pardo
authors.affiliation: Department of Neurology, La Paz University Hospital, Madrid, Spain.
authors.forename: Á
authors.initials: Á
authors.lastname: García-Gallardo
authors.affiliation: Department of Neurology, Gregorio Marañón University Hospital, Madrid, Spain.
authors.forename: A
authors.initials: A
authors.lastname: García-Pastor
authors.affiliation: Department of Neurology, Gregorio Marañón University Hospital, Madrid, Spain.
authors.forename: A
authors.initials: A
authors.lastname: Gil-Núñez
authors.affiliation: Department of Neurology, San Carlos University Hospital, Madrid, Spain.
authors.forename: C
authors.initials: C
authors.lastname: Gómez-Escalonilla
authors.affiliation: Department of Neurology, Rey Juan Carlos University Hospital, Madrid, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Guillán
authors.affiliation: Department of Neurology, La Paz University Hospital, Madrid, Spain.
authors.forename: Y
authors.initials: Y
authors.lastname: Herrero-Infante
authors.affiliation: Department of Neurology, Ramón y Cajal University Hospital, Madrid, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Masjuan-Vallejo
authors.affiliation: Department of Neurology, 12 de Octubre University Hospital, Madrid, Spain.
authors.forename: M Á
authors.initials: MÁ
authors.lastname: Ortega-Casarrubios
authors.affiliation: Department of Neurology, La Princesa University Hospital, Madrid, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Vivancos-Mora
authors.affiliation: Department of Neurology, La Paz University Hospital, Madrid, Spain.
authors.forename: E
authors.initials: E
authors.lastname: Díez-Tejedor
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000175:diagnosis* / Q000628:therapy*; D015331:Cohort Studies; D004632:Emergency Medical Services / Q000379:methods*; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D008297:Male; D010360:Patient Transfer; D010865:Pilot Projects; D012189:Retrospective Studies; D013030:Spain; D015607:Stents; D020521:Stroke / Q000175:diagnosis* / Q000628:therapy*; D017131:Thrombectomy; D061665:Time-to-Treatment
keywords: acute stroke; endovascular treatment; pre-hospital scales; stroke networks