Background Improving access to thrombolytic therapy for patients with ischemic stroke is challenging. We assessed a prehospital process based on firemen rescuers under strict medical direction, aimed at facilitating thrombolysis of eligible patients. Methods This was a prospective observational study conducted over 4 months in Paris, France. Prehospital patients with suspected stroke were included after phone consultation with a physician. If the time since the onset of symptoms was less than 6 hours, patients were transported directly to a neurovascular unit (NVU), if symptom onset was over 6 hours ago; they were transported to an emergency department. Confirmation of stroke diagnosis, the rate of thrombolysis, and the time intervals between the call and hospital arrival and imaging were assessed. Comparison used Fisher's exact test. Results Of the 271 patients transported to an NVU, 218 were diagnosed with a stroke (166 with ischemic stroke), 69 received thrombolytic therapy, and the mean stroke-thrombolysis interval was 150 minutes. Over 64 patients admitted to ED, 36 patients suffered a stroke (ischaemic: 24). None were thrombolysed. Globally, 36% of ischaemic strokes were thrombolysed (27% of all strokes diagnosed). The mean interval call-hospital was 65 min (ED vs NVU: p=0.61). The interval call-imaging was 202 min [IQR: 105.5-254.5] for ED and 92 min [IQR: 77 116] for NVU (p<0.001). Conclusions The prehospital management of stroke by rescuers, under strict medical direction, seemed to be feasible and effective for selection of patients suffering from stroke in an urban environment, and may improve the access to thrombolysis.

1. Original Contribution
Stroke: prospective evaluation of a prehospital management process based on
rescuers under medical direction☆,☆☆
Laure Alhanati, MD, Stéphane Dubourdieu, MD, Clément Hoffmann, MD, Francis Béguec, MD,
Stéphane Travers, MD, Hugues Lefort, MD, Olga Maurin, MD, Daniel Jost, MD, Laurent Domanski, MD,
Jean-Pierre Tourtier, MD ⁎
Fire Brigade of Paris, Emergency Medical Service, 1 Place Jules Renard, 75017 Paris, France
a b s t r a c ta r t i c l e i n f o
Article history:
Received 9 October 2013
Received in revised form 2 January 2014
Accepted 22 January 2014
Available online xxxx
Background: Improving access to thrombolytic therapy for patients with ischemic stroke is challenging. We
assessed a prehospital process based on firemen rescuers under strict medical direction, aimed at facilitating
thrombolysis of eligible patients.
Methods: This was a prospective observational study conducted over 4 months in Paris, France. Prehospital
patients with suspected stroke were included after telephone consultation with a physician. If the time since
the onset of symptoms was less than 6 hours, patients were transported directly to a neurovascular unit
(NVU); if symptom onset was more than 6 hours ago, they were transported to an emergency department
(ED). Confirmation of stroke diagnosis, the rate of thrombolysis, and the time intervals between the call and
hospital arrival and imaging were assessed. Comparison used Fisher exact test.
Results: Of the 271 patients transported to an NVU, 218 were diagnosed with a stroke (166 with ischemic
stroke), 69 received thrombolytic therapy, and the mean stroke-thrombolysis interval was 150 minutes. Of 64
patients admitted to the ED, 36 patients had a stroke (ischemic, 24). None were thrombolysed. Globally, 36%
of ischemic strokes were thrombolysed (27% of all strokes diagnosed). The mean interval call-hospital was 65
minutes (ED vs NVU, P = .61). The interval call-imaging was 202 minutes (interquartile range, 105.5-254.5)
for ED and 92 minutes (interquartile range, 77-116) for NVU (P b .001).
Conclusions: The prehospital management of stroke by rescuers, under strict medical direction, seemed to be
feasible and effective for selection of patients with stroke in an urban environment and may improve the
access to thrombolysis.
© 2014 Elsevier Inc. All rights reserved.
1. Introduction
Cerebrovascular accident (stroke) is a main cause of death
worldwide and is one of the most common causes of disability in
developed countries [1]. Strokes affect 130000 people each year in
France, making stroke the leading cause of acquired disability in
adults and the third leading cause of mortality [2]. Approximately 90%
of all strokes are due to cerebral ischemia [3]. The specific treatment
for ischemic stroke is recanalization of occluded arteries within the
very first hours of symptom onset [4-6]. Less than one-third of
patients with acute stroke arrive at the hospital early enough to
receive thrombolytic treatment, and less than 5% actually receive it [7-
11]. Of those patients, outcomes are closely related to the time to
treatment [12–14].
There is rare published trial of prehospital stroke diagnosis and
treatment; there are several reports of prehospital delay in acute
stroke care. The reported median times from symptom onset to arrival
at hospital vary strongly, ranging from 3 to 6 hours, and median times
from arrival at hospital to thrombolysis were assessed to be more than
1 hour [15-19].
The timely and accurate diagnosis of acute ischemic stroke by
prehospital providers is critical in the chain of survival in stroke, and
chances of successful treatment are time dependent.
Accurate diagnosis in the field may lead to improved treatment
intervals such as door-to-imaging and door-to-treatment times,
which could improve chances of success.
In accordance with international guidelines, the fire brigade of
Paris (Brigade des Sapeurs-Pompiers de Paris [BSPP]) has developed a
specific prehospital management procedure for stroke. It is based on
American Journal of Emergency Medicine xxx (2014) xxx–xxx
☆ Contribution of authors: Alhanati L: Design of the study, acquisition of data,
analysis and interpretation of data, drafting the article. Dubourdieu S: Conception and
design of the study, analysis and interpretation of data. Hoffmann C: Acquisition of data.
Béguec F: Acquisition of data. Travers S, Lefort H, Maurin O, Jost D, Domanski L:
Acquisition of data, analysis and interpretation of data. Domanski L: Interpretation of
data, design of the study. Tourtier JP: Design of the study, drafting the article intellectual
content, final approval of the version to be submitted.
☆☆ Disclosures: No funding of any kind, no conflict of interest of any kind for all
authors.
⁎ Corresponding author. Fire Brigade of Paris, Emergency Medical Service, 1 Place
Jules Renard, 75017 Paris. Tel.: +33 670208162; fax: +33 156796754.
E-mail address: medecinchef.bmu@pompiersparis.fr (J.-P. Tourtier).
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajem.2014.01.034
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajem
Please cite this article as: Alhanati L, et al, Stroke: prospective evaluation of a prehospital management process based on rescuers under
medical direction, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.034

2. management by firemen rescuers (under strict medical direction) and
immediate transport. The aim of this procedure is to facilitate rapid
admission to a neurovascular unit (NVU) after medical control of the
patient's assessment and after contacting a neurologist [20].
The objective of this study was to prospectively evaluate this
prehospital process of stroke management for improvement in
diagnosis, treatment, and time intervals.
2. Methods
2.1. Geographical situation
The BSPP employs 8500 firemen, and its mission is to provide
assistance and first-aid care to residents of Paris and the 3 adjacent
districts, which represents a population of 10 million people. There
are 40 hospital emergency departments (ED) and 14 NVUs in this
area. The fire brigade of Paris performs 500000 prehospital
emergency interventions per year and is equipped with ambulances
(Véhicules de Secours et d’Assistance aux Victimes) with a team of
3 fireman rescuers as well as medical transportation means:
intensive care ambulances with a physician and a nurse. Telephone
calls (emergency numbers in Europe: 112, emergencies; 18, fire
brigade) from the population requesting an intervention (2.1
million calls per year) are analyzed by specialized operators and
by physicians in the coordination center, and a rescue team can be
dispatched immediately.
2.2. The prehospital stroke management process
Before 2007, following the field rescuers evaluation, a medical
team was called to confirm the diagnosis and practice the transport to
NVU or emergency medical services, depending mainly on physician
assessment and disponibility of hospital. In February 2007, an
innovative specific process for stroke management by rescuers team
aimed at facilitating rapid admission to an NVU was set up by the Paris
Fire Brigade (at that time, prehospital management of stroke was
generally ensured by a medical team). As a result, following a call to
the emergency number by the victim or the victim's family and in the
absence of any immediate life-threatening situation detected at the
time of the call, an ambulance (Véhicules de Secours et d’Assistance
aux Victimes) teamed by 3 firemen rescuers was dispatched.
The work has been approved by the appropriate ethical commit-
tees related to the institution.
An on-the-spot assessment consisted of collecting the basic
elements: age, sex, medical history and treatments, functional
complaints, Glasgow score and signs of stroke on the Face Arm
Speech Test diagnosis scale, heart rate, blood pressure, respiratory
rate, oxygen saturation (SpO2), temperature, and capillary blood
glucose when a blood glucose apparatus was available at the patient's
home [21]. The firemen then transmitted assessment by telephone to
a physician in the medical coordination center.
In all cases of suspected stroke, this assessment was systemat-
ically reviewed by the physician who either confirmed or excluded
the suspicion of stroke. A specific standard form was then used
(Appendix 1) to record all the essential information items for the
neurologist, including the time since the onset of symptoms
(corresponding to the time when the patient's neurologic state
was last considered to be normal by the witness or by the patient in
the absence of a witness), a list of the patient's symptoms, and a
decision-making algorithm.
If the victim did not show any criteria for medical management
(severe consciousness disorder, life-threatening respiratory or circu-
latory distress, associated seizures, suspected meningeal hemor-
rhage), the coordinating physician took into account the time since
the onset of symptoms. In agreement with local neurologists, a
maximum estimated interval of 6 hours since the onset of the first
symptoms was considered to be potentially compatible with
thrombolytic therapy in the case of an ischemic stroke (4.5 hours
according to ischemic stroke recommendations and up to 6 hours for
certain types of stroke such as those involving the basilar trunk) [14].
If the time since the onset of symptoms was less than 6 hours, the
physician of the coordination center would contact the closest NVU
with an available place for the patient. A contraindication to
thrombolysis did not exclude the transfer to an NVU [22].
When direct transport to an NVU was decided, the patient was
transported urgently. When the time since the onset of symptoms was
longer than 6 hours, but less than 24 hours, the triage physician would
seek the opinion of the closest NVU's neurologist to determine
whether the patient should be transferred directly to the NVU,
depending on his/her clinical status and available place, or to a nearby
ED (ED management process).
The paramedics would systematically collect the patient's pre-
scriptions and also request a member of the patient's family to
accompany them or, failing this, would record a telephone number
where the relative could be reached. During transport, the patient was
placed in a supine position in the absence of contraindication. The
patient was placed under close neurologic and hemodynamic
monitoring and given oxygen inhalation. In the event of any
neurologic deterioration during transport, the coordinating physician
was urgently recontacted to decide the intervention of an intensive
care ambulance (sent on the spot with a physician).
2.3. Data collection
This prospective cohort study was conducted from September 1 to
December 31, 2011. All patients for whom the BSPP “Stroke” process
was applied were included in the study, except for patients
immediately presenting medical management criteria, for whom an
intensive care ambulance was directly dispatched. The data were
collected from various documents: specific Paris fire brigade coordi-
nating physician forms (Appendix 1) recording age, sex, time of the
emergency call, clinical symptoms, and transfer decision (to NVU or a
hospital ED). Hospital discharge summaries were also obtained. Close
contact was established with a corresponding physician in each
department (NVU and EDs) to define the method for recovering
hospital discharge summaries: they were either collected directly from
the department, sent by letter, e-mailed, or faxed. For each case, the
time since the onset of symptoms, the time of admission to the ward,
the initial National Institute of Health Stroke Score (NIHSS), the time of
medical imaging, whether thrombolysis was performed (including
start and end times), any reasons why thrombolysis was not
performed, and the final diagnosis were collected.
For calculating time intervals, some definitions were used. The
call-hospital interval matched with the interval between the time
when the call was received by the triage center and the time of the
patient's admission to hospital. The call-imaging interval was the
interval between the call and the time at which neurologic imaging
(computed tomography or magnetic resonance imaging) was per-
formed. At last, the stroke-thrombolysis interval was the time interval
between the time when the patient was last asymptomatic and the
time at which thrombolysis was performed.
The primary end points were the rate of stroke diagnosis
confirmations among patients transported by firemen rescuers
teams and the rate of patients who were thrombolysed in the NVU
management process and in the ED management process.
The secondary end points were the various prehospital manage-
ment time intervals: call-hospital, call-imaging, and stroke onset-
thrombolysis intervals.
The data were anonymized and entered into an Excel spreadsheet.
Statistical calculations were performed using Excel and Stata
software. The quantitative data were compared by Fisher exact test.
2 L. Alhanati et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Please cite this article as: Alhanati L, et al, Stroke: prospective evaluation of a prehospital management process based on rescuers under
medical direction, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.034

3. 3. Results
From September 1 to December 31, 2011, 462 patients were
included in the study: 225 women (48.7%) and 237 men (51.3%) with
a median age of 72 years (interquartile range [IQR]25-75, 58-81).
Of this total, 454 patients (98.3%) were transported by rescuers
teams: 357 patients (77.3%) were transferred to an NVU and 97 were
transferred to nearby EDs (21%). One patient (0.2%) received care by
an additional medical team. Data concerning the initial triage were
missing for 7 patients (1.5%) (Fig.).
3.1. Patients transferred to an NVU
The median age of patients transferred to an NVU was 72 years
(IQR, 58-82), and the median NIHSS score was 8 (IQR, 3-15.25).
Hospital discharge summaries were obtained for 271 (76%) of
these 357 patients and showed that 218 patients had a stroke, that is,
80.4% of the patients admitted to an NVU. The stroke was ischemic in
more than three-fourths of cases (n = 166). The other diagnoses (n =
53) consisted of seizures with no abnormality on imaging in slightly
more than 40% of cases (n = 23), psychiatric disorders (n = 6; 11.3%),
and migraines with aura (n = 4; 7.6%). Two cases of hypoglycemia
were also observed.
Regarding thrombolysed patients, the mean stroke-thrombolysis
interval was 150 minutes (IQR, 115-180). A total of 69 patients
received thrombolytic therapy: 25.5% of the patients admitted to an
NVU (69/271 discharge summaries available) and 42% of the patients
transferred to an NVU with an ischemic stroke (69/166 confirmed
ischemic strokes).
3.2. Patients transferred to a nearby ED
The median age of patients transferred to a nearby ED was 77 years
(IQR, 63-85), and the median NIHSS score was 7 (IQR, 4-15.5).
Of the 97 patients admitted to a nearby ED, hospital discharge
summaries were obtained for 64 (66%) and showed that 36 patients
(56%) had a stroke, which was ischemic in three-fourths of cases.
None of these patients were thrombolysed. Twenty-eight patients
(44%) had not suffered a stroke. The final diagnoses were simple
epileptic seizure in 9 cases, a psychiatric etiology in 4 cases,
hypoglycemia in 2 cases, migraine in 2 patients, and a different
etiology was identified in 11 patients (acute alcohol intoxication,
brain metastasis, subdural hematoma, malaise/fainting, etc).
3.3. Intervals
The median intervals were as follows: call-hospital, 64 minutes (IQR,
53-79) for admission to an ED vs 65 minutes (IQR, 52-75) for admission to
anNVU(P =.61);call-imaging,202minutes(IQR,105.5-254.5) forthe ED
and 92 minutes (IQR, 77-116) for the NVU (P b .001).
4. Discussion
Globally, 36% of all ischemic strokes (with discharge summaries)
were thrombolysed (27% of all strokes diagnosed). The thrombolysis
rate was 42% for patients with a constituted cerebral infarction who
were initially transferred to an NVU. This rate was much higher than
the national and Parisian average rates. In France, in 2005, only 1% of
patients received thrombolytic therapy, contrasting with European
studies in which the percentage of patients potentially eligible for
thrombolysis was estimated between 6% and 22% [23,24].
One of the possible explanations for this difference is that patients
probably called emergency services when their symptoms were more
straightforward and more severe, such as a motor deficit or a
consciousness disorder. Indeed, most patients in this study had
motor deficits (80% of patients transferred to an NVU).
Of the 254 patients with confirmed stroke in this study (patients
transferred to an NVU and patients transferred to an ED), 218 (85.8%)
were directly transferred to an NVU. This rate was much higher than
the national or even Paris region data, which estimated in 2009 that
around 27% of stroke victims were directly transferred to an NVU [25].
Fig. Flow of patients.
3L. Alhanati et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Please cite this article as: Alhanati L, et al, Stroke: prospective evaluation of a prehospital management process based on rescuers under
medical direction, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.034

4. This high rate, therefore, suggested the interest of the management
process, under strict medical regulation.
Relatively short management times were observed for patients
transferred directly to an NVU: imaging was performed with an
average of 92 minutes after the call vs 202 minutes for patients
transferred to EDs (P b .05), suggesting the value of hospital process
that is ready to admit patients and to prioritize their access to brain
imaging 24 hours a day. As emergency centers are more ubiquitous
than NVUs, it could also be argue that resources would likely be better
spent on ED-based systems to improve efficiency in diagnosing and
treating patients with acute ischemic stroke.
The interval call-hospital time would seem difficult to reduce, given
the number of basic steps, which includes management time for the
initial call, intervention arrival time, time required to perform the
firemen rescuers assessment, search for an available place, and transfer
time. This time interval was identical whether patients were
transferred to an ED or an NVU. A recent British study showed that
only 39.5% of patients reach hospital before the third hour of symptoms
and 41.2% reach hospital within 4.5 hours [26]. The Centers for Disease
Control and Prevention study, published in 2007, also showed that
patients transferred by ambulance reached hospital in an average of 94
minutes after the onset of the symptoms vs 172 minutes for patients
who arrived at the hospital by their own means [27].
To our knowledge, few studies invested prospectively the same
topic. In Finland, after an intensive prehospital and hospital
restructuring program, the median total time delay from symptom
onset to thrombolytic intervention decreased from 149 to 112
minutes [28]. If in-hospital delays decreased significantly from 67 to
34 minutes, the median prehospital delay stayed unchanged.
Recently, in Germany, innovative and costly prehospital strategy
based on specialized ambulance (equipped with a computed
tomographic scanner, point-of-care laboratory, and telemedicine
connection; approximately €300000) has permitted to obtain an
enthusiastic median time from symptom onset to therapy decision of
only 56 minutes, with a high level of evidence (randomized controlled
trial) [29]. Moreover, transcranial ultrasound for stroke diagnosis has
been described, and first clinical trials as well as numerous preclinical
work suggest that ultrasound can be used to accelerate clot lysis
(sonothrombolysis) in the presence as well as in the absence of tissue
plasminogen activator [30].
Our study presents a number of limitations, in particular, a
selection bias: the fire brigade of Paris manages an essentially urban
population with a dense hospital network. The Parisian region has
considerable medical resources, including 14 NVUs. It would,
therefore, seem difficult to fully transpose the results observed in
the Paris region to other districts, where emergency services are not
organized in the same way and where NVUs may be located at much
greater distances. In addition, the delivery model for prehospital care
is very different across the world, which makes comparisons difficult.
Another limitation of this study was the number of missing discharge
summaries, resulting in missing data.
5. Conclusions
It appeared feasible for rescuers, under strict medical control, to
diagnose stroke and rapidly transport these patients to an appropriate
destination in an urban environment, which may improve the access
to thrombolysis. However, there are still possibilities for improvement
on the efficiency of this procedure: continued training of firemen
rescuers and medical guidance as well as an increased number of
available beds in NVUs are needed to facilitate access to care for the
greatest number of stroke patients.
Further studies will, therefore, be needed to regularly reassess this
management process and further improve the time intervals involved
and, hopefully, improve the functional prognosis for the patients
concerned. More broadly, audit of prehospital process of care for
stroke must be encouraged.
References
[1] Rothwell PM, Coull AJ, Silver LE, et al. Population-based study of event-rate,
incidence, case fatality, and mortality for all acute vascular events in all arterial
territories (Oxford Vascular Study). Lancet 2005;366:1773–83.
[2] Aboderin I, Venables G. Stroke management in Europe. Pan European Consensus
Meeting on Stroke Management. Intern Med 1996;240:169–71.
[3] Caplan LR, Hier DB, D’Cruz I, et al. Cerebral embolism in the Michael Reese
Registry. Stroke 1983;14:530–40.
[4] The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study
Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med
1995;333:1581–8.
[5] Adams Jr HP, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of
adults with ischemic stroke: a guideline from the American Heart Association/A-
merican Stroke Association Stroke Council, Clinical Cardiology Council, Cardio-
vascular Radiology and Intervention Council, and the Atherosclerotic Peripheral
Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary
Working Groups: The American Academy of Neurology affirms the value of this
guideline as an educational tool for neurologists. Circulation 2007;115:e478–534.
[6] European Stroke Organisation Executive Committee. Guidelines for management of
ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008;25:
457–507.
[7] Katzan IL, Hammer MD, Hixson ED, Furlan AJ, Abou-Chebl A, Nadzam DM.
Utilization of intravenous tissue plasminogen activator for acute ischemic stroke.
Arch Neurol 2004;61:346–50.
[8] Lichtman JH, Watanabe E, Allen NB, Jones B, Dostal J, Goldstein LB. Hospital arrival
time and intravenous t-PA use in US academic medical centers, 2001-2004. Stroke
2009;40:3845–50.
[9] Reeves MJ, Broderick JP, Frankel M, et al. The Paul Coverdell National Acute Stroke
Registry: initial results from four prototypes. Am J Prev Med 2006;31:S202–9.
[10] Albers GW, Olivot JM. Intravenous alteplase for ischaemic stroke. Lancet
2007;369:249–50.
[11] California Acute Stroke Pilot Registry (CASPR) Investigators. Prioritizing interventions
to improve rates of thrombolysis for ischemic stroke. Neurology 2005;64:654–9.
[12] Panagos PD. The approach to optimizing stroke care. Am J Emerg Med 2008;26:808–16.
[13] Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours
after acute ischemic stroke. N Engl J Med 2008;359:1317–29.
[14] Saver JL. Time is brain quantified. Stroke 2006;37:263–6.
[15] O’Brien PC, Fleming TR. A multiple testing procedure for clinical trial. Biometrics
1979;35:549–56.
[16] Evenason KR, Rosamond WD, Morris DL. Prehospital and in-hospital delays in
acute stroke care. Neuroepidemiology 2001;20:65–76.
[17] Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue-type plasminogen
activator therapy in acute ischemic stroke: patient characteristics, hospital factors,
and outcomes associated with door-to-needle times within 60 minutes.
Circulation 2011;123:750–8.
[18] Asplund K, Glader EL, Norrving B, et al. Effects of extending the time window of
thrombolysis to 4.5 hours: observations in the Swedish stroke register (Riks-
Stroke). Stroke 2011;42:2492–7.
[19] Price CI, Clement F, Gray J, Donaldson C, Ford GA. Systematic review of stroke
thrombolysis service configuration. Expert Rev Neurother 2009;9:211–33.
[20] Adams H, Adams R, Del Zoppo G, Goldstein LB. Guidelines for the early
management of patients with ischemic stroke: 2005 guidelines update a scientific
statement from the Stroke Council of the American Heart Association/American
Stroke Association. Stroke 2005;36:916–23.
[21] Mohd Nor A, McAllister C, Louw SJ, Dyker AG, Davis M, et al. Agreement between
ambulance paramedic- and physician-recorded neurological signs with Face Arm
Speech Test (FAST) in acute stroke patients. Stroke 2004;35:1355–9.
[22] Govan L, Weir C, Langhorne P. Organized inpatient (stroke unit) care for stroke.
Stroke 2008;3:2402–3.
[23] Collins D, O Neil D, Mc Cormaack P. Potential for treatment with thrombolysis in
an Irish stroke unit. Ir Med J 1999;92:236–8.
[24] Fiorelli M, Falcou A. The Rome emergency departments network for acute stroke:
pilot study on incidence, referral pathways, and eligibility for thrombolytic
therapy in Rome urban area. TajL NeuroScience 1999;20:S137.
[25] de Peretti C, Nicolau J, Tuppin P, Schnitzler A, Woimant F. Acute and post-acute
hospitalizations for stroke in France: recent improvements (2007-2009). Presse
Med 2012;41:491–503.
[26] Addo J, Ayis S, Leon J, Rudd AG, McKevitt C, Wolfe CD. Delay in presentation after
an acute stroke in a multiethnic population in South London: the South London
Stroke Register. J Am Heart Assoc 2012;1:e001685.
[27] Centers for Disease Control andPrevention (CDC) Prehospital andhospital delaysafter
stroke onset–United States, 2005-2006. MMWR Morb Mortal Wkly Rep. 2007; 18:56:
474-8.
[28] Puolakka T, Vayrynen T, Happola O, Soinne L, Kuisma M, Lindsberg PJ. Sequential
analysis of pretreatment delays in stroke thrombolysis. Acad Emerg Med 2010;17:
965–9.
[29] Walter S, Kostopoulos P, Haass A, Keller I, Lesmeister M, Schlechtriemen T, 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.
[30] Hölscher T, Dunford JV, Schlachetzki F, et al. Prehospital stroke diagnosis and
treatment in ambulances and helicopters-a concept paper. Am J Emerg Med
2013;31:743–7.
4 L. Alhanati et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Please cite this article as: Alhanati L, et al, Stroke: prospective evaluation of a prehospital management process based on rescuers under
medical direction, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.034

5. Appendix 1. BSPP Medical Regulation Chart for a Suspected Stroke Patient
5L. Alhanati et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Please cite this article as: Alhanati L, et al, Stroke: prospective evaluation of a prehospital management process based on rescuers under
medical direction, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.034