Leaving No Large Vessel Occlusion Stroke Behind: Reorganizing Stroke Systems of Care to Improve Timely Access to Endovascular Therapy.

Abstract

HomeStrokeVol. 51, No. 7Leaving No Large Vessel Occlusion Stroke Behind Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBLeaving No Large Vessel Occlusion Stroke BehindReorganizing Stroke Systems of Care to Improve Timely Access to Endovascular Therapy Ryan A. McTaggart, MD, Jessalyn K. Holodinsky, PhD, Johanna M. Ospel, MD, Andrew K. Cheung, MD, Nathan W. Manning, MD, Jason D. Wenderoth, MD, Thanh G. Phan, MD, PhD, Richard Beare, PhD, Kendall Lane, BA, Richard A. Haas, MD, Noreen Kamal, PhD, Mayank Goyal, MD, PhD and Mahesh V. Jayaraman, MD Ryan A. McTaggartRyan A. McTaggart Correspondence to: Ryan A. McTaggart, MD, Department of Diagnostic Imaging, Warren Alpert School of Medicine at Brown University, Rhode Island Hospital 593 Eddy Street, APC 701 Providence, RI 02903. Email E-mail Address: [email protected] https://orcid.org/0000-0001-5853-5161 Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.). Search for more papers by this author , Jessalyn K. HolodinskyJessalyn K. Holodinsky Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (J.K.H.). Search for more papers by this author , Johanna M. OspelJohanna M. Ospel Department of Clinical Neurosciences, University of Calgary, Canada (J.M.O., M.G.). Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O.). Search for more papers by this author , Andrew K. CheungAndrew K. Cheung Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.). Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.). Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.). Search for more papers by this author , Nathan W. ManningNathan W. Manning Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.). Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.). Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.). Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (N.W.M., J.D.W.). Search for more papers by this author , Jason D. WenderothJason D. Wenderoth Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.). Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.). Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.). Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (N.W.M., J.D.W.). Search for more papers by this author , Thanh G. PhanThanh G. Phan Department of Neurology, Monash Health and School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P.). Search for more papers by this author , Richard BeareRichard Beare Department of Medicine, Peninsula Health and Central Clinical School, Monash University and Murdoch Children’s Research Institute Melbourne Australia (R.B.). Search for more papers by this author , Kendall LaneKendall Lane Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. Search for more papers by this author , Richard A. HaasRichard A. Haas Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.). Search for more papers by this author , Noreen KamalNoreen Kamal Department of Industrial Engineering, Dalhousie University, Halifax, Nova Scotia, Canada (N.K.). Search for more papers by this author , Mayank GoyalMayank Goyal Department of Clinical Neurosciences, University of Calgary, Canada (J.M.O., M.G.). Department of Radiology, Seaman Family MR Research Centre, Foothills Medical Centre, Calgary, Canada (M.G.). Search for more papers by this author and Mahesh V. JayaramanMahesh V. Jayaraman Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.). Search for more papers by this author Originally published17 Jun 2020https://doi.org/10.1161/STROKEAHA.119.026735Stroke. 2020;51:1951–1960is related toStroke Systems of CareSimulation Methods in Acute Stroke TreatmentEssential Workflow and Performance Measures for Optimizing Acute Ischemic Stroke Treatment in IndiaPath From Clinical Research to ImplementationOptimization of Endovascular Therapy in the Neuroangiography Suite to Achieve Fast and Complete (Expanded Treatment in Cerebral Ischemia 2c-3) ReperfusionOptimal Imaging at the Primary Stroke CenterSee related articles, p 1928, p 1932, p 1941, p 1961, p 1969 and p 1978Stroke care was revolutionized in 2015 with the publication of the first randomized control trials showing that endovascular therapy (EVT) is far more effective than intravenous thrombolysis alone for patients with large vessel occlusion (LVO) stroke,1–5 and later trials showed benefit up to 24 hours from last seen well in selected patients.6,7 While EVT is highly efficacious, it is also profoundly time dependent.8,9 Every 4-minute delay to substantial reperfusion results in one more patient out of 100 being more disabled.9 From the patient’s perspective, for every minute faster to recanalization, the average patient gains a week of disability-free life.10 While the upfront costs for EVT are higher than medical treatment alone, cost-effectiveness (economic dominance) has been proven in both industrialized nations and developing countries.11–16 Furthermore, any improvement in time to recanalization or recanalization itself favorably modifies the stroke cost curve.17Although the clinical trials of EVT have transformed what we do, it is now time to transform how we do it. Too few patients have access to EVT because we are too slow, and our systems of care remain poorly organized.10,18 There is an opportunity to learn from our colleagues in cardiology and trauma surgery who deal with diseases with similar time-dependence as good outcomes depend on transporting patients to most appropriate hospital as quickly as possible. To accomplish this, partnering with regional emergency medical services (EMS) professionals19,20 and establishing formal LVO protocols with non-Comprehensive Stroke Center (CSC) partners is absolutely essential.21This article will discuss how to improve early access to EVT starting with first medical contact with Emergency Medical Services (EMS) and moving forward to the arrival at a CSC capable of delivering EVT. We will discuss a variety of solutions, acknowledging that the optimal solution for regions will vary based on geography and available resources.Prehospital Stroke Systems of CareInitial Patient Evaluation—Use of a Field Stroke Severity ScaleUpon first reaching a patient with suspected stroke, EMS protocols in most regions use a stroke screen, such as field assessment stroke triage, Los Angeles prehospital stroke screen, or the Cincinnati prehospital stroke screen. These screens are intended to result in a binary, yes/no result of whether or not the patient may be having a stroke. However, an important next step in the evolution of field stroke care is the incorporation of a stroke severity scale in the EMS assessment of stroke patients. A variety of such field scales exist, including the Los Angeles Motor Scale, rapid arterial occlusion evaluation scale, field assessment stroke triage for emergency destination, and vision aphasia neglect. Although the differences among these scales are beyond the scope of this review, the performance of all of these is likely similar.22 When examining the utility of these scales for field destination triage, it may also be helpful to include patients with intracerebral hemorrhage as CSC appropriate.23Once a patient who meets field severity threshold for LVO is identified, EMS protocols should incorporate field severity in determining which hospital the patient is transported to. If the closest hospital for this patient is a CSC, they will presumably have timely access to EVT. However, for those instances where the closest hospital to the patient is a primary stroke center (PSC), we will now explore 4 different options to improve timely access to EVT:Efficient transfer protocols from PSCs to CSCsField triage to a more distant CSC rather than the closest PSCMobile interventional teams from the CSC performing EVT at the PSCMobile Stroke UnitsEfficient Transfer From PSCs to CSCs for EVTInterfacility transfer from PSCs to CSCs for potential EVT is historically problematic for several reasons, including the absence of LVO on arrival to CSC, and prolonged door-in door-out (DIDO) time at the PSC.24 At a minimum, patients presenting to PSCs who meet the local field severity threshold should undergo both noncontrast computed tomography (CT) and CT angiography (CTA) upon arrival. In Rhode Island, we worked with our PSC partners to implement a 3-part transfer process for LVO stroke patients (Figure 1),21 focusing on early CSC notification, early vessel imaging at the PSC, and cloud-based image sharing. This protocol both reduced onset to reperfusion times and improved outcomes for those patients where the protocol was fully executed.21 The reduction in onset to reperfusion time was driven entirely by reduced DIDO at the PSC. After this protocol was implemented, it was found that LVO patients with shorter DIDO had better outcomes.25 However, despite best efforts, overall DIDO did not improve over time. The shortest DIDO times were achieved when the EMS team that delivered the patient to the PSC remained with the patient until the CTA was performed.21 Every PSC should work with EMS to formalize a transfer agreement with their closest CSC to keep DIDO low—ideally <45 minutes.Download figureDownload PowerPointFigure 1. A primary stroke center (PSC) large vessel occlusion (LVO) protocol should be in place for LVO patients that present to any stroke center without endovascular capability. For many reasons, CT angiography (CTA) at the PSC is advantageous and attempts should be made to keep the EMS team that brought the patient to the PSC with the patient until a CTA confirms or excludes the LVO to keep door-in door-out times as short as possible.At PSCs, reducing DIDO should be as high a priority as reducing door to needle (DTN) time.Field Triage to a More Distant CSCThe concept of EMS transporting patients with a high likelihood of LVO directly to the CSC makes common sense. For many geographic regions,26–28 eliminating the PSC bottleneck may be the single greatest modifier of outcome for patients with suspected LVO. However, there are concerns there might be an opportunity cost (both clinical and financial) to bypassing PSCs. For this reason, several groups have attempted to model the impact of field diversion for LVO stroke.29–35 Holodinsky et al30 mathematically predicted better clinical outcomes for LVO patients directly triaged to the CSC under certain scenarios.31 They determined the magnitude of this improvement and transport radius were dependent on several factors including the DTN and DIDO at the PSC and quality of recanalization at the CSC. Indeed, one model showed that if the CSC could achieve modified Thrombolysis in Cerebral Infarction (mTICI) 2b or greater 90% of the time then direct transport to the CSC is superior even within a 90-minute transport radius.In the STRATIS registry (Systematic Evaluation of Patients Treated With Stroke Devices for Acute Ischemic Stroke), median onset to revascularization time was 109.5 minutes faster in the mothership patients as compared to drip-and-ship patients (odds ratio for functional independence 1.38 [95% CI, 1.06–1.79]).36 This difference in onset to revascularization time was due to longer DTN at the PSC than the CSC (median 54.5 versus 37 minutes), PSC DIDO (median >90 minutes) and the transport time from PSC to CSC (median 35 minutes).36 Of importance, both the models described in the paragraph above30,31 and data from the STRATIS registry36 are relevant only for patients with known LVO.In the field, EMS providers are faced with diagnostic uncertainty. As such, the drip-and-ship model becomes relevant due to inclusion of ischemic stroke without LVO in the decision-making process.29 Performance metrics at the PSC determine their weight in field triage decision making. For example, using an LVO screening tool such as the Los Angeles Motor Scale score, if there are 60 minutes of travel time between a PSC and a highly efficient CSC only a PSC with a median DTN time of 30 minutes and a median DIDO of 50 minutes would be worth a stop. In the case of slower performance metrics at the PSC (ie, median DTN of 60 minutes and DIDO of 120 minutes) field triage to the CSC would be preferred (unless the patient would miss the 4.5-hour tPA eligibility window). Slow PSC metrics that do not meet calls to action set out by the international stroke communities are the reality in many places. Even among hospitals involved in the Get With The Guidelines Target Stroke Program, post intervention median DTN was 67 minutes (interquartile range, 51–87 minutes).37Using rapid arterial occlusion evaluation threshold scale score of ≥5 and current PSC performance metrics (DTN and DIDO times of 55 and 102 minutes), Schlemm et al38 recently reported the unconditional mothership (direct to CSC) scenario was preferred for LVO patients in their models and would be worthwhile even with delay to thrombolysis thresholds as high as >80 minutes. These authors concluded that revision of the 15-minute threshold set by the Mission: Lifeline Stroke triage algorithm39 should be considered. A 30-minute threshold would provide direct EVT access to EVT to nearly 40 million more Americans.40A real-world study of field triage for patients with a Los Angeles Motor Scale score ≥4 was recently performed in Rhode Island.41 Despite a median additional transport time to the more distant CSC of 7 minutes, scene departure to IVT and arterial puncture were faster in the mothership group (50 versus 62 minutes and 93 versus 152 minutes, respectively; P<0.001). Among patients who were independent before stroke, the odds ratio for less disability in the mothership group was 2.06 (95% CI, 1.10–3.89, P=0.01) in a matched pairs analysis. Moreover, the rate of symptomatic intracranial hemorrhage was higher in the transfer group compared with the mothership group (7% versus 1%, P=0.06). These results are consistent with the above-mentioned modeled data.While the Rhode Island geography may seem unique it is likely more similar to many others than dissimilar. In the greater Cincinnati area, median additional transport time to a CSC is 12 minutes, in the United States eighty-five percent of EMS transports are in an urban area, and in 2011 nearly 60% of the population was within 60 minutes of a CSC. One limitation of the study is a lack of documented field severity score for all patients and the rate and potential impact of over or under-triage was not assessed. The potential for over and under triage is important and the optimal radius for reducing the undertriage of LVO patients to EVT centers changes based on geographic and population factors.34More real-world data on field triage will be obtained from an ongoing randomized trials such as the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion) and TRIAGE trial (Optimizing Triage and Hospitalisation in Adult General Medical Emergency Patients). Telemedicine platforms and more sophisticated portable diagnostic tools may improve LVO screening in the field.Mobile Interventional Stroke TeamsA potential extension of the PSC LVO protocol described above would be to dispatch a neurointerventional team to perform the EVT at the PSC42–46 rather than transferring the patient to the CSC. The concept may be best suited for anatomically straight forward cases in patients that present with borderline ischemic change where it would be more efficient to drive the doctor to the hospital while the patient is taken to an appropriately resourced fluoroscopy suite to avoid drip-and-ship eligibility decay. The paradigm has recently been modeled in Germany and was a superior option to drip-and-ship transport.43Mobile Stroke UnitsMobile stroke unit technology is the holy grail of stroke care and promises to place the highest-level expertise in every stroke victim’s driveway. Specialized teams can administer IVT to achieve golden hour thrombolysis. With on-board CTA capability, the mobile stroke unit can specifically triage patients to the right place, every time. However, the success of these units on a population level will be both patient and geo-specific. While capital costs for these units are not unreasonable, operating costs may be overwhelming. The existing programs are primarily driven by philanthropy, but the fleet will expand as billing codes for this technology mature.Comprehensive (Level 1) Stroke Center Arrival to Arterial PunctureCSCs should have dedicated, specialized teams for the timely assessment and treatment of suspected LVO patients. Standardizing workflow both before and during EVT reduces the cognitive load of the stroke and neurointerventional teams.47 This workflow should be specific for (1) the known LVO transfer patient that goes directly to the angiography suite (DTAS), (2) a direct (mothership) code stroke arrival that has initial acute stroke imaging at the CSC CT, or (3) a direct (mothership) code stroke arrival (mothership) that goes DTAS.48For patients who are not known LVO transfers, patients with stroke arriving at the CSC must have timely vessel imaging—CTA is to LVO what ECG is to ST-segment–elevation myocardial infarction. As discussed earlier, stroke clinical severity scores may predict the likelihood of a LVO stroke, but they do not confirm or exclude it. Furthermore, CTA alters medical decision making for acute stroke patients in 50% of cases.49 For this reason, all hospitals that receive stroke patients should consider including CTA in their initial, acute stroke imaging protocol.49–51 If we do not assess all code strokes with CTA, we will never know the prevalence of LVO stroke—information needed to drive change in stroke systems of care.A detailed discussion of the decision to perform EVT is beyond the scope of this article, and formal guidelines have been published.52,53 However, it is important to remember that, for the suspected or confirmed LVO patient, it is the worst day of their life. While limited data exists, a benefit from mechanical thrombectomy may be seen across the National Institutes of Health Stroke Scale spectrum,54 for proximal or dominant M2 occlusions,55 and even in patients with significant early ischemic change.8,56 How much imaging is required to make a decision to perform EVT? There is a debate as to whether multiphase CTA or combined single-phase CTA and CTP should be used. Ultimately, the decision-making process comes down to 2 factors: (1) does the patient have a disabling deficit? (2) does the operator feel they can open the vessel with reasonably low complication rate? If the answers are yes, then doing the case may be best for the patient. Although this is our approach, other centers may want to adhere more closely to existing guidelines.52,53Confirmed LVO Transfers and DTASOur PSC LVO protocol was described in detail above.21 Once the LVO is confirmed at the PSC, the patient is transferred as quickly as possible to the CSC. Patients such as this should be transported DTAS; imaging should only be repeated if there is a significant clinical change during transport. Even if a clinical change occurs during transfer, modern day flat-panel detectors may be sufficient to detect any finding that would change the treatment decision.57,58 For LVO transfers, arterial puncture should ideally happen <30 minutes after CSC arrival.Direct to CSC Mothership and Direct to CSC CTFor code stroke patients brought directly to the CSC (mothership), we suggest this standard workflow50:Have a specialized stroke team in-house 24/7 (analogous to a level I trauma team) meet all code stroke patients at the door or ambulance triage.Have a direct to CT policy (ie, moving the patient directly to the CT scanner on EMS stretcher) for all code stroke patients.Concerns about renal dysfunction should not preclude obtaining a CTA (neurons over nephrons).Develop a protocol with noncontrast CT/multiphase CTA or noncontrast CT/CTA/CTP as the default imaging on all code stroke patients.When possible, administer IVT in the CT scanner, between noncontrast CT and CTA.The neurointerventional team should be alerted as early as possible for suspected LVO patients, ideally before vessel imaging confirmation.For mothership LVO stroke patients, arterial puncture should ideally occur within 60 minutes.Direct to CSC Mothership and DTASWhile LVO transfers should by default go DTAS,21,59 some centers are also transporting mothership suspected LVO patients DTAS.48,60 Intriguing as this is, we think mothership LVO DTAS should not yet be the default workflow for several reasons. Many centers do not have a dedicated neuroangiography suites for this purpose during the day and do not have overnight in-house neurointerventional teams. The false-positive rate of clinical severity scores may lead to angio team burn-out. Current imaging within the neuroangiography suite (20 seconds) is too vulnerable to patient motion. Finally, the head and neck CTA allows the neurointerventional team to assess anatomy and plan the procedure—anatomic discovery during a case should be avoided.61Quality Improvement and Data MonitoringExecuting the prehospital, PSC, and CSC strategies described above may increase early access to EVT and improve outcomes for LVO stroke (Figure 2 and Material in the Data Supplement). That said, any interventions to improve systems of care should be monitored, with data and transparency the ultimate drivers for performance improvement and change. The South Florida Stroke Consortium has established elegant data dashboards using Get With The Guidelines Target Stroke Program data sets that allow EMS, PSCs, and CSCs to collaborate and establish regional quality improvement initiatives—an essential model for the future.62 Helpful steps for changing point-of-entry protocols for suspected LVO patients would include as follows:Download figureDownload PowerPointFigure 2. Reorganizing our stroke systems of care may improve early access to and eligibility for endovascular therapy (EVT). Loss (large vessel occlusion patients left behind) compounds when criteria for doing CTA are restrictive, when appropriate point-of-entry criteria do not exist, and when case selection criteria are restrictive. Despite the better (80%) good outcome rate for Region A, Region B has helped more LVO patients. Each person graphic equals 50 people (see Data Supplement).Establishment of a regional stroke care committee, with representation from all regional hospitals, EMS, and local health care boards/authoritiesComparison of existing stroke protocols in the region with those for other acute care diseases (trauma and ST-segment–elevation myocardial infarction protocols)Educating EMS on the importance of scoring stroke severity in the field, beyond simply using a stroke screenEngage EMS leadership to help select the field severity score that would work best for their regionEducating legislators on the need for triage mechanisms to save lives and reduce health care costs.Future DirectionsGeospatial Location of Stroke CentersThe current number and geospatial distribution of stroke centers in many areas are antiquated, and perhaps, harmful in the new EVT era. In Rhode Island, there are 10 PSCs within 20 miles of a CSC (Figure 3). As discussed above, in an urban setting such as this the currently observed DTN and DIDO times at the PSC for these patients is paralyzing—figuratively and literally. While work in this area is limited, Phan et al63 have found that 2 EVT stroke centers were sufficient for metropolitan Melbourne (population of ≈4.9 million and population density of 12 400 per km2, 5 hospitals providing TPA and 5 hospitals providing EVT) with no benefit beyond that number.63 In Melbourne, 81.6% (142 of 174) suburbs are within 30 minutes of 1 EVT hospital and 13.2% suburbs are within 30 minutes of 5 EVT hospitals. Ultimately, data, collaboration, and transparency should be used to determine stroke center need, location, and field triage patterns.Download figureDownload PowerPointFigure 3. Voronoi map of Rhode Island written such that any point within each Voronoi (colored) cell is closest to the seed (hospital). There are 4 primary stroke center (PSC; blue icon) hospitals within 10 miles and 10 PSC hospitals within 20 miles of the Comprehensive Stroke Center (CSC; red icon). The map is accessible at https://gntem2.github.io/RhodeIsland/. In the new mechanical thrombectomy era, accreditation needs, and geospatial distribution of stroke centers may need to evolve so patients have a better chance to get to the right place, the first time.Technology and the Democratization of Stroke CareCurrent challenges with prehospital care and the need to leverage technology to democratize care were recently reviewed.64 The first robotic neurointerventional case was recently performed using the same platform for which telerobotic cardiac procedures have been performed (Corindus Inc, Waltham, MA).65 This technology holds tremendous promise for LVO patients in geographically remote locations.ConclusionsOur stroke systems of care must evolve to meet the need for access and speed in the new LVO EVT era. At the CSC, standardized imaging and treatment protocols are recommended. All PSCs should have a standardized LVO protocol with the CSC closest to them. Legislators and EMS leaders need to modernize point-of-entry for stroke and mirror what has already been done for trauma. Field triage of suspected LVO stroke patients directly to the CSC avoids devastating and unnecessary treatment delays, disability, and the associated downstream costs. Mobile stroke treatment units, telemedicine, and other technology will help overcome geographic and political barriers to democratize stroke care so that more patients get early access to EVT. Let us all work together to leave no LVO behind.Sources of FundingNone.DisclosuresDr McTaggart is a consultant for Stryker. Dr Holodinsky reports equity ownership in DESTINE Health Inc. Dr Cheung is a consultant for Stryker and Medtronic. Dr Manning is a consultant for Medtronic, Stryker, and Microvention. Dr Wenderoth is a consultant for Medtronic, Stryker, Microvention, and BALT. Dr Phan reports honorarium for lectures for Genzyme, Pfizer, Boehringer Ingelheim, and Bayer. Dr Goyal is a consultant for Medtronic, Stryker, Microvention, GE Healthcare, and Mentice. Dr Jayaraman is a consultant for Medtronic. Dr Ospel reports grants from the University of Basel Research Foundation, Julia Bangerter Rhyner Foundation, Freiwillige Akademische Gesellschaft Basel. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 1958.Dr McTaggart participated in conceptualization, drafting, and critical revision of the article and figures. K. Lane participated in figures and critical revision of the article. All remaining authors participated in the critical revision of the article.The Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.119.026735.Correspondence to: Ryan A. McTaggart, MD, Department of Diagnostic Imaging, Warren Alpert School of Medicine at Brown University, Rhode Island Hospital 593 Eddy Street, APC 701 Providence, RI 02903. Email ryan.[email protected]org