ObjectiveTo assess the feasibility and potential scalability of telemedicine-enabled ambulances for the prehospital evaluation of patients with suspected acute stroke symptoms. Patients and MethodsA pilot study of telemedicine-enabled ambulances for evaluating patients with suspected acute stroke symptoms en-route at two tertiary academic comprehensive stroke centers from January 1, 2018 to February 5, 2024. Charts of included patients were reviewed for demographic data, vascular risk factors, final diagnosis, time from arrival to neuroimaging, door to needle (DTN) and door to puncture (DTP) times in patients eligible for acute treatment, and any reported technical challenges during audio-video consultations. ResultsForty-seven patients (mean age 68.0 years; 62% males) were evaluated via telemedicine-enabled ambulances, of which 35 (74%) where for hospital-to-hospital transferred patients. Mean time from arrival to neuroimaging was 11.8 minutes. Twenty-nine patients (62%) were diagnosed with acute ischemic stroke and the remainder were diagnosed with intracranial hemorrhage (n=13), seizure (n=2), brain mass (n=1) or other diagnoses (n=3). Four patients (9%) received intravenous thrombolysis with alteplase (mean DTN 30.3 minutes), and 15 patients (32%) underwent mechanical thrombectomy (mean DTP time 72 minutes). Technical challenges were reported in 15/42 (36%) cases, of which 10 (67%) were related to poor internet connectivity. ConclusionTelemedicine-enabled ambulances in EMS systems are novel, feasible and potentially scalable options for evaluating patients with suspected acute stroke in the prehospital setting. However, optimization of infrastructure, staffing models, and internet connectivity is necessary, and larger studies evaluating the clinical and cost effectiveness of this approach are needed before widespread implementation.