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Updated: Dec 30, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Prehospital selection of thrombectomy candidates beyond large vessel occlusion: M-DIRECT scale
Jorge Rodríguez-Pardo1, Nicolas Riera-López2, Blanca Fuentes1
1From the Department of Neurology (J.R.-P., B.F., M.A.d.L., S.S.-G., J.Á-F., E.D.-T.), Hospital Universitario La Paz, Universidad Autónoma de Madrid; Department of Neurology (J.V.-M.), Hospital Universitario La Princesa, Universidad Autónoma de Madrid; Stroke Code Coordination Center (N.R.-L., P.B.O., V.R.-M.), Servicio de Emergencias Médicas SUMMA-112; Department of Neurology (J.C.-R.), Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid; Department of Neurology (J.D.-G.), Hospital Universitario Doce de Octubre, Universidad Complutense de Madrid; Department of Neurology (J.E.-H.), Hospital Universitario Clínico San Carlos, Universidad Complutense de Madrid; Department of Neurology (A.G.-N.), Hospital Universitario Gregorio Marañón, Universidad Complutense de Madrid; and Department of Neurology (J.M.-V.), Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Spain. jrpardodedonlebun@salud.madrid.org blanca.fuentes@salud.madrid.org.
Objective:
Current prehospital scales used to detect large vessel occlusion reveal very low endovascular thrombectomy (EVT) rates among selected patients. We developed a novel prehospital scale, the Madrid-Direct Referral to Endovascular Center (M-DIRECT), to identify EVT candidates for direct transfer to EVT-capable centers (EVT-Cs). The scale evaluated clinical examination, systolic blood pressure, and age. Since March 2017, patients closer to a stroke unit without EVT capabilities and an M-DIRECT positive score have been transferred to the nearest EVT-C. To test the performance of the scale-based routing protocol, we compared its outcomes with those of a simultaneous cohort of patients directly transferred to an EVT-C.
Methods:
In this prospective observational study of consecutive patients with stroke code seen by emergency medical services, we compared diagnoses, treatments, and outcomes of patients who were closer to an EVT-C (mothership cohort) with those transferred according to the M-DIRECT score (M-DIRECT cohort).
Results:
The M-DIRECT cohort included 327 patients and the mothership cohort 214 patients. In the M-DIRECT cohort, 227 patients were negative and 100 were positive. Twenty-four (10.6%) patients required secondary transfer, leaving 124 (38%) patients from the M-DIRECT cohort admitted to an EVT-C. EVT rates were similar for patients with ischemic stroke in both cohorts (30.9% vs 31.5%). The M-DIRECT scale had 79% sensitivity, 82% specificity, and 53% positive predictive value for EVT. Recanalization and independence rates at 3 months did not differ between the cohorts.
Conclusions:
The M-DIRECT scale was highly accurate for EVT, with treatment rates and outcomes similar to those of a mothership paradigm, thereby avoiding EVT-C overload with a low rate of secondary transfers.
