European Stroke Organisation survey on reperfusion therapy practices

Rapid reperfusion remains critical in acute ischaemic stroke, yet substantial prehospital delays persist. Clinicians across Europe widely use stroke code protocols and reperfusion strategies. However, clinicians lack routine data in clinical practice on prehospital triage, workflow organisation and performance monitoring.

The European Stroke Organisation (ESO) Endovascular Task Force conducted a multinational, cross-sectional, scenario-based e-survey. The survey targeted emergency medical services (EMS), primary stroke centres (PSCs) and comprehensive stroke centres (CSCs). It evaluated how teams assess patients in the prehospital setting, select transport methods, organise workflows, monitor time intervals and audit practices in European stroke networks.

A total of 296 responses from 43 European countries were analysed. Most originated from urban settings and CSCs. Stroke code activation and hospital pre-notification occurred in over 90% of EMS scenarios. Among EMS respondents, 80.4% transported patients with mild-to-moderate symptoms to the nearest hospital capable of intravenous thrombolysis. However, in cases with suspected LVO, transport destinations varied: 49.0% were transported to PSCs, 31.4% were transported to CSCs and 19.6% were transported to the nearest hospital regardless of reperfusion capability. Monitoring of key time intervals was inconsistent. Emergency medical services did not monitor call-to-hospital arrival times in 25.5% of services. Only 46.7% of PSCs and 53.5% of CSCs routinely monitored EMS arrival times. At the PSC level, 25.0% did not monitor door-in-door-out time, and 30.0% reported dedicated stroke teams were unavailable during nights and weekends. At the CSC level, admission-to-reperfusion time was monitored in 90.8% of centres, but only 28.6% audited delays when they occurred. Additionally, 42.2% of CSCs reported no on-site neuro-interventional team availability during nights or weekends. Fewer than two-thirds of EMS and PSC services, and about one-third of CSCs, reported regular audit activity.

Although stroke code activation and pre-notification are widely implemented across Europe, this survey identifies important gaps in systematic time monitoring and audit practices, alongside a lack of continuous (24/7) specialist coverage across the stroke care pathway. Key performance metrics are frequently not tracked, and audit-driven quality improvement remains limited.