Suspected stroke is a common scenario for emergency medical services (EMS) which typically triggers urgent transportation to the nearest stroke-admitting hospital with prenotification according to local protocols.1 2 This linear pathway is appropriate for the majority of presentations and facilitates access to time-critical treatments, such as intravenous thrombolysis. However, suspected stroke is also a heterogeneous population, and it is likely that care delivery and resource utilisation would be improved by earlier triage for two subgroups at opposite ends of the clinical severity spectrum:

1. Patients with transient symptoms suggestive of transient ischemic attached (TIA), who could avoid immediate hospitalisation if rapid outpatient specialist review is available.

2. Patients with ongoing severe symptoms indicative of possible large vessel occlusion, who might benefit from bypassing the nearest hospital in favour of a comprehensive stroke centre (CSC) with the facilities required to provide mechanical thrombectomy.

As there are no portable diagnostic tests to identify these subgroups in standard ambulances, triage decisions must rely on clinical assessment alone, which may result in undesirable trade-offs for some aspects of care. In this challenging context, what evidence do we currently have, and still need, regarding the benefits of a more sophisticated emergency stroke pathway?

Following a systematic review which identified no previously published examinations of …