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The mission lifeline severity-based stroke treatment algorithm: We need more time
  1. J Mocco1,
  2. David Fiorella2,
  3. Felipe C Albuquerque3
  1. 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA
  2. 2Department of Neurosurgery, State University of New York at Stony Brook, Stony Brook University Medical Center, Stony Brook, NY, USA
  3. 3Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
  1. Correspondence to Dr J Mocco, The Mount Sinai Health System, 1450 Madison Ave, KCC-1 North New York, NY 10029, USA; j.mocco{at}

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On March 10th, 2017 the American Heart Association presented their Mission Lifeline Severity-Based Stroke Treatment Algorithm For EMS. This document consisted of single page algorithm written to provide guidance to EMS providers regarding the triage and transport of suspected stroke patients, as well as a single explanatory page ( Specifically, patients with suspected emergent large vessel occlusion (ELVO) (based on pre-hospital stroke assessment), who were last know well within 6 hours, are to be considered for direct transfer to an endovascular capable center if such a direct transfer will not delay arrival at a stroke center by more than 15 minutes.

The AHA acknowledges that level I data are lacking to support a firm recommendation on the acceptable delay in arrival at a stroke center when considering re-routing patients. They therefore state that the committee felt it “was best to err on the side of caution and initially set the additional transport delay to 15 minutes”.

The JNIS applauds the AHA's effort to further the important conversation of stroke patient triage and transfer. We also recognize that the document's authors acknowledge fallability of any algorithm, and clearly state that this algorithm is not a final or comprehensive answer to the many problems currently relevent to communities struggling to provide timely care for stroke patients. However, we feel that there are a number of critical limitiations to the document that should be addressed and discussed in the broader community. It is our hope to engender a constructive conversation, which will ultimately lead to a revised recommendation and the best possible care for stroke patients.

In 2015 and 2016, seven concordant randomized controlled trials powerfully and unequivocally demonstrated that for ELVO, thrombectomy results in markedly better patient outcomes than does treatment with IV-tPA alone.1–7 The differences between treatment groups were massive, …

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