Introduction: Early recognition and referral are critical to minimizing morbidity and mortality in acute stroke, but evaluation and referral processes differ worldwide. In this systematic review we examined the accuracy of recognition tools, referral patterns, outcomes, and factors affecting efficiency in primary and emergency care settings.
\nMethods: Following PRISMA 2020 guidelines, we searched PubMed, Scopus, Web of Science, and Cochrane Library for studies published January 2003–December 2025. Eligible studies included randomized controlled trials, cohort, case-control, cross-sectional, and large case series (> 30 patients) involving adults with acute ischemic or hemorrhagic stroke. Risk of bias was assessed using Cochrane Risk-of-Bias 2 (RoB) and RoB in non-standardized studies-I. We extracted data on diagnostic accuracy, referral pathways, outcomes, and systemic factors.
\nResults: We identified 206 papers, of which 33 studies met our inclusion criteria. Recognition tools such as Face, Arms, Speech, Time (FAST); Recognition of Stroke in the Emergency Room, the Cincinnati Prehospital Stroke Scale, and National Institutes of Health Stroke Scale showed good pooled sensitivity (79-95%) but variable specificity (52-84%). Newer technologies, including the PreHospital Ambulance Stroke Test, FAST-ED, and artificial intelligence (AI)-based models, showed promise but need validation. Referral strategies such as emergency medical services prenotification, dispatcher triage, and mobile stroke units reduced prehospital delays. Seven studies reported onset-to-door times 12-22 minutes faster and 7-12% increase in reperfusion eligibility. Increased referral efficiency was associated with a reduction in mortality of approximately 8-12% and improvements in functional independence of 10-15%, with persistent disparities reported in resource-limited settings.
\nConclusion: Early recognition and referral improve outcomes in patients with acute stroke. Structured tools and system-level interventions reduce mortality, while AI and mobile stroke units show promise. Strengthening referral systems and adopting cost-effective triage strategies may support equitable implementation, particularly in low-resource settings, as addressing systemic and geographic barriers is critical for equitable stroke care.
","language":"eng","license":{"name":"Creative Commons Attribution 4.0","short_name":"CC BY 4.0","text":"Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.\r\n\r\nNo additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.","url":"https://creativecommons.org/licenses/by/4.0"},"keywords":[{"word":"Acute Stroke"},{"word":"Prehospital stroke recognition"},{"word":"diagnostic accuracy"},{"word":"EMS prenotification"},{"word":"Referral patterns"}],"section":"Systematic Review (Limit 4000 words)","is_remote":true,"remote_url":"https://escholarship.org/uc/item/3pt1v7mj","frozenauthors":[{"first_name":"Thamer Majed","middle_name":"","last_name":"Almunif","name_suffix":"","institution":"College of Medicine, Imam Muhammad Ibn Saud Islamic University, Department of Family Medicine, Riyadh, Saudi Arabia","department":""},{"first_name":"Abdulaziz Fahd","middle_name":"","last_name":"Alkaabba","name_suffix":"","institution":"College of Medicine, Imam Muhammad Ibn Saud Islamic University, Department of Family Medicine, Riyadh, Saudi Arabia","department":""},{"first_name":"Khaled Waleed","middle_name":"","last_name":"Alomran","name_suffix":"","institution":"College of Medicine, Imam Muhammad Ibn Saud Islamic University, Department of Family Medicine, Riyadh, Saudi Arabia","department":""},{"first_name":"Abdullah Mfwadh","middle_name":"","last_name":"Alanazi","name_suffix":"","institution":"College of Medicine, Imam Muhammad Ibn Saud Islamic University, Department of Family Medicine, Riyadh, Saudi Arabia","department":""},{"first_name":"Faris Nashmi","middle_name":"","last_name":"Alharbi","name_suffix":"","institution":"College of Medicine, Imam Muhammad Ibn Saud Islamic University, Department of Family Medicine, Riyadh, Saudi Arabia","department":""},{"first_name":"Safar Saad","middle_name":"","last_name":"Alshahrani","name_suffix":"","institution":"College of Medicine, Imam Muhammad Ibn Saud Islamic University, Department of Family Medicine, Riyadh, Saudi Arabia","department":""},{"first_name":"Naif Mansour","middle_name":"","last_name":"Alsaeed","name_suffix":"","institution":"College of Medicine, Imam Muhammad Ibn Saud Islamic University, Department of Family Medicine, Riyadh, Saudi Arabia","department":""},{"first_name":"Rayan Ahmed","middle_name":"","last_name":"Alabdulkader","name_suffix":"","institution":"College of Medicine, Imam Muhammad Ibn Saud Islamic University, Department of Family Medicine, Riyadh, Saudi Arabia","department":""},{"first_name":"Sultan Adel","middle_name":"","last_name":"Alibraheem","name_suffix":"","institution":"College of Medicine, Imam Muhammad Ibn Saud Islamic University, Department of Family Medicine, Riyadh, Saudi Arabia","department":""},{"first_name":"Khaled saeed","middle_name":"","last_name":"Alzahrani","name_suffix":"","institution":"College of Medicine, Imam Muhammad Ibn Saud Islamic University, Department of Family Medicine, Riyadh, Saudi Arabia","department":""},{"first_name":"Mohammed Hamad","middle_name":"","last_name":"Albagieh","name_suffix":"","institution":"College of Medicine, Imam Muhammad Ibn Saud Islamic University, Department of Family Medicine, Riyadh, Saudi Arabia","department":""}],"date_submitted":"2025-09-03T06:49:03.661000Z","date_accepted":"2025-12-20T21:07:01.226000Z","date_published":"2026-01-24T09:40:00Z","render_galley":null,"galleys":[{"label":"PDF","type":"pdf","path":"https://journalpub.escholarship.org/westjem/article/50827/galley/48035/download/"}]}