Since the publication of the first five randomized controlled trials demonstrating the benefit of endovascular therapy (EVT) for large vessel occlusion (LVO) stroke, EVT has become widely adopted. ^{Reference Goyal, Menon and van Zwam1} Both clinical experience and pooled analyses confirm that the shorter the interval from symptom onset to reperfusion, the better the neurological outcome.

However, rapidly and reliably routing patients with suspected LVO to a comprehensive stroke center (CSC) remains challenging. Only a limited number of hospitals can assume CSC status because continuous EVT capability requires an angiography suite, stroke-trained staff, neurointervention, a neurointensive unit and a neurosurgical backup. ^{Reference Pierot, Jayaraman and Szikora2} In geographically vast and low population density countries, such as Canada, logistics becomes even more complex.

Two organizational models have emerged:

• Drip-and-ship. Patients receive an initial assessment and intravenous thrombolysis at the nearest primary stroke center (PSC) and are secondarily transferred for EVT if required.

• Mothership. Emergency medical services (EMS) bypass PSCs and transport the patient directly to the nearest CSC.

Each strategy has context-specific advantages and drawbacks, and the optimal choice is influenced by the population density, geographic distribution, interhospital transfer times and EMS resources.

To establish a system, several factors must be considered:

• The unknown diagnosis of the patients on the field (stroke vs other diseases and stroke subtypes)

• Geographical distribution of the patients with respect to the stroke center

• Immediate cost and longtime sustainability of the system

Panzini et al. ^{Reference Panzini, Halabi and Stang3} describe an innovative, province-wide pathway in Alberta that combines algorithm-based triage with existing EMS infrastructure. Paramedics apply the Alberta Stroke Screening Tool (diagnosis) together with the Los Angeles Motor Scale (severity) at the first point of contact. Subsequently, an emergency call is made to the vascular neurological team. When an LVO is likely, the ambulance proceeds directly to the nearest CSC. Among all suspected strokes during the study period, only 2.7 % activated this system, yet the time metrics were compelling: the median first-medical-contact-to-groin-puncture interval was 3.2 h (IQR 1.3–7.6) for patients routed straight to a CSC versus 6.5 h (IQR 4.6–7.9) for those initially delivered to a PSC and then transferred due to incorrect assignment. In summary, the efficacy of the systems roughly halved the time to the groin puncture.

These results demonstrate that even in sparsely populated regions, a highly efficient EVT pathway can be implemented at a reasonable cost by refining existing EMS protocols rather than creating entirely new systems. Broader adoption will require ongoing quality monitoring, staff education and periodic recalibration of the triage algorithm as stroke systems have evolved.