Despite significant progress in hospital quality initiatives and the organization of regional stroke systems of care, a significant gap persists between the number of patients eligible for acute ischemic stroke reperfusion therapies and those who receive them in a timely manner. This gap reflects persistent delays and variability across the prehospital and interhospital phases of care, from prehospital dispatch and field assessment to destination selection and interhospital transfer workflows. This expert narrative review synthesizes current evidence on acute stroke systems of care, with a particular focus on prehospital identification of stroke, destination decision-making for suspected large-vessel occlusion, and interhospital transfer for patients requiring endovascular thrombectomy. Key processes, including prehospital response and scene times, destination decision-making, and door-in-door-out metrics, are examined to illustrate how system-level bottlenecks affect access to and outcomes of reperfusion therapies. Emerging and novel technologies are also described, including mobile stroke units, blood-based biomarkers for prehospital stroke diagnosis, portable neuroimaging modalities, physiological and device-based detection systems, and cross-cutting tools such as telestroke, all aimed at shifting accurate diagnosis and treatment decisions earlier in the stroke care pathway.

Stroke is less common in children than in adults, yet equally devastating. Nevertheless, children with symptoms of acute stroke commonly present to community hospitals or adult stroke centers where experience and institutional protocols for pediatric stroke diagnosis and management may be limited. Despite advances in pediatric stroke awareness and the implementation of stroke pathways in many children's hospitals, significant gaps remain in the timely recognition, diagnosis, and management of pediatric stroke. A key contributing factor is the lack of system-level infrastructure to guide pediatric acute stroke care. This special report examines the challenges and barriers to achieving Pediatric Stroke Readiness at a national level in the United States and presents 5 engagement case studies highlighting efforts to establish processes and networks for pediatric stroke management across diverse care settings. The cases emphasize the development and implementation of systems of care in which pediatric stroke centers collaborate with first responders, community hospitals, and adult stroke centers to improve the delivery of acute stroke care for children. The strategies underscore different engagement approaches and identify opportunities for future research and quality improvement. These case studies also illustrate educational materials and clinical pathways that may serve as resources for others pursuing similar initiatives.