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Purpose   Many patients suffer a stroke at a significant distance from a specialized center capable of delivering endovascular therapy. As a result, they require rapid transport by helicopter emergency medical services, sometimes while receiving a recombinant tissue plasminogen activator infusion (drip and ship). Despite its critical role in the new era of reperfusion, helicopter emergency medical services remains a poorly evaluated aspect of stroke care.Method   Comprehensive narrative review of all published articles of helicopter emergency medical services related to acute stroke care in the inter-hospital and pre-hospital settings, including technical aspects and physical environment implications.Findings   Helicopter emergency medical services transports are conducted during a critical early time period when specific interventions and ancillary care practices may have a significant influence on outcomes. We have limited knowledge of the potential impact of the unusual physical factors generated by the helicopter on the ischemic brain, which affects our ability to establish rational guidelines for ancillary care and the delivery of specific interventions.Discussion   Unlike the pre-hospital and hospital settings where stroke interventions are delivered, the inter-hospital helicopter emergency medical services transfer setting remains a “black box” for acute stroke care and research. This gap is particularly relevant for many patients living in rural areas, or in congested urban areas, that depend on helicopter emergency medical services for rapid access to a tertiary stroke center.Conclusion   Addressing the helicopter emergency medical services stroke gap in clinical trials and acute care delivery would homogenize capabilities through all care settings, thus minimizing potential disparities in research access and outcomes based on geographical location.

Helicopter transportation in the era of thrombectomy: The next frontier for acute stroke treatment and research