4. Index test and reference standard.

Study ID	Setting	Index tests	Test administrator	Training	Reference standard
Andsberg 2017	Prehospital	PreHAST	Nurse	4‐hour educational program, covering basic stroke knowledge and assessment and grading of stroke symptoms according to PreHAST; it included practical PreHAST training in pairs, where each ambulance nurse performed the PreHAST items under supervision and proper execution. During the study an instruction video for PreHAST was available on YouTube.	2 stroke physicians, blinded to the PreHAST scores, independently reviewed the medical records of the participants, including evaluation of history, clinical and radiologic findings. In case of disagreement, a third evaluator adjudicated the final diagnosis.
Berglund 2014	Prehospital	FAST	Nurse or paramedic	1 lecture about stroke and the FAST test, prior to start of the study.	CT brain scan and in some cases CTA or MRI, neurologic examination, if necessary, EEG (differential diagnosis), laboratory tests. All participants received a final diagnosis by a neurologist or stroke specialist.
Bergs 2010	Prehospital	CPSS, FAST, LAPSS, MASS	Nurse	All nurses were briefed on purpose of study, stroke scales and guidelines.	Diagnosis at ER discharge (unspecified).
Bray 2005a	Prehospital	CPSS, LAPSS, MASS	Paramedic	1‐hour educational session on stroke and use of the prehospital stroke scale.	Standard criteria for diagnosis of stroke or TIA (Warlow 2001); review of discharge diagnosis (no further details).
Bray 2010	Prehospital	CPSS, MASS	Paramedic	1‐hour educational program and instruction on use of the MASS.	Discharge diagnosis based on hospital stroke registry.
Chen 2013	Prehospital	LAPSS	Paramedic	3 hours' LAPSS‐based stroke training session with 3 experts from study team.	2 blinded neurologists reviewed the ER charts, recorded final ER discharge diagnoses, and verified absence or presence of potential stroke symptoms. The medical documents and neuroimaging records were reviewed before the final diagnoses were verified.
Chenkin 2009	Prehospital	OPSST	Paramedic	90‐minute training session on the stroke screening tool prior to implementation.	Hospital discharge diagnosis (no further details).
Ding 2009	Prehospital	LAPSS	Emergency physician	Not reported.	Hospital final diagnosis made by a specialist group including a neurologist, a radiologist and a generalist.
English 2018	Prehospital	CPSS	Paramedic	1‐hour online module annually on stroke recognition and assessment in the field as part of their required job training.	Hospital discharge diagnosis (no further details).
Fothergill 2013	Prehospital	FAST, ROSIER	Paramedic	1‐hour stroke educational program, scenario based demonstration of ROSIER, 15‐minute educational DVD.	Final diagnosis made by a stroke consultant or other senior medical physician caring for the person within 72 hours of the person's admission to hospital, based on CT and MRI scans. The final diagnosis was confirmed by a senior stroke consultant.
Frendl 2009	Prehospital	CPSS	Paramedic	1‐hour interactive educational presentation on stroke recognition and use of the CPSS.	Hospital discharge diagnosis based on the results of routine clinical, laboratory and radiographic evaluations.
Kidwell 2000	Prehospital	LAPSS	Paramedic	Video vignettes of paramedics performing the LAPSS examination on 3 people with stroke, 1 stroke mimic person, and 1 healthy person. Following a LAPSS‐focused education session, trainees had to pass an exam which, if failed, was followed by further training.	For all runs, 1 blinded author reviewed ER charts, recorded final ER discharge diagnoses and confirmed absence or presence of potential stroke symptoms. On all potential target stroke runs, 1 blinded author additionally examined all inpatient medical records to confirm hospital discharge diagnoses of stroke/TIA by review of reports from imaging studies and attending physician notes. For people with the diagnosis of TIA, a consensus on final diagnosis was reached after complete medical record review and case discussion with a second stroke neurologist. In all people with cerebral infarct and intracerebral hemorrhage, the diagnosis of the blinded reviewer agreed with the charted diagnosis of the attending neurologist.
Kim 2017	Prehospital	CPSS	Paramedic	Not reported.	Hospital medical records.
Mingfeng 2012	Prehospital	CPSS, ROSIER	Emergency physician	6‐hour course on ROSIER and CPSS.	The final discharge diagnosis of stroke/TIA made by neurologists and based on CT or MRI.
Mingfeng 2017	Prehospital	CPSS, ROSIER	GP	Trained by emergency physicians on the use of the ROSIER scale and CPSS for 10 hours before the study.	Final discharge diagnosis of stroke or TIA made by neurologists reviewing all diagnostic information including CT scan of the brain (immediately after transfer), blood tests and 12‐lead ECG conducted in the ER; comprehensive neurologic assessment including additional tests, such as continuous ECG monitoring, 24‐hour Holter ECG, duplex carotid and cardiac ultrasound, TCD, MRI or MRA, and conventional cerebral angiography were performed as requested by the neurologists once the person was transferred to the neurology ward. The neurologists who made the final diagnosis were blinded to the results from the ROSIER and CPSS.
Ramanujam 2008	Prehospital	CPSS	Paramedic	Annual 1‐hour education session on recognizing stroke.	Discharge diagnosis for people in stroke registry.
Studnek 2013	Prehospital	CPSS, MedPACS	Paramedic	2‐hour continuing education lecture regarding neurologic emergencies.	Discharge diagnosis of stroke/TIA.
Jackson 2008	ER	ROSIER	Emergency physician	No training reported.	Patients' records were later followed up to determine accuracy of initial diagnosis; stroke confirmed on investigation (no further details reported).
Jiang 2014	ER	ROSIER	Emergency physician or nurse	The research staff received the specific training by a stroke nurse and a module/exam provided by the NIHSS website.	The final diagnoses were made after people suspected of stroke were reviewed by the stroke team and after review of clinical symptoms and the acute neuroimaging (CT and MRI).
Lee 2015	ER	FAST, ROSIER	Emergency physician	3 hours of training on theory of stroke and the acute stroke registration system from an emergency medicine specialist.	Ischemic stroke and bleeding were determined in accordance with brain CT and MRI results. The final diagnosis was confirmed at the time through the electronic medical record.
Nor 2005	ER	ROSIER	Emergency physician	Regular educational program on the use of the instrument with twice monthly updates given to small groups of ER staff.	Final diagnosis made by the consultant stroke physician, after assessment and review of clinical symptomatology and brain imaging findings.
Vanni 2011	ER	CPSS	Nurse	No training reported.	TIA was excluded from the target condition. Stroke diagnosis established by a consensus of 3 experts, blinded to the index test results, after reviewing all clinical data and brain imaging results.
Whiteley 2011	ER	FAST, ROSIER	Emergency physician or nurse	No training reported.	Diagnosis made by a panel of experts, who had access to the clinical findings, imaging results and the person's subsequent clinical course.

CPSS: Cincinnati Prehospital Stroke Scale; CT: computed tomography; CTA: computed tomography angiography; ECG: electrocardiogram; ER: emergency room; EEG: electroencephalogram; FAST: Face Arm Speech Time; LAPSS: Los Angeles Prehospital Stroke Scale; MASS: Melbourne Ambulance Stroke Scale; MRA: magnetic resonance angiography; MRI: magnetic resonance imaging; NIHSS: National Institutes of Health Stroke Scale; OPSST: Ontario Prehospital Stroke Screening Tool; PreHAST: PreHospital Ambulance Stroke Test; ROSIER: Recognition of Stroke in the Emergency Room; TCD: transcranial Doppler; TIA: transient ischemic attack.