Generalized Safety and Efficacy of Simplified Intravenous Thrombolysis Treatment (SMART) Criteria in Acute Ischemic Stroke: The MULTI SMART Study Sigrid B. Sørensen, MD,*† Nobl Barazangi, MD, PhD,*‡§ Charlene Chen, MD,*‡§ Christine Wong, MD,*‡§ David Grosvenor, MPH,*‡‖ Jack Rose, MD,*‡§ Ann Bedenk, RN,*‡§ Megan Morrow, RN,*‡§ Dan McDermott, MD,¶ Jens D. Hove, MD, PhD,†#** and David C. Tong, MD, FAAN, FAHA, FANA*‡§ Background: Common intravenous recombinant tissue plasminogen activator (IV rt-PA) exclusion criteria may substantially limit the use of thrombolysis. Prelim- inary data have shown that the SMART (Simplified Management of Acute stroke using Revised Treatment) criteria greatly expand patient eligibility by reducing thrombolysis exclusions, but they have not been assessed on a large scale. We evaluated the safety and efficacy of general adoption of SMART thrombolysis cri- teria to a large regional stroke network. Methods: Retrospective analysis of consecutive patients who received IV thrombolysis within a regional stroke network was per- formed. Patients were divided into those receiving thrombolysis locally versus at an outside hospital. The primary outcome was modified Rankin Scale score (≤1) at discharge and the main safety outcome was symptomatic intracranial hemor- rhage (sICH) rate. Results: There were 539 consecutive patients, and 50.5% received thrombolysis at an outside facility. Ninety percent of the patients possessed common conventional IV rt-PA contraindications. There were no significant differences between local and network treated patients in favorable outcome (45.4% versus 37.4%; odds ratio [OR], .72; P > .09), mortality (9% versus 14%; OR, 1.6; P > .07), or sICH rate (2.6% versus 5.1%; OR, 2.0; P = .13). Multivariate analysis showed no association between receiving IV rt-PA at an outlying spoke hospital and higher rate of sICH or worse outcome at discharge. Conclusions: Generalized application of SMART criteria is safe and effective. Widespread application of these criteria could sub- stantially increase the proportion of patients who might qualify for treatment. Key Words: Ischemic stroke—telemedicine—thrombolysis—stroke management. © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved. From the *CPMC Center for Stroke Research, San Francisco, California; †University of Copenhagen, Copenhagen, Denmark; ‡California Pacific Medical Center (CPMC) Comprehensive Stroke Care Center, San Francisco, California; §CPMC Department of Neurosciences; ‖Palo Alto Medical Foundation, Palo Alto, California; ¶CPMC Department of Emergency Medicine, San Francisco, California; #Cardiovascular Section, Department of Medicine, Hvidovre Hospital, Hvidovre, Denmark; and **Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Hvidovre, Denmark. Received September 11, 2015; revision received December 30, 2015; accepted January 6, 2016. Disclosures: Dr. Rose reported receiving personal fees from UCB for continuing service on the Speakers’ Bureau. Dr. Hove reported re- ceiving support from Amgen for his continuing service on an advisory board. Dr. Barazangi reported receiving personal fees from Genentech only in 2012 for completed work on the Speakers’ Bureau. No other authors reported disclosures. Address correspondence to David C. Tong, MD, FAAN, FAHA, FANA, CPMC Comprehensive Stroke Care Center and CPMC Center for Stroke Research, 2100 Webster Street, Suite 404, San Francisco, CA 94115. E-mail: tongdc@sutterhealth.org. 1052-3057/$ - see front matter © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2016.01.016 ARTICLE IN PRESS Journal of Stroke and Cerebrovascular Diseases, Vol. ■■, No. ■■ (■■), 2016: pp ■■–■■ 1