Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Acute Ischemic Stroke

This clinical policy from the American College of Emergency Physicians addresses key issues in acute stroke management in adult patients presenting to the emergency department. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: 1) In adult patients with a suspected acute ischemic stroke, can a clinical decision instrument be used to identify patients who have a large vessel occlusion on computed tomography angiography or magnetic resonance angiography? 2) In adult patients with a suspected acute ischemic stroke, does the addition of perfusion imaging to a computed tomography angiography or magnetic resonance angiography identify patients more likely to benefit from thrombectomy? 3) In adult patients with a suspected acute ischemic stroke qualifying for intravenous thrombolysis, is tenecteplase safe and effective compared with alteplase? 4) In adult patients who present with acute vertigo with possible stroke, are there history or physical examination findings (eg, Head Impulse-Nystagmus-Test of Skew examination) that can risk stratify for acute ischemic stroke? Evidence was graded, and recommendations were made based on the strength of the available data.