14
Emergency Evaluation and Treatment
3.1. Stroke Scales
COR LOE
Recommendation
1 B-NR
1. In patients with suspected AIS, the use of a stroke severity
rating scale, preferably the NIHSS, is recommended for
measuring clinical deficits at baseline and after reperfusion
therapies.
3.2. Initial, Vascular, and Multimodal Imaging Approaches
COR LOE
Recommendations
IVT Evaluation
1 A
1. In patients with suspected AIS, emergent brain imaging
with NCCT or MRI is recommended on initial evaluation
to assess ischemic burden (eg, ASPECTS) and exclude
intracranial hemorrhage before initiating reperfusion
interventions (see Figure 2).
1 B-NR
2. In hospital systems that care for patients with suspected AIS,
protocols based on process improvement initiatives should be
established so that emergent brain imaging can be performed
as rapidly as possible (eg, within 25 minutes) to facilitate
timely reperfusion interventions.
1 B-NR
3. In patients with suspected AIS and LVO, emergent vascular
imaging with contrast-enhanced CTA and/or CTP should
not be delayed to obtain serum creatinine concentration.
2a C-LD
4. (New and of High Impact) In pediatric patients with suspected
AIS, emergent brain and vascular imaging with MRI/MRA
of the cervical and intracranial vessels is reasonable to identify
patients with large vessel occlusion and to differentiate arterial
ischemic stroke from hemorrhagic stroke or stroke mimics.
2a C-LD
5. (New and of High Impact) In pediatric patients with
suspected AIS, emergent brain and vascular imaging with
CT/CTA of the cervical and intracranial vessels is reasonable
if MRI/MRA imaging is not available immediately (within
25 minutes) to identify patients with large vessel occlusion.
2a B-R
6. In patients with suspected AIS who awaken from symptoms
or have unknown time of onset >4.5 hours from last known
well, but are otherwise eligible for thrombolysis, MRI
DWI-FLAIR mismatch selection can be useful to determine
eligibility for extended window IVT.
2a B-R
7. In patients with suspected AIS who awaken with symptoms or
have unknown time of onset 4.5 to 24 hours from last known
well, CTP or MR DWI-PWI (perfusion-weighted imaging )
selection with automated postprocessing software analysis can
be useful to determine eligibility for extended window IVT.
