The clinical policy on the management of adult patients presenting to the emergency department (ED) with acute ischemic stroke, was approved by the ACEP Board of Directors in April 2023.

Developed by the ACEP Clinical Policies Committee, the guidance was published in the August 2023 issue of the Annals of Emergency Medicine. You can find it on ACEP’s website, www.acep.org/clincialpolicies, as well as in the ECRI Guidelines Trust.

Approximately 800,000 people in the United States are diagnosed with a stroke each year at an estimated cost of approximately 46 billion dollars. As a result, stroke remains one of the leading causes of death, as well as the leading cause of disability. Nearly 30 percent of all patients with an acute ischemic stroke have a large vessel occlusions (LVO), whereas 12 percent of acute stroke patients are thought to be candidates for endovascular thrombectomy (EVT). Because timely access to the expertise and resources needed to perform EVT is limited for much of the U.S. population, question one examines the use of out-of-hospital decision aids to assist in identifying suspected LVO patients who may be candidates for EVT.

Diagnosing an acute stroke patient with an LVO who may be a candidate for EVT requires advanced imaging, such as computed tomography angiography (CTA). However, identifying which suspected stroke patients are likely to have an LVO can be challenging. This has implications for determining who should receive advanced imaging, such as a CTA, in the ED or potentially be diverted to an EVT-capable stroke center. Question two examines the addition of computed tomography perfusion (CTP) to CTA or MRA to identify patients more likely to benefit from thrombectomy.

Recently, there has been interest in the use of tenecteplase for acute ischemic stroke. Question three compares the published literature comparing the safety and effectiveness of tenecteplase versus alteplase.

Finally, patients who present with dizziness can present a diagnostic challenge to emergency physicians trying to differentiate a peripheral from a central cause. Although the rate of misdiagnosis of stroke in patients who are discharged home from the ED with a diagnosis of peripheral vertigo is less than 0.2 percent, up to 37 percent of posterior circulation strokes are missed on initial presentation. Because the mortality of a missed posterior circulation stroke can be significantly higher than those with cerebellar strokes in general, Question four examines the strategies that are needed to prevent misdiagnosis.