The critical questions were based on feedback from ACEP members. A systematic review of the evidence was conducted and the committee made recommendations (Level A, B, or C) based on the strength of evidence available. This clinical policy underwent internal and external expert review and was available for review by ACEP members during an open comment period. Responses received were used to refine and enhance the final policy.

Critical Questions and Recommendations

Question 1: In adult patients with a suspected acute ischemic stroke, can a clinical decision instrument be used to identify patients who have an LVO on CTA or MRA?

Patient Management Recommendations

• Level A recommendations: None specified.
• Level B recommendations: None specified.
• Level C recommendations: In adult patients with suspected stroke, either the Los Angeles Motor Scale (LAMS) or Rapid Arterial Occlusion Evaluation Scale (RACE) may be used to identify patients with increased likelihood of an LVO.

Question 2: In adult patients with a suspected acute ischemic stroke, does the addition of perfusion imaging to a CTA or MRA identify patients more likely to benefit from thrombectomy?

Patient Management Recommendations

• Level A recommendations: None specified.
• Level B recommendations: None specified.
• Level C recommendations: Obtain CTP or MR-based diffusion/perfusion imaging in patients with acute ischemic stroke because of LVO, especially if the time the patient was last known normal was between 6 and 24 hours before arrival to the ED.

Question 3: In adult patients with a suspected acute ischemic stroke qualifying for intravenous thrombolysis, is tenecteplase safe and effective compared with alteplase?