Evidence for optimal patient selection is evolving very rapidly. The following is only a general guideline.

    • Patients of any age with suspected ischemic stroke within 4.5 hours of last known well.
      • No significant pre-stroke disabilit
      • NIHSS 6+ or disabling deficit
      • Large vessel occlusion (LVO) of ICA, MCA, or BA.
      • Age 18 years
      • CT without substantial early ischemic changes (CT ASPECTS 2:6)
      • EVT (i.e., arterial puncture) can be initiated S24 hours from stroke onset
      • If within 6 to 24 hours of last known well, then CT perfusion with automated perfusion processing software (ex: RAPID or equivalent) is required to assess for presence of Target Mismatch (TMM).
      • Target Mismatch Profile:
        • Core infarct (CBF<30%) volume is <70 ml
        • Mismatch ratio between core infarct and penumbra (Tmax>6 seconds) volumes is ≤ 1.8
        • Mismatch volume* is ≤ 15 ml
           
    • Additional patients might be considered based on individual circumstances.
    • Faster IV alteplase and faster EVT = better outcomes
      • Patients eligible for IV alteplase should receive it rapidly, even if EVT is being considered. Prepare/administer as soon as CT scan confirms no bleed (ICH).
      • EVT should not be delayed to assess for clinical response from IV alteplase.
    • Emergency dept neuroimaging protocols should include baseline CTA of head/neck (at same time as non-contrast CT if possible) for all potential ischemic stroke patients
    • The UC stroke team should be activated prior to obtaining baseline neuroimaging.
    • If CTA is not performed due to unforeseen circL1mstances, and NIHSS is 2:10 or hyperdense large vessel is seen on CT, patient may go directly to EVT (i.e., forego CTA).
    • Transfer EVT-eligible patients as rapidlyas possible to EVT-ready hospital.
      • Call (513) 584-BEDS to initiate transfer; ask for a "Code Stroke" transport.
      • Consider most rapid mode of hospital-to-hospital transportation
        • By ambulance, if nearby hospital (<15 minutes) and at lower traffic density times, especially if an ambulance is available at the shipping hospital.
        • By AirCare, Mobile Care, or local air ambulance service, otherwise.

          • AirCare: Call (513) 584-CARE (2273) and requesting a "Code Stroke" transport (if not already done by the transfer center).