13. Quality improvement EMS services: Develop regional systems of stroke care consisting of healthcare facilities providing initial emergency care, including administration of IV alteplase, and centers capable of performing endovascular stroke treatment with comprehensive periprocedural care to which rapid transport can be arranged when appropriate. A Develop triage paradigms and protocols to ensure that patients with a known or suspected stroke are rapidly identified and assessed by use of a validated and standardized tool for stroke screening by emergency medical services leaders, in coordination with local, regional, and state agencies and in consultation with medical authorities and local experts. B Stroke centers/units: certify stroke centers by an independent external body. B Show 6 more Organization of care: develop, adopt, and adhere to care protocols reflecting current care guidelines as established by national and international professional organizations in all hospitals caring for stroke patients within a stroke system of care. B Show 4 more Telemedicine: implement teleradiology systems (approved by the US FDA) for timely review of brain imaging in patients with suspected acute stroke in sites without in-house imaging interpretation expertise. Recognize that teleradiology systems (approved by the US FDA) implemented within a telestroke network are effective in supporting rapid imaging interpretation in time for IV alteplase administration decision making. A https://web.pathway.md/diseases/recwd1RIpW03JSM4H 26/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway Show 5 more Outcome measures: organize a multidisciplinary quality improvement committee in healthcare institutions to review and monitor stroke care quality benchmarks, indicators, evidence-based practices, and outcomes. Consider forming a clinical process improvement team and using a stroke care registry for such quality of care assurances. Consider using a data repository to identify the gaps or disparities in quality stroke care. Consider initiating specific interventions once the gaps have been identified to address these gaps or disparities. B Show 2 more Public health measures: design and implement public education programs focused on stroke systems and the need to seek emergency care in a rapid manner. B Health equity: assess and address social determinants of health (literacy level, language proficiency, medication affordability, food insecurity, housing, and transportation barriers) when managing stroke risk factors to reduce healthcare disparities. B Show 3 more References 1. William J Powers, Alejandro A Rabinstein, Teri Ackerson et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50 12):e344-e418. Open 2. Dawn O Kleindorfer, Amytis Towfighi, Seemant Chaturvedi et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021 Jul;52 7):e364-e467. Open 3. George Ntaios, Tomasz Dziedzic, Patrik Michel et al. European Stroke Organisation ESO guidelines for the management of temperature in patients with acute ischemic stroke. Int J Stroke. 2015 Aug;10 6 941 9. Open 4. Blanca Fuentes, George Ntaios, Jukka Putaala et al. European Stroke Organisation ESO guidelines on glycaemia management in acute stroke. Eur Stroke J. 2018 Mar;3 1 5 21. Open 5. Rainer Dziewas, Emilia Michou, Michaela Trapl-Grundschober et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J. 2021 Sep;6 3 LXXXIX CXV. Open 6. Furie KL, Kasner SE, Adams RJ et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association. Stroke. 2011 Jan;42 1 227 76. Open 7. Marios Psychogios, Alex Brehm, Elena L pez-Cancio et al. European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease. Eur Stroke J. 2022 Sep;7 3 III IV. Open 8. Powers WJ, Rabinstein AA, Ackerson T et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Mar;49 3):e46-e110. Open https://web.pathway.md/diseases/recwd1RIpW03JSM4H 27/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway 9. Bushnell C, McCullough LD, Awad IA et al. Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 May;45 5 1545 88. Open 10. Christine Kremer, Zuzana Gdovinova, Yannick Bejot et al. European Stroke Organisation guidelines on stroke in women: Management of menopause, pregnancy and postpartum. Eur Stroke J. 2022 Jun;7 2 I XIX. Open 11. A Kobayashi, A Czlonkowska, G A Ford et al. European Academy of Neurology and European Stroke Organization consensus statement and practical guidance for pre-hospital management of stroke. Eur J Neurol. 2018 Mar;25 3 425 433. Open 12. Sonia Alamowitch, Guillaume Turc, Lina Palaiodimou et al. European Stroke Organisation ESO expedited recommendation on tenecteplase for acute ischaemic stroke. Eur Stroke J. 2023 Mar;8 1 8 54. Open 13. Stephanie Debette, Mikael Mazighi, Philippe Bijlenga et al. ESO guideline for the management of extracranial and intracranial artery dissection. Eur Stroke J. 2021 Sep;6 3 XXXIX LXXXVIII. Open 14. Martin Dennis, Valeria Caso, L Jaap Kappelle et al. European Stroke Organisation ESO guidelines for prophylaxis for venous thromboembolism in immobile patients with acute ischaemic stroke. Eur Stroke J. 2016 Mar;1 1 6 19. Open 15. Brown MD, Burton JH, Nazarian DJ et al. Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department. Ann Emerg Med. 2015 Sep;66 3 322 333.e31. Open 16. James Sall, Blessen C Eapen, Johanna Elizabeth Tran et al. The Management of Stroke Rehabilitation: A Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med. 2019 Dec 17;171 12 916 924. Open 17. Martin Holtkamp, Ettore Beghi, Felix Benninger et al. European Stroke Organisation guidelines for the management of post-stroke seizures and epilepsy. Eur Stroke J. 2017 Jun;2 2 103 115. Open 18. Persani L, Brabant G, Dattani M et al. 2018 European Thyroid Association ETA Guidelines on the Diagnosis and Management of Central Hypothyroidism. Eur Thyroid J. 2018 Oct;7 5 225 237. Open 19. US Preventive Services Task Force, Carol M Mangione, Michael J Barry et al. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2022 Aug 23;328 8 746 753. Open 20. Steven E. Kahn, Cheryl A.M. Anderson, John B. Buse et al. Standards of Care in Diabetes 2023. Diabetes Care. 2023 Jan;46 Supplement_1 S1 S291. Open 21. Chandril Chugh. Acute Ischemic Stroke: Management Approach. 2019 Jun;23 Suppl 2 S140 S146.2019 Jun;23 Suppl 2 S140 S146. Open 22. Tapuwa D Musuka, Stephen B Wilton, Mouhieddin Traboulsi et al. Diagnosis and management of acute ischemic stroke: speed is critical. 2015 Sep 8;187 12 887 93.2015 Sep 8;187 12 887 93. Open 23. Angela M Carter, Andrew J Catto, Michael W Mansfield et al. Predictive variables for mortality after acute ischemic stroke. 2007 Jun;38 6 1873 80.2007 Jun;38 6 1873 80. Open 24. Eric J ttler, Andreas Unterberg, Johannes Woitzik et al. Hemicraniectomy in Older Patients with Extensive Middle-Cerebral-Artery Stroke. N Engl J Med. 2014 Mar 20;370 12 1091 100. Open https://web.pathway.md/diseases/recwd1RIpW03JSM4H 28/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway 25. Gronseth GS, Mess SR. Practice advisory: Etanercept for poststroke disability: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2016 Jun 7;86 23 2208 11. Open 26. Sacks D, Black CM, Cognard C et al. Multisociety consensus quality improvement guidelines for intraarterial catheter-directed treatment of acute ischemic stroke, from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology. J Vasc Interv Radiol. 2013 Feb;24 2 151 63. Open 27. Schellinger PD, Bryan RN, Caplan LR et al. Evidence-based guideline: The role of diffusion and perfusion MRI for the diagnosis of acute ischemic stroke: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2010 Jul 13;75 2 177 85. Open 28. Jauch EC, Saver JL, Adams HP Jr et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar;44 3 870 947. Open 29. Culebras A, Mess SR, Chaturvedi S et al. Summary of evidence-based guideline update: prevention of stroke in nonvalvular atrial fibrillation: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2014 Feb 25;82 8 716 24. Open 30. American Association of Neurological Surgeons. Choosing Wisely AANS recommendations. Choosing Wisely. 2014. Open 31. Turc G, Bhogal P, Fischer U et al. European Stroke Organisation ESO European Society for Minimally Invasive Neurological Therapy ESMINT Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke. J Neurointerv Surg. 2019 Feb 26. pii: neurintsurg-2018 014569. Open 32. Pengfei Yang, Yongwei Zhang, Lei Zhang et al. Endovascular Thrombectomy with or without Intravenous Alteplase in Acute Stroke. N Engl J Med. 2020 May 21;382 21 1981 1993. Open 33. Bruce C V Campbell, Peter J Mitchell, Leonid Churilov et al. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. N Engl J Med. 2018 Apr 26;378 17 1573 1582. Open 34. Gregory W Albers, Michael P Marks, Stephanie Kemp et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018 Feb 22;378 8 708 718. Open 35. Craig S Anderson, Thompson Robinson, Richard I Lindley et al. Low-Dose versus Standard-Dose Intravenous Alteplase in Acute Ischemic Stroke. N Engl J Med. 2016 Jun 16;374 24 2313 23. Open 36. Arthur Wang, Noorie Pednekar, Rachel Lehrer et al. DRAGON score predicts functional outcomes in acute ischemic stroke patients receiving both intravenous tissue plasminogen activator and endovascular therapy. Surg Neurol Int. 2017 Jul 18;8 149. Open 37. Jennifer E. Fugate, DO and Alejandro A. Rabinstein, MD. Absolute and Relative Contraindications to IV rt-PA for Acute Ischemic Stroke. Neurohospitalist. 2015 Jul; 5 3 110 121. Open 38. Arturo Ren , M nica Mill n, Luis San Rom n et al. Effect of Intra-arterial Alteplase vs Placebo Following Successful Thrombectomy on Functional Outcomes in Patients With Large Vessel Occlusion Acute Ischemic Stroke: The CHOICE Randomized Clinical Trial. JAMA. 2022 Mar 1;327 9 826 835. Open https://web.pathway.md/diseases/recwd1RIpW03JSM4H 29/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway 39. Shinichi Yoshimura, Nobuyuki Sakai, Hiroshi Yamagami et al. Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med. 2022 Apr 7;386 14 1303 1313. Open 40. Bruce C V Campbell, Peter J Mitchell, Timothy J Kleinig et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015 Mar 12;372 11 1009 18. Open 41. RESCUE BT Trial Investigators, Zhongming Qiu, Fengli Li et al. Effect of Intravenous Tirofiban vs Placebo Before Endovascular Thrombectomy on Functional Outcomes in Large Vessel Occlusion Stroke: The RESCUE BT Randomized Clinical Trial. JAMA. 2022 Aug 9;328 6 543 553. Open 42. P Lyden, T Brott, B Tilley et al. Improved reliability of the NIH Stroke Scale using video training. NINDS TPA Stroke Study Group. Stroke. 1994 Nov;25 11 2220 6. Open 43. Pengfei Yang, Lili Song, Yongwei Zhang et al. Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke ENCHANTED2/MT a multicentre, open-label, blinded- endpoint, randomised controlled trial. Lancet. 2022 Nov 5;400 10363 1585 1596. Open 44. Hui-Sheng Chen, Yu Cui, Zhong-He Zhou et al. Effect of Argatroban Plus Intravenous Alteplase vs Intravenous Alteplase Alone on Neurologic Function in Patients With Acute Ischemic Stroke: The ARAIS Randomized Clinical Trial. JAMA. 2023 Feb 9;e230550. Open 45. Mikael Mazighi, Sebastien Richard, Bertrand Lapergue et al. Safety and efficacy of intensive blood pressure lowering after successful endovascular therapy in acute ischaemic stroke BP TARGET a multicentre, open-label, randomised controlled trial. Lancet Neurol. 2021 Apr;20 4 265 274. Open 46. N Attal, G Cruccu, R Baron et al. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol. 2010 Sep;17 9 1113-e88. Open 47. Xiaochuan Huo, Gaoting Ma, Xu Tong et al. Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct. N Engl J Med. 2023 Apr 6;388 14 1272 1283. Open 48. Russell Chabanne, Thomas Geeraerts, Marc Begard et al. Outcomes After Endovascular Therapy With Procedural Sedation vs General Anesthesia in Patients With Acute Ischemic Stroke: The AMETIS Randomized Clinical Trial. JAMA Neurol. 2023 Apr 3;e230413. Open 49. Silke Walter, Heinrich J Audebert, Aristeidis H Katsanos et al. European Stroke Organisation ESO guidelines on mobile stroke units for prehospital stroke management. Eur Stroke J. 2022 Mar;7 1 XXVII LIX. Open 50. Guillaume Turc, Georgios Tsivgoulis, Heinrich J Audebert et al. European Stroke Organisation European Society for Minimally Invasive Neurological Therapy expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischaemic stroke and anterior circulation large vessel occlusion. Eur Stroke J. 2022 Mar;7 1 I XXVI. Open 51. Catharina Jm Klijn, Maurizio Paciaroni, Eivind Berge et al. Antithrombotic treatment for secondary prevention of stroke and other thromboembolic events in patients with stroke or transient ischemic attack and non-valvular atrial fibrillation: A European Stroke Organisation guideline. Eur Stroke J. 2019 Sep;4 3 198 223. Open 52. Jesse Dawson, ine Merwick, Alastair Webb et al. European Stroke Organisation expedited recommendation for the use of short-term dual antiplatelet therapy early after minor stroke and high-risk TIA. Eur Stroke J. 2021 Jun;6 2 CLXXXVII CXCI. Open 53. Else Charlotte Sandset, Craig S Anderson, Philip M Bath et al. European Stroke Organisation ESO guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage. Eur https://web.pathway.md/diseases/recwd1RIpW03JSM4H 30/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway Stroke J. 2021 Jun;6 2 XLVIII LXXXIX. Open 54. Eivind Berge, William Whiteley, Heinrich Audebert et al. European Stroke Organisation ESO guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J. 2021 Mar;6 1 I LXII. Open 55. Nadinda A M van der Ende, Bob Roozenbeek, Lucas E M Smagge et al. Safety and Efficacy of Dual Thrombolytic Therapy With Mutant Prourokinase and Small Bolus Alteplase for Ischemic Stroke. JAMA Neurol. 2023 May 22;e231262. Online ahead of print. Open 56. Steven J Warach, Anna Ranta, Joosup Kim et al. Symptomatic Intracranial Hemorrhage With Tenecteplase vs Alteplase in Patients With Acute Ischemic Stroke: The Comparative Effectiveness of Routine Tenecteplase vs Alteplase in Acute Ischemic Stroke CERTAIN Collaboration. JAMA Neurol. 2023 May 30;e231449. Open https://web.pathway.md/diseases/recwd1RIpW03JSM4H 31/31