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Neurosurgery. 2019 Jul 1;85(suppl_1):S38-S46. doi: 10.1093/neuros/nyz067.

Initial Emergency Room Triage of Acute Ischemic Stroke.

Waqas M1,2, Vakharia K1,2, Munich SA1,2, Morrison JF1,2, Mokin M3, Levy EI1,2,4,5, Siddiqui AH1,2,4,5,6.

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Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.
Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.
Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida.
Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.
Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York.
Jacobs Institute, Buffalo, New York.


Early recognition and differentiation of acute ischemic stroke from intracranial hemorrhage and stroke mimics and the identification of large vessel occlusion (LVO) are critical to the appropriate management of stroke patients. In this review, we discuss the current evidence and practices surrounding safe and efficient triage in the emergency room. As the indications of stroke intervention are evolving to further improve stroke care, focus has begun to revolve around recognition of LVO and provision of endovascular thrombectomy with or without the administration of tissue plasminogen activator. Systems of stroke care are being organized to achieve this goal without delay. Clinical history is important in determining time of onset or last known well time, but, alone or along with an examination, it cannot reliably predict an LVO or exclude intracranial hemorrhage and stroke mimics. The choice of imaging is influenced mainly by the duration of symptoms. On the basis of recent trials, patients presenting after the 6-h therapeutic window can be considered for endovascular thrombectomy if the computed tomographic or magnetic resonance perfusion imaging shows favorable findings. The Society of NeuroInterventional Surgery has established time metrics for each step of triage and initial management. Hospitals are required to develop multidisciplinary stroke teams and emergency protocols to meet these goals. There also needs to be coordination of the emergency medical services with the emergency facility of an appropriate stroke center (a primary stroke center, comprehensive stroke care center, or a thrombectomy-capable stroke center).


Acute ischemic stroke; Emergency room triage; Endovascular thrombectomy; Large vessel occlusion


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