1. NCHCT to rule out bleed

2. Start IV tPA if appropriate

3. CTA Head and Neck to look for large vessel occlusion (M1, M2, ICA, or basilar)

4. If LVO present, NIHSS ≥ 6, ASPECTS ≥ 6 (consider for ASPECTS = 3-5) , activate NeuroIR

1. NCHCT to rule out bleed

2. CTA Head and Neck to look for large vessel occlusion (M1, M2, ICA, or basilar)

3. If LVO present, NIHSS ≥ 6, ASPECTS ≥ 6 (consider for ASPECTS = 3-5) , activate NeuroIR

1. NCHCT to rule out bleed

2. CTA Head and Neck to look for large vessel occlusion (M1, M2, ICA, or basilar)

   • If basilar occlusion present, activate NeuroIR

3. If M1 or ICA (consider for M2) occlusion, then:

4. CT Perfusion Brain, inform NeuroIR of potential thrombectomy candidate

5. See DEFUSE-3 and DAWN Criteria for NeuroIR eligibility

Eligible for Thrombectomy if occlusion in M1 or ICA (consider M2) and the following applies:

1. Infarct core is < 70 cc, mismatch ratio is ≥ 1.8, mismatch volume ≥ 15 cc

Eligible for Thrombectomy if occlusion in M1 or ICA (consider M2) and any of the following apply:

1. Infarct core is 0 to < 21 cc, NIHSS ≥ 10, and age ≥ 80 years

2. Infarct core is 0 to < 31 cc, NIHSS ≥ 10, and age < 80 years

3. Infarct cores is 31 to < 51 cc, NIHSS ≥ 20, and age < 80 years

EXTEND Criteria for IV tPA

1. NIHSS 4-26

2. Pre-stroke mRS < 2

3. In wake-up stroke, approximate last known well is calculated by:

   1. (bedtime - symptom discovery time)/2

4. CTP results

   1. Mismatch:Core ratio > 1.2

   2. Mismatch volume > 10 cc

   3. Infarct Core ≤ 70 cc

5. Patients with LVO anticipating thrombectomy are excluded from EXTEND protocol IV tPA