I B-NR Recommendation reworded for clarity from 2013 AIS Guidelines. See Table XCV in online Data Supplement 1 for original wording. The 2013 recommendation referred to initial emergency care as described elsewhere in the guidelines, which specified administration of IV alteplase as part of this care. The current recommendation is unchanged in intent but reworded to make this clear. When several IV alteplase capable hospital options exist within a defined geographic region, the benefit of bypassing the closest to bring the patient to one that offers a higher level of stroke care, including mechanical thrombectomy, is uncertain. IIb B-NR New recommendation. Effective prehospital procedures to identify patients who are ineligible for IV thrombolysis and have a strong probability of large vessel occlusion (LVO) stroke should be developed to facilitate rapid transport of patients potentially eligible for thrombectomy to the closest healthcare facilities that are able to perform mechanical thrombectomy. IIb C-EO New recommendation. At least 6 stroke severity scales targeted at recognition of LVO in the prehospital setting to facilitate transfer to endovascular centers have been published.31 36 The 2018 AHA systematic review on the accuracy of prediction instruments for diagnosing LVO in patients with suspected stroke concluded that No scale predicted LVO with both high sensitivity and high specificity. 4 Specifically, the probability of LVO with a positive LVO prediction test was thought to be only 50% to 60%, whereas >10% of those with a negative test may have an LVO. Thus, more effective tools are needed to identify suspected stroke patients with a strong probability of LVO. 